Arguably considered the catalyst for Neurofeedback training development, Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most extensively researched applications of Neurofeedback training (NFT).
Electroencephalography (EEG) research, the basis for neurofeedback therapy, spanning 1962 to the present, has consistently demonstrated abnormal cortical patterns associated with ADHD subtypes. For example, an excess of theta activity (4-8 Hz) and lack of beta activity (15-32 Hz) as characteristic of the inattentive subtype (La Marca & O’Connor 2016). From this research, NFT therapy has consistently demonstrated that the various subtypes of ADHD are associated with abnormal patterns of cortical activity.
As this research continues to progress, advances in technological ability continue to refine theoretical understanding and a large body of empirical evidence lauding the efficacy and safety of NFT has emerged. Given this information, Neurofeedback/EEG Biofeedback for ADHD was listed at the highest level of efficacy (Level 1- Best Support) from 2012 by PracticeWise. PracticeWise scientifically reviews and evaluates various disorders and the efficacy of therapies, and is used by the American Academy of Paediatrics. Likewise, the American Psychological Association has also recognised that research has shown that this treatment has the highest (‘Level 5’ by their ratings) level of efficacy for ADHD treatment interventions.
Furthermore, NFT has consistently demonstrated little or no notable side effects (Moriyama & colleagues, 2012) as well as inducing a significantly positive impact on neuropsychological and behavioural outcomes associated with ADHD, especially in reducing inattention and hyperactivity symptoms (Levesque, Beauregard & Mensour, 2006). Other studies present its’ ability to increase levels of emotion self-regulation and self-control directly addressing overactivity and functional deficits in the default mode network and limbic system networks (Hodgson, Hutchinson, & Denson, 2012).
Below is a summary of the current scientific evidence for neurofeedback in ADHD as well as an extensive reference list.
EFFICACY OF NEUROFEEDBACK FOR ADHD
The following body of evidence explores the evidentiary basis for the efficacy and specificity of Neurofeedback therapy, from inception to present in order to promote understanding and serve as a summary for your convenience.
Pimenta and colleagues (2021) conducted a systematic review of RCTs to examine the efficacy of neurofeedback training for children with ADHD and investigate the variables that impact outcomes. Overall, neurofeedback produced clinically significant improvements, with remission rates varying between 32 – 47%. Although these rates were slightly lower than for medication, the symptom improvement following NF training was maintained and only increased over time, while medication effects were short-lasting. Further, this review demonstrated that by personalising the NF parameters to each individual case, effects were greater than standard NF procedure and superior to medication. Together, these results suggest that not only can neurofeedback significantly improve symptoms, but it also provides a more enduring and effective alternative to medications.
Wang and colleagues (2021) examined the influence of theta/beta neurofeedback training on resting state brain connectivity and ADHD symptoms. They used EEG to assess the resting state brain connectivity before and after NF in 22 children with ADHD and 15 age-matched controls. Results showed that neurofeedback training altered resting state brain activity in ADHD children, ensuing greater efficiency of signalling and denser connectivity post-training. Importantly, the post-training EEG scans of ADHD children more closely resembled healthy controls. Further, parent-reported symptom severity was significantly reduced post-training.
Dobrakowski and Łebecka (2020) examined the effect of frequency training neurofeedback on the working memory of children with ADHD. Forty-eight children (6-12 years) were randomly assigned to either neurofeedback or a control group. Children receiving neurofeedback underwent 10 weeks of training to increase low beta amplitude and decrease theta and high beta. After training, children receiving neurofeedback demonstrated significantly greater working memory compared to children in the control group, and this difference was maintained in a follow-up assessment one year after training ceased.
Bluschke and colleagues (2020) examined the effects of theta/beta neurofeedback on rapid response execution and inhibition processes on a Go/Nogo task in the inattentive and combined ADHD subtypes, compared to controls. Participants included 17 with inattentive, 19 with combined subtype and 19 healthy controls. Neurofeedback training was conducted in two weekly 1hr sessions over eight weeks. Results indicate that the theta/beta neurofeedback protocol enhances execution of motor responses in the inattentive subtype and improved inhibition of action in the combined subtype. No changes occurred in the healthy controls.
Van Doren & colleagues (2019) conducted a meta-analysis into the efficacy of neurofeedback in ADHD. In the 10 studies included, within-group NF effects on inattention were of medium effect size (ES) (SMD = 0.64) at post-treatment and increased to a large ES (SMD = 0.80) at FU. Regarding hyperactivity/impulsivity, NF ES were medium at post-treatment (SMD = 0.50) and FU (SMD = 0.61). Non-active control conditions yielded a small significant ES on inattention at post-treatment (SMD = 0.28) but no significant ES at FU. Active treatments (mainly methylphenidate), had large ES for inattention (post: SMD = 1.08; FU: SMD = 1.06) and medium ES for hyperactivity/impulsivity (post: SMD = 0.74; FU: SMD = 0.67). Between-group analyses also revealed an advantage of NF over non-active controls [inattention (post: SMD = 0.38; FU: SMD = 0.57); hyperactivity-impulsivity (post: SMD = 0.25; FU: SMD = 0.39)], and favored active controls for inattention only at pre-post (SMD = – 0.44). Compared to non-active control treatments, NF appears to have more durable treatment effects, for at least 6 months following treatment.
Rubia & colleagues ( 2019) used functional connectivity analyses to investigate whether fMRI-Neurofeedback of rIFC resulted in dynamic functional connectivity changes in underlying neural networks. rIFC showed increased positive functional connectivity after relative to before fMRI-Neurofeedback with dorsal caudate and anterior cingulate and increased negative functional connectivity with regions of the default mode network (DMN) such as posterior cingulate and precuneus. Furthermore, the functional connectivity changes were correlated with clinical improvements and the functional connectivity and correlation findings were specific to the rIFC-Neurofeedback group. The findings show for the first time that fMRI-Neurofeedback of a typically dysfunctional frontal region in ADHD adolescents leads to strengthening within fronto-cingulo-striatal networks and to weakening of functional connectivity with posterior DMN regions and that this may be underlying clinical improvement.
