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Neurofeedback
– also known as EEG Biofeedback – is an approach for treating ADHD that has
been studied and practiced for a number of years. In neurofeedback
treatment, individuals are provided with real-time feedback about their
brainwave activity and taught to use that information to modulate certain
aspects of their minds. As a treatment for ADHD, neurofeedback is based
on findings that measurements of brain activity in many individuals with ADHD
indicate reduced activity in the prefrontal region and frontal lobes (cortical
slowing). Neurofeedback treatment is designed to train individuals to
increase the production of brainwave patterns that reduce or eliminate this
cortical slowing, and thus reduce or eliminate many associated ADHD symptoms.
Within the medical and scientific communities, a diverse range of viewpoints
exists on the utility of neurofeedback treatment for ADHD. At one
extreme, there are prominent researchers who argue that, although
neurofeedback treatment is consistent with current theories about the
biological underpinnings of ADHD, there is a lack of scientific data
documenting the efficacy of this approach. On the other hand, some
neurofeedback researchers and practitioners argue that published studies
clearly establish the effectiveness of this treatment.
As is often the case in such debates, a careful review of the available
literature suggests that a more reasonable position falls somewhere in
between these views. Two controlled studies and numerous, carefully conducted
case studies have reported positive results. Based on this body of prior
work, neurofeedback treatment has been considered a “promising” approach for
which additional study was clearly warranted. This is the conclusion of Dr.
Eugene Arnold in the most comprehensive review of alternative treatment
approaches for ADHD published to date, and most ADHD experts would agree that
additional controlled studies are required to unequivocally establish the
efficacy of neurofeedback treatment for ADHD.
A recently conducted investigation -- “The Effects of Stimulant Therapy, EEG
Biofeedback & Parenting Style on the primary symptoms of ADHD” (Monastra
et. al.) represents a significant step in this direction. Preliminary
reports of this research were presented at the CHADD (Children and Adults
with Attention Deficit-Hyperactivity Disorder) national conference in 1999
and the annual convention of the American Psychological Association (APA) in
2000. A manuscript describing this study is currently under editorial review.
As with many studies of neurofeedback treatment, this investigation was
conducted in an actual clinical setting as opposed to an academic research
setting. Participants were 100 children (83 boys and 17 girls) with an
average age of 10 (range 6-19). Each child was diagnosed with ADHD and
treated at the Family Psychology Clinic, a private outpatient psychological
clinic in upstate New York.
The ADHD diagnosis was established using a structured interview and
standardized parent and teacher behavior rating scales.
After each child/teen was diagnosed, his or her parents were informed of a
comprehensive treatment approach that included stimulant medication, parent
counseling, school consultation to establish and monitor a program of
academic support, and neurofeedback. Approximately half of the participants
(n=51) opted to include neurofeedback as part of their child’s treatment.
Because this study was conducted in a clinic setting where parents paid for
treatment (as opposed to an academic research setting where treatment is
often provided at no charge), it was not possible to randomly assign children
to receive neurofeedback as part of their treatment package. One
limitation associated with non-random assignment is the possibility that
children in the two groups, or their families, may have differed in a
systematic way prior to the beginning of treatment. If this were found,
it would be difficult to attribute any differences found at the end of
treatment to differences in the treatment they received. Fortunately,
however, this does not seem to have been true.
Information presented indicates that the two groups (i.e. children whose
treatment included neurofeedback and those who did not) did not differ in
age, gender composition, IQ, or socioeconomic status. In addition, the
representation of the different ADHD subtypes (i.e. inattentive and combined)
was virtually identical. Finally, pre-treatment parent and teacher
ratings of ADHD symptoms, scores on the TOVA (a computerized test of
sustained attention that is often used in ADHD evaluations and to monitor the
effects of medication treatment), and results of a QEEG scan were also
equivalent. (Note: A QEEG scan is a technique used to identify the pattern of
cortical under-activity characteristic of ADHD. Recent research
indicates this technique shows considerable promise as an objective procedure
to assist in the diagnosis of ADHD.
Treatment
Participants received treatment over the course of 12 months. The
different treatment components are described below.
Stimulant medication: All participants received treatment with Ritalin
throughout the year. The average daily dose was 25 mg (10 mg in the
morning, 10 mg at midday, and 5 mg in the late afternoon) for children in
both groups.
Parent Counseling: Parents participated in a ten-session parenting class,
followed by individual consultation on an “as needed” basis. The
parenting class was designed to increase parents’ understanding of ADHD and
help them increase the use of systematic reinforcement strategies and
positive parental attention. Information on nutrition, problem solving with
teens, and the educational rights of children with ADHD was also
presented. The average number of clinical contact hours
(parenting classes and subsequent individual consultation) totaled 25 for
parents in the neurofeedback group and 27 for the other parents.
School Consultation: At the conclusion of the diagnostic evaluation, parents
were informed about procedures to obtain special educational services for
their children under the appropriate federal regulations. In accordance
with applicable laws, school districts evaluated each child and developed,
revised, and implemented an individualized educational program (IEP) or a
plan of academic support/accommodation (“504 Plan”) for each with the
assistance of the treating clinician. For each group, the mean number
of on-site consultations during the treatment year was 3.
Neurofeedback: For children whose parents elected to include neurofeedback in
their child’s treatment, “attention training” sessions lasting 30 to 40 minutes
were conducted on a weekly basis. Periodic QEEG scans were used to
determine training effectiveness. Training continued until the patient no
longer exhibited abnormal cortical slowing. The average number of
sessions required to reach this criterion was 43.
