What is neurofeedback?
Due to increasing coverage in major publications like Discover, Time and Newsweek, neurofeedback has become a popular, albeit controversial, intervention used for the treatment of AD/HD. Scientists have known for many years that the brain emits various brain waves that are indicatives of the electrical activity of the brain. Different types of brain waves are emitted depending on whether the person is in a focused and attentive state or a drowsy/daydream state. Neurofeedback allows a person to view these brain waves on a computer screen as they occur. By teaching a person to produce the brain waves patterns associated with a relaxed, alert and focused state, and then practicing this skill for many hours, neurofeedback practitioners believe that individuals with AD/HD can learn to maintain this state. As a result, many symptoms of AD/HD will diminish. However, many scientists do not believe that such claims have been sufficiently documented.

How is neurofeedback training conducted?
A typical clinical session of neurofeedback training for a child with Ad/HD involves pasting electrodes (sensors that pick up the electrical activity of the brain) to the head with a conductive gel. This is a completely painless process. Wires from this electrodes are connected to a device that amplifies the small signal from the electrodes. The child sits in a comfortable chair and watches a computer monitor. The monitor displays a picture, such as a moving graph, that indicates the degree to which the child is producing the desired pattern of brainwave activity. The goal is for the child to learn to produce the type of brain wave activity associated with a focused and attentive state.

Over the course of numerous training sessions, it may gradually become easier for the child to achieve and maintain this state for longer periods of time. Supporters of  neurofeedback often describe this training as an exercise program for the brain. The training continues until the child is able to consistently achieve and maintain a pattern that shows a relaxed and attentive state. This training typically requires 40 to 60 sessions, with sessions ranging from $40 to $120. By the conclusion of treatment, neurofeedback advocates believe that increases in attention and reductions in impulsivity evident during training will transfer to important areas of the child’s life (e.g., home and school). There are several published studies discussed in this article that are consistent with this position. Critics of neurofeedback however, do not believe there is credible evidence to indicate that such a transfer occurs.

A Brief History of Neurofeedback
As early as the 1970s, neurofeedback was used as an experimental treatment for neurological conditions such as epilepsy. When clients were taught to relax and produce site-specific brain wave activity, they reduced the frequency of the seizures (Sterman et al., 1974). In subsequent research, scientists reported that neurofeedback could help reduce the symptoms associated with AD/HD (Lubar & Shouse, 1976). Later, the National Aeronautics and Space Administration (NASA) began to investigate whether attention training using neurofeedback could help to prevent accidents among astronauts and pilots during flight. This led NASA scientist to develop a new application of neurofeedback training technology where children’s ability to maintain a desired EEG state was linked to their ability to control video games. This approach to neurofeedback treatment has gradually become more widespread.

As promising reports of neurofeedback treatment emerged, it moved from an experimental technique with preliminary research support to a treatment provided to a growing number of children. Many scientists who research AD/HD expressed concern that neurofeedback was an expensive and unproven treatment that could dissuade parents from selecting other treatments that are supported by greater empirical support evidence (i.e., stimulant medication and behavior therapy). These scientists argued that the efficacy of neurofeedback had not been conclusively demonstrated through carefully controlled clinical trials, and that parents should be extremely cautions about selecting this treatment.

The Current State of the Evidence for Neurofeedback Treatment
The debate about the value of neurofeedback treatment for AD/HD has continued for the past several decades. Advocates point to a number of published studies that support numerous anecdotal reports from parents and clinicians about the utility of this approach. Critics argue that all these studies have significant limitations that prohibit making any firm conclusion about the effectiveness of neurofeedback treatment. A review of two recently published studies may help clarify why these strongly opposing views continue to be held with such conviction.