Clinical trials have garnered interesting results attesting to both the presence of unique EEG patterns in the ADHD brain and the effiacy of theta suppression/beta enhancement and theta suppression/ alpha enhancement protocols on symptom reduction. Duffy, Shankardass, McAnulty and Als (2017) posit the existence of complex bi-hemispheric neural connections within the ADHD brain; characterising it as a series of multiple yet unique responses to stimuli which when summed together are distinctively related to ADHD. EEG electrodes were placed across all areas on participants heads, with responses recorded in real time. Results showed lower level processing such as visual, auditory (occipital, parietal) was not signficantly affected in ADHD brains compared to control, however more erratic patterns ensued in connections projecting to prefrontal lobes, characteristic of ADHD symptoms such as lack of sustained, deliberate attention. With further development, the authors suggest this EEG screening method could be adapted as a ‘screening test’ due to the distinct and unique EEG patterns in the ADHD brain.
Mohagheghi & colleagues (2017) conducted a randomised controlled trial evaluating the efficacy of theta suppression protocol with either beta or alpha enhancement in ADHD patients. These treatment protocols have been demonstrated as strengthening inhibitory connections between prefrontal cortex, normalising brain activity (Moriyama et al., 2012). Sixty children were assigned to either with parental and child self reports as well as objective measures testing continuous performance over forty sessions. Statistically significant symptomatic reductions were found in hyperactivity, inattention and omissive behaviours, with alpha enhancement protocol demonstrating better suppression and brain activity normalisation; which was maintained at an eight week post intervention follow up.
A study in 2017 by Nooner and colleagues establishes the effectiveness of neurofeedback on symptoms of ADHD in a relatively short period of time. The study was able to detect improvements in the behavioural symptoms of childhood ADHD within the first 12 sessions. As most neurofeedback treatment occurs over a period of 30-40 sessions, observing improvements in such a short amount of time supports the efficacy of neurofeedback as a long term treatment for ADHD symptoms.
Whereby subjects show The Nordic Journal of Psychiatry published an article addressing the efficacy of NF + methylphenidate (MPH), MPH alone and NF alone. Duric & colleagues (2017) used one hundred and thirty adolescents and children participants in the study, finding core symptoms improved and persisted six months after treatment in all conditions. Fascinatingly, improvements in inattention and other core ADHD symptoms in the combination NF + MPH treatment were comparable in efficacy to medication (MPH) only. While authors suggest further research is needed to explore the long term effects (over six months) of multi-modal treatment, they suggest it is highly likely children and adolescents who poorly respond to purely pharmacological treatment or are looking at alternative treatment options to traditional stimulant medication with less impact on their health or quality of life.
Eun-Jeong Lee and colleagues (2017) documented the improvement of inattention symptoms in children diagnosed with ADHD after combining neurofeedback with medication. The trial demonstrated that NFT paired with medication significantly reduced abnormal theta wave activity, suggesting NFT can be used safely and effectively with children who are also being treated with medication. This has promising implications for weaning children off medication while treating the root causes rather than the symptoms of ADHD.
Van doren and colleagues (2017) attested to these positive changes in attention and demonstrated that such changes are attainable even with relatively fewer training sessions. They found that NFT significantly decreased the theta/beta ratio by the end of the second NFT session, which corresponds to an increase in attentional control. This reduction was found across multiple brain regions, and these findings reveal that even in the short-term, NFT has the ability to substantially increase attention regulation in children with ADHD.
A game-based cognitive and NFT protocol combination for children with clinical and subclinical ADHD was developed in 2017 by Johnstone and colleagues. Questionnaires measuring symptom severity were completed by parents and researchers blinded to the treatment conditions, and pre-training/post-training cognitive performance was measured by EEG. After the completion of 25 sessions, a clear decrease in symptom severity was found in both groups, suggesting that NFT may be effective for treating subclinical as well as clinical ADHD.
Numerous studies strongly attest to improved academic performance, particularly in literacy, resultant from NFT in children with ADHD. La Marca and O’Connor (2016) assessed five Year 4 students, each of whom received five 30-minute sessions of NFT per week for 8 weeks. Following the intervention, improvements were observable on objective measures of attention and comprehension, thus suggesting that NFT significantly improved the children’s engagement with texts and better understanding of the content. Therefore, NFT represents a viable treatment option for improvement in reading achievement levels in children with ADHD.
Annet Bluschke and colleagues (2016) from the University of Dresden examined the effect of an 8-week theta/beta NFT protocol on impulsivity levels in 19 children with ADHD, with the medial frontal cortices as the primary biological targets. The researchers found that when comparing these children to children in a waitlist control group, the theta/beta NFT protocol led to significant reductions in impulsiveness and associated behaviours. This study provides evidence that theta/beta NFT protocols modulate response inhibition control processes on a neuroanatomical level.
Ryoo and Son (2015) compared college-aged Korean ADHD participants in either a no-treatment condition or NFT condition. The participants in the NFT condition received 15 sessions over a 4-week period, and demonstrated significant improvements on a number of outcomes, including aberrant EEG activity and performance on a computerised attention test. These improvements were maintained at a follow-up assessment, suggesting that the benefits of NFT for ADHD persist even after the completion of the NFT protocol – a clear advantage over the use of medication.
In a randomised controlled trial, Meisel and colleagues (2014) compared the effectiveness of a theta/beta NFT protocol to a standard pharmacological treatment (methylphenidate) in a group of 23 children with ADHD. Parents and teachers completed behavioural rating scales of symptom severity at pre-treatment and intervals spanning from directly after to six months post treatment. Improvements to ADHD symptom severity were found in both treatment groups, however only children who underwent NFT demonstrated significant improvements in academic performance. Moreover, the effects persisted for at least six months. These findings offer further evidence for the efficacy of neurofeedback as a beneficial non-pharmacological ADHD intervention.
