Neurofeedback typically involves computer-based exercises, which provide feedback regarding attention levels to enable behavioural training.1,2
Patients’ brain activities are measured by electroencephalogram (EEG) whilst performing a task, usually a computer game, in which patients receive points when their brain activity shows positive changes.1,3
This gives immediate feedback to patients on their level of attention during a task.2 Patients are then trained to monitor and change their brainwave patterns.2
Alterations in EEG activity patterns have previously been linked to behavioural problems
Children with ADHD have been shown to have increased EEG theta (4–7 Hz) and decreased EEG beta (13–30 Hz) activity compared with children without ADHD.1,2
Beta waves are associated with attention and thinking, whilst theta waves are associated with drowsiness or daydreaming.2 Sensorimotor rhythm (SMR) activity (13–15 Hz) is positively associated with motor inhibition.1
Most neurofeedback programmes aim to decrease EEG theta and increase EEG beta and SMR activity.1
Alternatively, neurofeedback training of slow cortical potentials (<0.1 Hz) aims to teach the patient to increase and decrease brain activity.1
Meta-analysis of 13 randomised controlled trials of neurofeedback in children and adolescents aged 3 to 18 years with ADHD showed that in most-proximal assessments, neurofeedback had a small to moderate significant effect on inattention (standardised mean difference [SMD] 0.36; p=0.009), impulsivity/hyperactivity (SMD 0.26; p=0.004) and total ADHD symptoms (SMD 0.35; p=0.004).4 However, in sensitivity analyses considering only trials with an active/sham control, effects were no longer significant for inattention and total ADHD symptoms, and in probably blinded assessments, there were no significant effects on symptoms of ADHD.4
In a randomised controlled trial of neurofeedback in adolescents with ADHD (n=71; aged 12–24 years), patients aimed to increase sensorimotor activity, while reducing theta, alpha and electromyographic activity.1 Stimulant medication was used by 44% of the neurofeedback group and 62% of the treatment-as-usual group at baseline.
- Neurofeedback training was carried out over a 25-week period (mean number of training sessions was 37, minimum number was 19).1
- Patients in the neurofeedback group were better able to suppress theta waves during the latter sessions (p=0.01).1
- Inattention and hyperactivity/impulsivity on the ADHD Rating Scale showed similar improvements in both treatment groups.1
- A larger percentage of patients in the neurofeedback group reported an improvement in attention compared with the treatment-as-usual group, as measured on the non-standardised behavioural questionnaire (38% vs 12%).1
Further evidence supporting the effectiveness of neurofeedback comes from a double-blind, randomised, controlled trial in which children aged 7–11 years with ADHD received 40 sessions of neurofeedback (n=34), cognitive training (n=34) or control conditions (n=36) over a 6-month period.2 At baseline, 49% of the participating children were taking medication for ADHD.2
During neurofeedback sessions, children practised computer-based activities intended to suppress theta brainwaves and increase beta brainwaves, ultimately allowing them to score points while learning how to improve attention.2
At a 6-month follow-up, children who received neurofeedback had significantly greater improvements in subscale scores for the Conners’ 3–Parent Assessment Report (inattention, hyperactivity/impulsivity and executive functioning subscales) from pre-intervention observations, compared with children who underwent cognitive training or control conditions (Figure).2
Figure: Effects of neurofeedback and cognitive training on ADHD symptoms in children (n=104) with ADHD. Figure developed using information from Steiner NJ et al. Pediatrics 2014; 133: 483-492.2
A similar system of neurofeedback has also been investigated in a smaller randomised, controlled trial, in which children aged 7–14 years with ADHD could receive 40 sessions of neurofeedback (n=14) or standard pharmacological intervention based on national guidelines (n=13).3 During neurofeedback sessions, children worked on computer games that required concentration to win, with visual and auditory reinforcement given when theta brainwaves were suppressed and beta brainwaves were increased. Both interventions were associated with some improvements in parent- and teacher-rated ADHD symptoms (Figure) and functional impairment, but improvements in academic performance were only observed with neurofeedback. With neurofeedback, some improvements persisted at 2- and 6-month follow-up assessments.3
Figure: Impact of neurofeedback and standard pharmacological treatment on total ADHD-RS scores (note that pharmacological treatment, but not neurofeedback, was continued during follow-up). Reproduced with kind permission from Meisel V et al. Biol Psychol 2013; 94: 12-21.3
- Bink M, van Nieuwenhuizen C, Popma A, et al. Behavioral effects of neurofeedback in adolescents with ADHD: a randomized controlled trial. Eur Child Adolesc Psychiatry 2015; 24: 1035-1048.
- Steiner NJ, Frenette EC, Rene KM, et al. In-school neurofeedback training for ADHD: sustained improvements from a randomized control trial. Pediatrics 2014; 133: 483-492.
- Meisel V, Servera M, Garcia-Banda G, et al. Neurofeedback and standard pharmacological intervention in ADHD: a randomized controlled trial with six-month follow-up. Biol Psychol 2013; 94: 12-21.
- Cortese S, Ferrin M, Brandeis D, et al. Neurofeedback for attention-deficit/hyperactivity disorder: meta-analysis of clinical and neuropsychological outcomes from randomized controlled trials. J Am Acad Child Adolesc Psychiatry 2016; 55: 444-455.