In the first study (Monastra et al., 2001), 101 children and adolescents with AD/HD received multimodal treatment that included stimulation medication, behavioral therapy and school consultation services. Fifty-one of these participants also received neurofeedback because their parents decided to include it in their children’s overall treatment plan. Participants in each group (multimodal treatment vs. multimodal treatment plus neurofeedback) did not differ in the severity of symptoms before treatment began, and the treatment provided differed only by whether it included neurofeedback. Twelve months later, according to parent and teacher behavior ratings, participants whose treatment included neurofeedback showed greater improvement and no longer demonstrated the brain wave patterns that were substantially different from children without AD/HD. These gains remained evident a week after medication was discontinued and suggested that adding neurofeedback to a multimodal treatment program was associated with important incremental benefits.

In a second study (Fuchs et al., 2003), parents of 34 children with AD/HD between the ages of 8 and 12, chose either stimulant medication or neurofeedback treatment for their children. The majority —the parents of 22 children— opted for neurofeedback treatment. After three months, children in both groups showed significant and comparable reductions in AD/HD symptoms according to parents and teachers. Laboratory tests of attention also showed equivalent improvement.

What conclusions can be drawn from these recent reports? Clearly, in both studies, children who received neurofeedback appeared to benefit from this treatment. These benefits were evident in reports from parents and teachers, as well as on laboratory measures of attention. Given the compelling nature of these results, which are consistent with results from other studies, why do many scientists continue to regard neurofeedback as an unproven and highly experimental treatment for AD/HD?

The reason of this skepticism is that although children in these studies appeared to improve, limitations in the researches’ methods made it impossible to know what was responsible for the improvement. An important limitation o both studies is that parents decided whether to use neurofeedback with their child, rather than this being determined by chance (i.e., random assignment). The absence of random assignment makes it impossible to rule out other factors the groups may have differed on besides whether they received neurofeedback as an explanation for the results obtained. This limitation is found in virtually all studies of neurofeedback.

Another limitation is the failure to control for the substantial extra attention the therapist provided to children who received neurofeedback treatment. It is possible that this extra attention —and not neurofeedback training— accounted for the children’s improvement. Although this may be unlikely given the intractability of AD/HD symptoms to adult attention and support alone, it cannot be conclusively ruled out as an explanation.

It is also important to note that neither study permitted any conclusion about whether providing children with “feedback” on their brain wave activity was a necessary treatment component. Perhaps focusing on various computer tasks several times each week over an extended period would help children develop their attention skills regardless of whether such feedback is provided. The experimental controls that would be necessary to determine this were not included in either study.

Finally, because children in these studies were not followed for any sustained time period after treatment ended, it is not known whether improvements associated with neurofeedback persisted beyond the end of training. Some neurofeedback proponents have claimed that unlike medication treatment, where benefits are typically not sustained after medication is stopped, improvements are sustained because the child has learned a new skill (e.g., the ability to produce and maintain a focused, attentive state). We are unaware, however, of studies in which this claim has been documented.

It is important to emphasize that the limitations discussed previously were unavoidable because these studies were conducted in regular treatment settings where parents paid for the services provided. In this context, assigning children to different treatments at random is not possible. Providing equivalent attention from a therapist to children whose parents did not choose neurofeedback —or the type of control necessary to establish that direct feedback on brain wave activity— is also impractical. The fact that these limitations could not be avoided, however, does not eliminate the problems created for interpreting the study results. Thus we believe that neurofeedback critics are correct to stress that the efficacy of this treatment has yet to be conclusively demonstrated according to accepted scientific standards.

On the other hand, it is also important to recognize that these studies reflect the context in which parents actually make treatment decisions for their child. That is, parents are aware of and are presented with different treatment options and must decide which to pursue. From this perspective, the promising results from these studies can be interpreted to suggest that when parents select neurofeedback treatment for their child, either alone or in combination with more conventional approaches, there is a reasonable chance they will find it to be helpful.

What next?
In many ways, the debate about neurofeedback that is evident today is no different from that was taking place 10 to 15 years ago. On the one hand, there is evidence that children with AD/HD who receive neurofeedback treatment obtain some benefits from the experience. On the other hand, for the reasons previously discussed, the efficacy of neurofeedback has not been conclusively demonstrated according to widely accepted scientific standards. As one critic recently pointed out, the evidence to date world not meet FDA standards for classifying neurofeedback as a medical intervention for AD/HD (Barkley, 2003). Uncertainty about the efficacy of neurofeedback will continue until large scale studies that include the necessary experimental controls are conducted.