Another comparison study, conducted by Naomi Steiner, Elizabeth Frenette, Kirsten Rene, Robert Brennan, and Ellen Perrin (2014) randomly assigned 104 children ADHD to either a NFT, cognitive training (CT), or waitlist control condition. Changes from pre- to post-intervention on a range of psychological tests, parent reports, teacher reports, and systematic classroom observations were recorded. It was found that children who received NFT improved significantly on tests of attention, executive function, motor control and verbal off-task behaviour, compared to no improvements in the CT or control conditions. Stimulant medication dosages significantly increased for children in the CT and control conditions but not for those in the NFT condition. These results illustrate that, compared to CT and waitlist control conditions, children in the NFT condition made greater improvements in ADHD symptomatology, without the need to increase medication intake. These findings have significant implications for supplementing medication with NFT as a frontline treatment for ADHD.
Gevensleben, Rothenberger, Moll and Heinrich (2012) conducted a literature review of randomised control trials of NFT for ADHD. In several previous studies, ADHD was associated with increased slow wave activity and/or reduced alpha activity and/or beta activity in the resting EEG. The researchers suggested that for patients whom received NFT, clinically-significant reductions were obtained for symptoms such as inattention, impulsivity and hyperactivity. Additionally, the researchers suggested that protocols such as slow cortical potential (SCP) training could address issues with maintaining optimal arousal and activation levels. Whilst there have been few studies with direct comparisons of NFT and cognitive-behavioural therapy or medication, NF and CBT both reached a medium effect size in this study. The increasing quality of recent results provides further evidence that NF is an effective and increasingly accepted treatment for ADHD.
Ali Reza Bakhshayesh, Sylvana Hänsch, Anne Wyschkon, Mohammad Javad Rezai and Günter Esser (2011) compared the effects of electroencephalogram (EEG) neurofeedback and electromyography (EMG) Biofeedback in children with ADHD. The aim of the EEG neurofeedback was to reduce the theta/beta ratio, while EMG Biofeedback focused on forehead muscle relaxation. Thirty-five children with ADHD were randomly assigned to complete 30 sessions in either a therapy or control group. Psychophysiological measures, behavioural rating scales (completed by teachers and parents), and psychometric measures were administered before and after the assessment. Compared to the Biofeedback group, a significant reduction in primary ADHD symptoms and a reduction in theta/beta ratios were found across the behavioural and psychometric measures in the NF group. Additionally, improvements of inattention were also found in the NF group, reflected in decreased reaction times on neuropsychological tests. These findings clearly demonstrate that the reduction in ADHD symptoms is achieved through the self-regulation of brain activity, rather than being a placebo effect produced by the presence of medical and electronic equipment.
In a meta-analysis conducted by Martijn Arns, Sabine de Ridder, Ute Strehl, Marinus Breteler and Anton Coenen (2009), it was found that the results of the existing literature validated the claim that NFT reduces the impulsivity and hyperactivity associated with ADHD. Given the large effect size across a range of study designs, NFT was awarded a Level 5 rating, meaning that it could be considered an “Efficacious and Specific” treatment in this context.
Gevensleben and colleagues (2009a) investigated the impact of different NF protocols (theta/beta training and SCP training) on the resting EEG, as well as the association between distinct EEG measures and behavioural improvements. Seventy-two children (ages 8-12) diagnosed with ADHD were given either the combined NF/SCP training or attention skills training (AST; control) and sessions took place two to three times a week. Results suggest that the combined NF training was accompanied by a reduction of theta activity. Protocol-specific EEG changes (theta/beta training: decrease of posterior-midline theta activity; SCP training: increase of central-midline alpha activity) were associated with improvements in the German ADHD rating scale, which provides further evidence that distinct neuronal mechanisms may contribute to behavioural improvements in children with ADHD.
In a randomised controlled trial encompassing 102 children (ages 8-12) with ADHD, Gevensleben and colleagues (2009b) examined the clinical efficacy of NFT. A combined NF protocol (18 sessions of theta/beta training, preceded or followed by 18 sessions of slow cortical potential training) was compared to a computerised attention skills training protocol (AST; 36 sessions). Behaviour ratings provided by parents and teachers indicated that children who received NF training showed significant behavioural improvements, compared to no change in children in the control group. In a 6-month follow up study, Gevensleben and colleagues (2010) found that these reductions had been sustained in 50% of the children in the NF group. This study found significant results across multiple domains of assessments, including the core symptoms of ADHD are home and school, changes in the centro-parietal regions of the brain, and maintenance of parent-rated improvement at 6 month follow up. These exciting findings further highlight the long-term benefits of NFT in the absence of continued treatment.
Holtman and colleagues (2010) examined 34 German children (7-12 years old) with ADHD-combined, ADHD-combined with comorbid conduct disorder, and ADHD-inattentive type. Majority of the children were on medication which was kept constant throughout the study. The children were randomly assigned to twenty 30-min sessions, twice a week for a fortnight of theta/beta NF or a cognitive-training control condition. Whilst both groups showed improvement on testing, only the NF had a significant reduction of impulsivity errors. Despite study limitations such as no attempt to blind or follow-up, the study found that NF led to normalisation of a key neurophysiologic correlate of response inhibition.
Renate Drechsler, Marc Straub, Mirko Doehnert, Hartmut Heinrich, Hans-Christoph Steinhausen and Daniel Brandeis (2007) looked at the efficacy of NF training compared with group therapy for children with ADHD. In addition to neuropsychological testing, pre- and post-treatment assessments were conducted by parents and teachers of children’s behaviour and executive function. Parents and teachers of children in the NF group reported greater cognitive and behavioural improvements than parents and teachers of children who received group therapy. Moreover, improvements were seen on tests of attention and cognitive ability in children in the NF group. Furthermore, the researchers observed improvements in the regulation of cortical activation in children who received NF training, compared to no improvement in children who received group therapy. The researchers therefore concluded that NF had a specific training effect on SCPs.
In 2007, Leins conducted a study comparing theta-beta training with SCP training, while controlling for confounding variables such as parental expectancies of therapy, parental satisfaction with therapy, and parenting styles. Thirty-eight children (aged 8-13) were allocated to either the SCP group (n = 19) or the theta/beta group (n = 19). It was found that in both groups, parent and teacher reported improvements of cognitive and behavioural symptoms, and the researchers reported significant increases in full-scale-IQ, performance-IQ and attention. A six-month follow-up revealed that these clinical effects remained stable for both groups. The lack of difference between groups on all outcome measures demonstrates that theta/beta and SCP training can improve behaviour, attention, and IQ significantly.