As is evident from the above discussion, the overall treatment regimens for
the two groups of children appear to have been virtually identical, except
for the inclusion of neurofeedback treatment in one of the groups. Because
the groups did not differ in systematic ways before treatment began, the
researchers could evaluate whether including neurofeedback training made any
appreciable difference in the children’s outcomes.
Results
A comprehensive set of treatment outcome measures was collected on each
child one year after treatment had begun. These measures included: 1)
parent and teacher ratings of inattentive and hyperactive/impulsive behavior
using the Attention Deficit Disorder Evaluation Scale (ADDES), a widely used
standardized behavior rating scale; 2) the children’s scores on the TOVA; and
3) the children’s Attention Index score, based on a QEEG scan. Each
measure was collected twice: once when participants were still on medication
and a second time after they had been off medication for an entire week.
The authors predicted that children in both groups would show behavioral
improvements and “normalized” TOVA results when medication treatment was
still in place, and would not differ from each other in terms of overall
results. They also predicted that the improvements for the
neurofeedback group would be significantly better upon the second outcome
assessment, when the children were no longer receiving medication.
(This prediction was based on prior research suggesting that neurofeedback training
can yield sustained reductions in ADHD symptoms while medication-induced
improvements typically last only as long as the child is on
medication.) Finally, researchers expected that only children who
received neurofeedback would show normalized Attention Index scores on the
QEEG.
Outcomes when Children were still on
Medication
As predicted, TOVA scores at the first outcome assessment were well
within the normal range for both groups. In contrast to expectations,
parent and teacher ratings of ADHD symptoms remained in the clinical range
for children who had not received neurofeedback. For participants whose
treatment included neurofeedback, however, parent and teacher ratings of ADHD
symptoms were all in the normal range and were significantly better than
ratings for the other participants. These results are shown below.
(Note: Scores below 7 are considered to indicate significant
difficulty. The numbers reported represent the average score for each
group.)
No neurofeedback Neurofeedback included
Parent inattention
4.63
8.59
Parent hyperactivity
6.06
8.65
Teacher inattention
4.96
9.35
Teacher hyperactivity
5.96
9.63
Similar results were obtained on the outcome measures taken after the
children had been without medication for an entire week. As before,
children whose treatment had not included neurofeedback continued to show
significant ADHD symptoms according to parent and teacher ratings. In
addition, the TOVA results for these participants fell in the clinical range
on 3 of the 4 subscales.
In contrast, parent and teacher ratings of the neurofeedback group all
remained within the normal range, as did their TOVA results.
Furthermore, the QEEG scan showed that the average Attention Index score for
the neurofeedback group was also within the normal range, indicating that the
cortical slowing characteristic of ADHD that was present at the beginning of
treatment was no longer evident. As expected, the average Attention
Index scores for participants not receiving neurofeedback continued to
indicate
significant cortical slowing.
Summary and Implications
These results provide compelling evidence that incorporating
neurofeedback into a comprehensive treatment approach for ADHD can yield
important benefits. As discussed above, only the participants whose
treatment included attention training via neurofeedback showed behavioral
improvement upon follow up, and these benefits were evident even after
medication was discontinued. These children were doing substantially better according
to both parents and teachers than participants who had not received
neurofeedback. In addition, the pattern of cortical slowing that is
found in many individuals with ADHD, and which is specifically targeted by
neurofeedback, was no longer evident. This suggests that the gains
associated with neurofeedback training cannot be attributed to the placebo
effect, but instead reflect meaningful changes in EEG activity.
This is a very impressive set of findings. As with any study, however,
it is important to recognize its inherent limitations. First, it is
surprising that no significant gains in parent and teacher ratings were
obtained for the non-neurofeedback group, even when medication treatment was
still in place. Recently published results from the MTA study document
substantial benefits from medication treatment alone, and in combination with
behavioral interventions, over a 14-month period. Based on these
results, as well as results from other studies, improved symptom ratings from
parents and teachers would have been anticipated. Because the same
treatments were delivered to participants who also received neurofeedback,
this does not call into question the incremental gains associated with
neurofeedback. However, it does raise the question of whether such
incremental gains would have been detected if the benefits provided by the
other intervention components were as expected.
Several other cautions need to be noted. Because random assignment to
treatment conditions was not feasible, one cannot rule out the possibility
that parents who opted to include neurofeedback in their child’s treatment
were a more highly motivated group of parents, and this is why their children
did better. After all, this was a time-consuming and expensive
addition. The fact that there was no differential attendance in parent
counseling sessions between the two groups mitigates these concerns,
however. In addition, the EEG changes revealed by the QEEG scan make it
unlikely that enhanced parent motivation alone could explain the differential
treatment results. This is because these better results were associated
with documented changes in neurophysiological processes known to be
associated with ADHD, and it seems implausible that parents’ motivation, or
other extraneous factors , could have produced such changes.
Finally, it is important to emphasize that neurofeedback was delivered as
part of a comprehensive treatment plan that included three other components.
There is thus no basis for determining whether neurofeedback alone would have
yielded positive results. And, although gains were sustained beyond the
active use of medication, it is unclear whether these gains would persist
without ongoing intervention. These issues would be important to
address in subsequent research.
These cautions notwithstanding, this is an important study that makes a significant
contribution to establishing a clear place for attention training using
neurofeedback in the treatment of ADHD. One hopes that subsequent
studies building on this impressive piece of work, and which incorporate
important controls such as random assignment that were not possible in this
investigation, will soon be forthcoming.
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