Until such research becomes available, parents considering neurofeedback treatment for their children should be aware that despite the promising results reported, there are other interventions (e.g., medication treatment, behavior therapy and their combination) whose efficacy has been clearly demonstrated in a number of carefully controlled studies. For this reason, these are the interventions that are recommended in treatment guidelines recently published by the American Academy of Child and Adolescent Psychiatry (1997) and the American Academy of Pediatrics (2001).

One hopes that the research necessary to provide more definitive answers to important questions about neurofeedback treatment will soon be forthcoming so that parents can make informed decisions about this treatment. The issues about neurofeedback that are unresolved today may remain so far many years unless scientists begin to initiate the necessary studies.

David Rabiner, Ph.D., is a senior research scientist in the Center for Child and Family Policy at Duke University and a former member of CHADD’s Professional Advisory Board. He writes a free e-mail newsletter called “Attention Research Update” that is available at www.helpforadd.com

Olafur Palsson, Psy.D., is a clinical psychologist: He is an associate professor in the department of medicine at the University of North Carolina at Chapel Hill. Dr Palson conducts research on the relationship between mental activity and physical health. He has worked with scientists at NASA’s Langley Research Center for several years to develop new ways to train brain functioning to treat AD/HD and enhance the mental performance of pilots in the cockpit.

Peter Freer, M.S. ED., is the founder and CEO of Unique Logic + Technology, Inc., a leader in feedback-based attention training. Mr. Freer is a veteran teacher with extensive training in computer science and educational psychology. He is currently developing a hybrid feedback system combining NASA-based technology with the aforementioned patents.

Originally published in Attention! December 2003, 30-35, CHADD.
Reproduced thanks to Patricia Grady from the National Resource Center on AD/HD and to Petrina Chong-Hollingsworth, both from CHADD.

A Spanish translation of this article appeared in the newsletter nº 6 issued by the Asociación Peruana de Déficit de Atención (APDA), on December 11, 2004.

American Academy of Child and Adolescent Psychiatry (1997) «Practice parameters for the assessment and treatment of children, adolescents and adults with attention-deficit hyperactivity disorder». Journal of the American Academy of Child and Adolescent Psychiatry, 36, pp. 85S-121S.

American Academy of Pediatrics (2001) «Clinical practice guidelines. Treatment of the school- aged child with attention-deficit/hyperactivity disorder». Pediatrics, 108, pp. 1033-1044.

Barkley, R. A. (2003)  «Editorial commentary on EEG and neurofeedback findings in AD/HD». The AD/HD Report, 11, pp. 7-9.

Fuchs, T.,  Birbaumer N.,  Lutzenberger W.,  Gruzelier J. H. y  Kaiser J. (2003) «Neurofeedback treatment for AD/HD in children: A comparison with methylphenidate». Applied Psychophysiology and Biofeedback, 28, pp. 1-12.

Lubar, J. F. y  Shouse M. N. (1976) «EEG and behavioral changes in a hyperactive child concurrent with training of the sensorimotor rhythm (SMR). A preliminary report». Biofeedback and Self-Regulation, 1, pp. 293-306.

Monastra V. J., Monastra D. M.  y  George S. (2001) «The effects of stimulant therapy, EEG biofeedback and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder». Applied Psychophysiology and Biofeedback, 27, pp.231-249.

Monastra V. J.,  Lubar J. F. y  Linden M. (2001) «The development of a quantitative electroencephalographic scanning process for attention-deficit/hyperactivity disorder: Reliability and validity studies». Neuropsychology, 15, pp. 136-144.

Sterman, M. B.,  Macdonald L. R. y  Stone R. K. (1974) «Biofeedback training of the sensorimotor electroencephalogram rhythm in man: Effects on epilepsy». Epilepsia, 15, pp. 395-416.

Additional Resource
Loo, S. K. (2003) «EEG and neurofeedback findings in AD/HD». The AD/HD Report.