In tasks that require selective attention, it has been observed through functional neuroimaging that the anterior cingulate cortex (ACC) of individuals with ADHD functions abnormally. Johanne Levesque, Mario Beauregard and Boualem Mensour (2006) explored the impact of NFT on neural substrates of selective attention in children with ADHD. Children were assigned to either a NF training group or a no-training control group. Scans were taken while children performed a selective attention task one week before and one week after receiving treatment, and no activation in the anterior cingulate cortex (ACC) was recorded in either group prior to treatment. Compared to the control group, children who received NF training showed significant activation in the right ACC.
Strehl et. al (2006) found that EEG training had a significant positive effect on the behaviour, attention, and IQ scores of children with ADHD. Baseline scores were compared to post-treatment scores and 6-month follow-up scores for a group of twenty-eight children between the ages of 8 and 13 diagnosed with ADHD. Following training there was a significant reduction of behaviour problems over multiple assessments. Performance IQs also increased significantly from screening to follow-up. For children with below average attention scores, there was a significant increase from baseline to post-treatment and again from post-treatment to follow-up scores. For children with above average attention, there was a significant increase in scores between baseline and post-training. Both parent and teacher reports improved following training and it was shown that there were stable improvements over the follow-up period of six months.
A 2005 review published by Loo and Barkley acknowledges the progress and promising results of using EEG biofeedback to treat ADHD. The authors offer further research directions and ways to increase the scientific rigour when testing the efficacy of ADHD. For example, Loo and Barkley argue that treatments effects must generalise to non treatment settings and should persist over time to truly be efficacious.
In 2004, Heinrich, Gevensleben, Freisleder, Moll, and Rothenberger were the first to successfully use slow cortical potentials (SCPs) neurofeedback to change the polarity in EEGs in children with ADHD. SCPs are slow event-related direct current shifts of the EEG that reflect the excitation threshold of large cortical cell assemblies. Although this study did not use randomisation, there have been a number of studies that have used SCP NF with randomisation to find promising effects (See Gevensleben et al., 2009a, 2009b and Leins et al., 2007)
A paper presented by Orlandi and Greco at the 2004 International Society for Neuronal Regulation was the first of it’s kind to include blinding in a randomised study of NF for paediatric ADHD. The study examined thirty-six 9-11 year old American boys with ADHD-combined (DSM-IV) without comorbidity, medication or psychotherapy. Although children and treatment staff were not blinded to the study, the evaluations were done by blinded clinicians and blinded parents. The children were randomly assigned to forty 45-min theta/beta/SMR NF sessions twice per week for 20 weeks, or to a control condition of equal duration, frequency and intensity in the same setting. Children receiving neurofeedback therapy showed significant improvements on parent ratings and on blinded-clinician ratings of symptom severity.
Barry, Clarke and Johnstone (2003) conducted a review on the electrophysiology of ADHD. The review identified many robust group differences and this method of objective diagnosis has a number of advantages as it does not rely on the observations and perceptions of the child’s parents and teachers. As EEG provides a direct measure of brain functioning, it appears a highly appropriate tool for assessing ADHD.
Thomas Fuchs, Niels Birbaumer, Werner Lutzenberger, John H. Gruzelier, and Jochen Kaiser (2003) compared the symptom reduction of 34 children (aged 8-12) diagnosed with ADHD under typical stimulant medication or NFT. The children’s parents chose which treatment their child would receive; twelve chose stimulant medication and 22 chose EEG biofeedback (NFT). Treatment was provided for 12 weeks, measuring beta rhythms and primary sensorymotor cortex activity. Both treatments were associated with better performance on all psychological tests of attention, noting increases in speed and accuracy. Additionally, teachers and parents reported a similarly significant reduction in ADHD-related behaviours in both groups post treatment. These results highlight the potential for NF as an alternative to medication alone in improving ADHD-related behaviours; presenting a comparably effective non – pharmacological treatment option.
Vincent Monastra, Donna Monastra and Susan George (2002) conducted a study that compared the effects that Ritalin, EEG biofeedback, and parenting styles had on children with ADHD. One hundred children (aged 6-19) with ADHD participated in the study and all received Ritalin, counselling from parents, as well as academic support. Of these children fifty-one also received EEG feedback therapy. Following the treatments, the children were assessed with and without stimulant therapy. While using Ritalin, children recorded significant improvements on the Test of Variables of Attention and Attention Deficit Disorders Evaluation Scale. However, when the children were tested without Ritalin, only the children that received the EEG feedback maintained these improvements.
Palsson and colleagues (2001) conducted a study comparing the effects of standard NF therapy with a new video game NF therapy. In their sample of 22 American 9 to 13 year olds (86% boys) who were diagnosed with ADHD hyperactive-impulsive type were randomised to either standard NF or video game NF. Both NF therapies were designed to reduce theta/alpha and strengthen SMR/beta and were given for 60 minutes, 1-2 times per week for 40 sessions (approx. 20 weeks). The study found significant pre-post improvements of for core ADHD symptoms and that the video game NF was associated with more positive QEEG changes than the standard NF. Hyperactive scores significantly decreased for both NF therapies.
In a large multi-centre trial consisting of 1089 participants, David A. Kaiser and Siegfried Othmer (2000) conducted a study whereby the participants underwent 20+ SMR-beta NF training sessions. Training consisted of 30 minutes of visual and auditory feedback. A strength of this study is the large sample population obtained from 32 clinics that is highly representative of the patient population with varying comorbidity and demographics. The findings suggested that NF training significantly improved attentiveness, impulsivity control and response consistency. For participants with moderate pre-training deficits, significant improvement was seen on all measures after 20 sessions of training. Of the 1098 total subjects, 157 continued training and were re-tested after forty or more sessions, which led to significant improvement in impulse control and response consistency. Overall, this trial exhibited an eighty-five percent response rate for NF training.
