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The Role of Neurofeedback in the Treatment of ADHD

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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. (You can review the article on alternative treatments here.)

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. For more information on this procedure, click here.)


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.


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"Dr. David Rabiner is a clinical child psychologist and Director of Undergraduate Studies in the Dept. of Psychology and Neuroscience at Duke University. Since 1997, he has written Attention Research Update, an online newsletter that helps parents, professionals, and educators keep (more...)
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