Monastra, Lubar, Linden, VanDeusen, Green, Wing and Fenger (1999) conducted a study utilising 492 individuals ages 6-30 years old. The participants were classified into 3 groups (ADHD, inattentive; ADHD, combined; and control) based on results of clinical interviews., behaviour rating scales and continuous performance tests. The QEEG results provide initial guidelines for clinical researchers seeking to examine the validity of a QEEG indicator as a laboratory test for ADHD. The results also indicate significant maturational effects in cortical arousal in the prefrontal cortex and evidence of cortisol slowing in both ADHD groups, regardless of age and sex. This study helped strengthen the notion of using a neurometric test for diagnosing ADHD that is far less intrusive and expensive than other procedures.
Linden, Habib and Radojevic (1996) published the first randomised study of NF for paediatric ADHD. The study randomly assigned 18 US children, aged 5 to 15, diagnosed with ADHD or ADD (DSM-III-R), to wait-list control or forty 45-min, twice per week, theta/beta NF sessions over 6 months. Results indicated the NF group demonstrated a significant increase in composite IQ and a significant reduction in parent-rated inattention compared with the wait-list group. Despite no attempts to blind parents, child or therapists, and finding no significant differences between groups on parent ratings of hyperactivity-impuslvity or aggressive behaviour, this published randomised study was a crucial step forward for the field.
Rossiter and La Vaque (1995) compared the use of EEG biofeedback and psychostimulant medication for the reduction of ADHD symptoms. Overall, it was found that both medication and EEG treatments showed significant improvement on measures of inattention, impulsivity, information processing and variability. It was further discussed that whilst both treatment methods showed positive results, the lasting impact of biofeedback is superior to the symptom masking effects of medication.
In 1994, Fine and colleagues presented the very first documented randomised study of neurofeedback for paediatric ADHD. Seventy-one 8-11 year olds from the United states, diagnosed with ADHD were randomised to theta/beta/SMR NF therapy via a video game, cognitive training or no treatment. The study found that both the neurofeedback and cognitive training groups showed significant improvement on parent-rating scales and laboratory test variables. Despite study limitations, this was a very important study for the field and more convincing the all previous uncontrolled studies.
A 1992 study conducted by Mann, Lubar, Zimmerman, Miller and Muenchen revealed the unique differences and brain patterns of 25 male children (9-12 years old). The 16 channel topographic brain mapping revealed increased theta and decreased beta when compared with 27 controls matched for age and grade level. The differences were more pronounced when the participants were tested for reading and drawing skills, but were decreased when they were at rest. This study was one of the first to map out the neurophysiology of ADHD.
Tansey and Bruner (1983) conducted a case study of a 10 year old boy with attention deficit disorder with hyperactivity, as well as reading difficulties and ocular instability. After completing a SMR (14-Hz) neurofeedback training protocol, the child’s ocular instability and reading difficulties resolved, and his hyperactivity was reduced to a greater extent than when the child had been receiving Ritalin. Furthermore, the researchers concluded that a diagnosis of attention deficit disorder with hyperactivity was no longer applicable. These early findings provide strong evidence of the powerful effects of neurofeedback training for ADHD. In a 10-year follow-up assessment, Tansey (1993) found that the boy’s ocular instability, reading difficulties and hyperactivity had not returned after the completion of an SMR (14-Hz) neurofeedback protocol, and that he was performing well socially and academically. The researcher thus concluded that the beneficial effects of neurofeedback training had remained stable. Although this was a case study, the findings suggest that the effects of NF training are significant and long-lasting, and support the large body of research regarding the effectiveness of NF training for children with ADHD.
Initial research within Neurofeedback served to explore the manipulation of brain wave activity via operant conditioning (Hammond, 2007). Perhaps most interesting are the landmark studies conducted by Sterman & Clemente (1962). This pioneer study regarding stimulation of the basal forebrain area within immobilised adult cats significantly propelled the development of Neurofeedback therapy (NFT). Given thalamic projections to the preoptic region of the hypothalamus were associated with sleep and central nervous system (CNS) suppression, Sterman & Clement (1962) explored this area as a potential biological target for reducing cortical activity with wide therapeutic application. Bilateral EEG activity within subcortical areas, displayed decreases shown to be proportional to intensity of stimulation. Following this work, a litany of researchers explored the applications of EEG within the context of this CNS suppression, culminating in Sterman, Wyrwicka & Roth (1969) feline feeding/drinking behaviour study.
Interestingly, during feeding and drinking, EEG patterns in cats revealed a marked shift from more variable activity to slow wave EEG patterns, with decreases in activity occurring less than one minute from stimulation in both medial and posterior dorsomedial cortex of cats either consuming a food or liquid reward. Exploration into why frequency, amplitude and duration characteristics remained consistent within the sensorimotor cortex for cats given a reward substance, this study identified the existence of a ‘sensorimotor rhythm’ (SMR); as an oscillation (12 – 16 Hz) associated with a relaxed state, almost identical to sleep stage two (Sterman, Wyrwicka & Roth, 1969).
Following studies exploring the role of NFT in ADHD treatment (then referred to as ‘hyperkinesia’), stemmed from Lubar and Shouse (1976). This experiment aimed to elucidate the effects of SMR-increase/slow-wave-decrease NF training on the activity of primary somatosensory and motor cortices; and their subsequent impact on symptoms of hyperkinesia. After 7 months of NF training, the researchers reported a decrease in hyperactivity and an increase in motor inhibition, measured using behavioural observation in the classroom and muscular tone. Other researchers have attested to these findings by further elucidating the role of the SMR in relation to ADHD suggesting significant efficacy and reliability of postive effects (Lubar & Lubar, 1984). Children ( n = 6 ) with varying degrees of hyperkinesis were allocated into training conditions either on SMR (12 – 15 Hz) or (16 – 20 Hz) beta activity, consisting of two sessions per week spanning 10 to 27 months (Lubar & Lubar, 1984). This NFT was conducted adjunct to academic and spatial training tasks. Results illustrated improvements in academic performance and decreases in hyperkinetic behaviour; suggesting a firm place for NFT in holistic management of ADHD.
In 1973, Nall conducted the first outcome study of neurofeedback on 48 children with hyperactivity and learning disorders. However, the study did not find significant academic or behavioural differences between a group receiving alpha neurofeedback and a no-treatment control group.
References
Ahmsdlou, M., Rostami, R., & Sadeghi, V. (2012). Which attention-deficit/hyperactivity disorder children will be improved through Neurofeedback therapy? A graph theoretical approach to neocortex neuronal network of ADHD. Neuroscience Letters, 516, 156-160.
Arns, M., de Ridder, S., Strehl, U., Breteler, M., & Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta-analysis. Clinical EEG and neuroscience, 40(3), 180-189.
Arns, M, Heinrich, H., & Strehl, U. (2014). Evaluation of neurofeedback in ADHD: the long and winding road. Biological psychology, 85, 108-115.
Bakhshayesh, A. R., Hanschm S., Wyschkon, A., Rezai, M. J., & Esser, G. (2011). Neurofeedback in ADHD: a single-blind randomized controlled trial. European child & adolescent psychiatry, 20(9), 481.
Barry, R. J., Clarke, A. R., & Johnstone, S. J. (2003). A review of electrophysiology in attention-deficit/hyperactivity disorder: I. Qualitative and quantitative electroencephalography. Clinical Neurophysiology, 114, 171-183.
Bluschke, A., Broshwitz, F., Kohl, S., Roessner, V., & Beste, C. (2016). The neuronal mechanisms underlying improvement of impulsivity in ADHD by theta/beta neurofeedack. Scientific Reports, 6, 1-9.
Bluschke, A., Schreiter, M.L., Friedrich, J., Adelhöfer, N., Roessner, V., Beste, C. (2020) Neurofeedback trains a superordinate system relevant for seemingly opposing behavioral control deficits depending on ADHD subtype. Developmental Science; 23, e12956. https://doi.org/10.1111/desc.12956
Deilami, M., et al. (2016). Case report: The effect of Neurofeedback therapy on reducing the symptoms associated with attention deficit hyperactivity disorder: A case series study. Basic and Clinical Neuroscience, 7, 167-171.
Denkowski, K. M., Denkowski, G. C. & Omizo, M. M. (1984). Predictors of success in the EMG biofeedback training of hyperactive male children. Biofeedback and Self Regulation, 9(2), 253-264.
Dreschsler, R., Straub, M., Doehnert, M., Heinrich, H., Steinhausen, H. C., & Brandeis, D. (2007). Controlled evaluation of a neurofeedback training of slow cortical potentials in children with attention deficit/hyperactivity disorder (ADHD). Behavioral and Brain Functions, 3(1), 35.
Dobrakowski, P., & Łebecka, G. (2020). Individualized neurofeedback training may help achieve long-term improvement of working memory in children with ADHD. Clinical eeg and Neuroscience, 51(2), 94-101. https://doi.org/10.1177/1550059419879020
Duffy, F. H., Shankardass, A., McAnulty, G. B., & Als, H. (2017). A unique pattern of cortical connectivity characterizes patients with attention deficit disorders: a large electroencephalographic coherence study. BMC medicine, 15(1), 51.
Duric, N. S., Assmus, J., Gundersen, D., Duric Golos, A., & Elgen, I. B. (2017). Multimodal treatment in children and adolescents with attention-deficit/hyperactivity disorder: a 6-month follow-up. Nordic Journal of Psychiatry, 1-9.
Duric, N. S., Assmus, J., Gundersen, D., & Elgen, I. B. (2012). Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports. BMC psychiatry, 12(1), 107.
Fine, A. H., Goldman, L., & Sandford, J. (1994, August). Innovative techniques in the treatment of ADHD: An analysis of the impact of EEG biofeedback training and a cognitive computer generated training. Paper presented at the meeting of the American Psychological Association, Los Angeles, CA.
Fuchs, T., Birbaumer, N., Lutzenberger, W., Gruzelier, J.H., Kaiser, J. (2003). Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: a comparison with methylphenidate. Applied psychophysiology and biofeedback, 28(1),1-12.
Gevensleben, H., Holl, B., Albrecht, B., Schlamp, D., Kratz, O., Studer, P., & Heinrich, H. (2009a). Distinct EEG effects related to neurofeedback training in children with ADHD: a randomized controlled trial. International journal of psychophysiology, 74(2), 149-157.
Gevensleben, H., Holl, B., Albrecht, B., Vogel, C., Schlamp, D., Kratz, O., & Heinrich, H. (2009b). Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial. Journal of Child Psychology and Psychiatry, 50(7), 780-789.
Gevensleben, H., Holl, B., Albrecht, B., Schlamp, D., Kratz, O., Studer, P., & Heinrich, H. (2010). Neurofeedback training in children with ADHD: 6-month follow-up of a randomised controlled trial. European child & adolescent psychiatry, 19(9), 715-724.
Gevensleben, H., Rothenberger, A., Moll, G. H., & Heinrich, H. (2012). Neurofeedback in children with ADHD: validation and challenges. Expert review of neurotherapeutics, 12(4), 447-460.
Hammond, D. C. (2007). What is neurofeedback?. Journal of Neurotherapy, 10(4), 25-36.
Heinrich, H., Gevensleben, H., Freisleder, F. J., Moll, G. H., & Rothenberger, A. (2004). Training of slow cortical potentials in attention-deficit/hyperactivity disorder: Evidence for positive behavioral and neurophysiological effects. Biological Psychiatry, 55, 772-775
Hodgson, K., Hutchinson, A. D., & Denson, L. (2012). Non pharmacological treatments for ADHD: A meta-analytic review. Journal of Attention Disorders, 18(4), 275-282.
Holtmann, M., Grasmann, D., Cionek-Szpak, E., Hager, V., Panzer, N., Beyer, A., & Stadler, C. (2009). Specific effects of neurofeedback on impulsivity in ADHD. Kindheit und Entwicklung, 18, 95-104.
Johnstone, S. J., Roodenrys, S. J., Johnson, K., Bonfield, R., & Bennett, S. J. (2017). Game-based combined cognitive and neurofeedback training using Focus Pocus reduces symptom severity in children with diagnosed AD/HD and subclinical AD/HD. International Journal of Psychophysiology, 116, 32-44.
Kaiser, D. A., & Othmer, S. (2000). Effect of neurofeedback on variables of attention in a large multi-center trial. Journal of Neurotherapy, 4(1), 5-15.
Lansbergen, M. M., van Dongen-Boomsma, M., Buitelaar, J. K., & Slaats-Willemse, D. (2011). ADHD and EEG-neurofeedback: a double-blind randomized placebo-controlled feasibility study. Journal of neural transmission, 118(2), 275-284.
La Marca, Jeffry P. & E. O’Connor, Rollanda (2016). Neurofeedback as an Intervention to Improve Reading Achievement in Students with Attention-
Deficit/Hyperactivity Disorder, Inattentive Subtype. NeuroRegulation 3(2), 55-77.
Lee, Eun-Jeong et al. (2017). Additive effects of neurofeedback on the treatment of ADHD: A randomized controlled study. Asian Journal of Psychiatry, Volume 25 , 16 – 21.
Leins, U., Goth, G., Hinterberger, T., Klinger, C., Rumpf, N., & Strehl, U. (2007). Neurofeedback for children with ADHD: a comparison of SCP and Theta/Beta protocols. Applied psychophysiology and biofeedback, 32(2), 73-88.
Levesque, J., Beauregard, M., & Mensour, B. (2006). Effect of neurofeedback training on the neural substrates of selective attention in children with attention-deficit/hyperactivity disorder: A function magnetic resonance imaging study. Neuroscience Letters, 394, 216-221.
Linden, M., Habib, T., & Radojevic, V. (1996). A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback & Self-Regulation, 21, 35-49.
Lofthouse, N., Arnold, L. E., Hersch, S., Hurt, E., & DeBeus, R. (2012). A review of neurofeedback treatment for pediatric ADHD. Journal of Attention Disorders, 16(5), 351-372.
Loo, S. K., & Barkley, R. A. (2005). Clinical utility of EEG in attention deficit hyperactivity disorder. Applied Neuropsychology, 12, 64-76
Lubar, J. F., & Shouse, M. N. (1976). EEG and behavioral changes in a hyperkinetic child concurrent with training of the sensorimotor rhythm (SMR). Biofeedback and Self-regulation, 1(3), 293-306.
Lubar, J. O., & Lubar, J. F. (1984). Electroencephalographic biofeedback of SMR and beta for treatment of attention deficit disorders in a clinical setting. Biofeedback and self-regulation, 9(1), 1-23.
Lubar, J. F., Swartwood, M. O., Swartwood, J. N., & O’Donnell, P. H. (1995). Evaluation of the effectiveness of EEG neurofeedback training for ADHD in a clinical setting as measured by changes in TOVA scores, behavioral ratings, and WISC-R performance. Biofeedback and Self-regulation, 20(1), 83-99.
Lubar, J. F., Swartwood, M. O., Swartwood, J. N., & Timmermann, D. L. (1995)b. Quantitative EEG and auditory event-related potentials in the evaluation of attention-deficit/hyperactivity disorder: Effects of methylphenidate and implications for neurofeedback training. Journal of Psychoeducational Assessment, 34, 143-160.
Mann, C. A., Lubar, J. F., Zimmerman, A. W., Miller, C. A., & Muenchen, R. A. (1992). Quantitative analysis of EEG in boys with attention-deficit-hyperactivity disorder: Controlled study with clinical implications. Pediatric neurology, 8(1), 30-36.
Meisel, V., Servera, M., Garcia-Banda, G., Cardo, E., & Moreno, I. (2013). Neurofeedback and standard pharmacological intervention in ADHD: A randomized controlled trial with six-month follow-up. Biological Psychology, 94(1), 12-21. doi:10.1016/j.biopsycho.2013.04.015
Mohagheghi, A., Amiri, S., Moghaddasi Bonab, N., Chalabianloo, G., Noorazar, S. G., Tabatabaei, S. M., & Farhang, S. (2017). A Randomized Trial of Comparing the Efficacy of Two Neurofeedback Protocols for Treatment of Clinical and Cognitive Symptoms of ADHD: Theta Suppression/Beta Enhancement and Theta Suppression/Alpha Enhancement. BioMed Research International, 2017.
Moriyama. T. S., Polanczyk, G., Caye, A., Banaschewski, T., Brandeis, D., & Rohde, L. A. (2012) Evidence-based information on the clinical use for neurofeedback for ADHD. Neurothereapeutics, 9, 588-598.
Monastra, V. J., Lubar, J. F., Linden, M., VanDeusen, P., Green, G., Wing, W., & Fenger, T. N. (1999). Assessing attention deficit hyperactivity disorder via quantitative electroencephalography: An initial validation study. Neuropsychology, 13(3), 424.
Monastra, V. J., Lubar, J. F., & Linden, M. (2001). The development of a quantitative electroencephalographic scanning process for attention deficit–hyperactivity disorder: Reliability and validity studies. Neuropsychology, 15(1), 136.
Monastra, V. J., Monastra, D. M., & George, S. (2002). The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Applied psychophysiology and biofeedback, 27(4), 231-249.
Monastra, V. J. (2005). Electroencephalographic biofeedback (neurotherapy) as a treatment for ADHD: Rationale and empirical foundation. Child and Adolescent Psychiatric Clinics of North America, 14, 55-82.
Moriyama, T. S., Polanczyk, G., Caye, A., Banaschewski, T., Brandeis, D., & Rohde, L. A. (2012). Evidence-based information on the clinical use of neurofeedback for ADHD. Neurotherapeutics, 9(3), 588-598.
Nall, A. (1973). Alpha training and the hyperactive child: Is it effective? Academic Therapy, 9, 5-19.
Nooner, K. B., Leaberry, K. D., Keith, J. R., & Ogle, R. L. (2017). Clinic outcome assessment of a brief course neurofeedback for childhood ADHD symptoms. The Journal of Behavioural Health Services and Research, 44(3), 506-514.
Orlandi, M. A., & Greco, D. (2004, August). A randomized, doubleblind clinical trial of EEG neurofeedback treatment for attention-deficit/hyperactivity disorder. Paper presented at the meeting of the International Society for Neuronal Regulation, Fort Lauderdale, FL.
Palsson, O. S., Pope, A. T., Ball, J. D., Turner, M. J., Nevin, S., & deBeus, R. (2001, March). Neurofeedback videogame ADHD technology: Results of the first concept study. Paper presented at the annual meeting of Association for Applied Psychophysiology & Biofeedback, Research Triangle Park, NC.
Perreau-Linck, E., Lessard, N., Levesque, J., & Beauregard, M. (2010). Effects of neurofeedback training on inhibitory capacities in ADHD children: A single blind randomized placebocontrolled study. Journal of Neurotherapy, 14, 229-242.
Picard, C., Moreau, G., Guay, M. C., & Achim, A. (2006, September). Double double-blind sham study of neurofeedback treatment in children with ADHD. Paper presented at the meeting of the International Society for Neurofeedback and Research, Atlanta, GA.
Pimenta, G. M., Brown, T., Arns, M., & Enriquez Geppert, S. (2021). Treatment efficacy and clinical effectiveness of EEG neurofeedback as a personalized and multimodal treatment in ADHD: A critical review. Neuropsychiatric Disease and Treatment, 17, 637–648. https://doi.org/10.2147/NDT.S251547
Rockstroh, B., Elbert, T., Lutzenberger, W., & Birbaumer, N. (1990). Biofeedback: Evaluation and therapy in children with attentional dysfunctions. In A. Rothenberger (Ed.), Brain and behavior in child psychiatry (pp. 345-355). Berlin, Germany: Springer
Rossiter, T. R., & La Vaque, T. J. (1995). A comparison of EEG biofeedback and psychostimulants in treating attention deficit/ hyperactivity disorders. Journal of Neurotherapy, 1, 48-59.
Ryoo, M., & Son, C. (2015). Effects of Neurofeedback training on EEG, continuous performance task (CPT), and ADHD symptoms in ADHD-prone college students. Journal of Korean Academy of Nursing, 45, 928.
Shouse, M. N., & Lubar, J. F. (1979). Operant conditioning of EEG rhythms and ritalin in the treatment of hyperkinesis. Biofeedback and Self-regulation, 4(4), 299-312.
Steiner, N. J., Frenette, E. C., Rene, K. M., Brennan, R. T., & Perrin, E. C. (2014). Neurofeedback and cognitive attention training for children with attention-deficit hyperactivity disorder in schools. Journal of Developmental and Behavioral Pediatrics : JDBP, 35(1), 18-27.
Sterman, M. B., & Clemente, C. D. (1962). Forebrain inhibitory mechanisms: cortical synchronization induced by basal forebrain stimulation. Experimental neurology, 6(2), 91-102.
Sterman, M. B., Wyrwicka, W., & Roth, S. (1969). Electrophysiological correlates and neural substrates of alimentary behavior in the cat. Annals of the New York Academy of Sciences, 157(1), 723-739.
Strehl, U., Leins, U., Goth, G., Klinger, C., Hinterberger, T., & Birhaumer, N. (2006). Self-regulation of slow cortical potentials: A new treatment for children with attention-deficit/ hyperactivity disorder. Pediatrics, 118, 1530-1540.
Tansey, M. A. (1993). Ten-year stability of EEG biofeedback results for a hyperactive boy who failed fourth grade perceptually impaired class. Biofeedback and Self Regulation, 18(1), 33-44.
Tansey, M. A. & Bruner, R. L. (1983). EMG and EEG biofeedback training in the treatment of a 10-year-old hyperactive boy with a developmental reading disorder. Biofeedback and Self Regulation, 8(1), 25-37.
Urichuk, L., Hnatko, G., Baydala, L., Wikman, E., Hoover, H. J., Vohra, S., & Schachter, H. (2009, September). Neurofeedback treatment of ADHD—A feasibility study. Paper presented at the meeting of the Canadian Psychiatric Association, St. John’s, Canada
Van der Oord, S., Prins, P., Oosterlaan, J., & Emmelkamp, P. (2008). Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: A meta-analysis. Clinical Psychology Review, 28(5), 783-800.
Jessica, V. D., Arns, M., Heinrich, H., Vollebregt, M. A., Strehl, U., & Loo, S. K. (2019). Sustained effects of neurofeedback in ADHD: A systematic review and meta-analysis. European Child & Adolescent Psychiatry, 28(3), 293-305. doi:http://dx.doi.org/10.1007/s00787-018-1121-4
Van Doren, J., Heinrich, H., Bezold, M., Reuter, N., Kratz, O., Horndasch, S. & Studer, P. (2017). Theta/beta neurofeedback in children with ADHD: feasibility of a short-term setting and plasticity effects. International Journal of Psychophysiology, 112, 80-88.
Vernon, D., Frick, A., & Gruzelier, J. (2004). Neurofeedback as a treatment for ADHD: A methodological review with implications for future research. Journal of Neurotherapy, 8(2), 53-82.
Wang, S., Zhang, D., Fang, B., Liu, X., Yan, G., Sui, G., Huang, Q., Sun, L., & Wang, S. (2021). A study on resting EEG effective connectivity difference before and after neurofeedback for children with ADHD. Neuroscience, 457, 103–113. https://doi.org/10.1016/j.neuroscience.2020.12.038
Wangler, S., Gevensleben, H., Albrecht, B., Studer, P., Rothenberger, A., Moll, G. H., & Heinrich, H. (2011). Neurofeedback in children with ADHD: specific event-related potential findings of a randomized controlled trial. Clinical Neurophysiology, 122(5), 942-950.
Xiong, Z., Shi, S. & Xu, H. (2005). A controlled study of the effectiveness of EEG biofeedback training on children with attention deficit hyperactivity disorder. Journal of Huazhong University of Science and Technology, 6(4), 533-540.