Study: fMRI Neurofeedback Appears Ineffective at Treating ADHD in Boys
fMRI neurofeedback did not improve ADHD symptoms in this study of boys. Future research is needed to expand on the study limitations presented in this large double-blind, sham-controlled randomized ADHD trial of the right inferior frontal cortex.
March 6, 2023
Neurofeedback may not be an effective tool for treating ADHD in boys, according to research published in the American Journal of Psychiatry that studied whether functional MRI neurofeedback (NF) was a safe and effective alternative to pharmacological treatment for ADHD. Cognitive and clinical symptoms of ADHD did not significantly improve in subject who received fMRI-NF in this double-blind, sham-controlled randomized, controlled trial. 1
Neurofeedback: Is It Effective?
The brain’s frontal cortex — responsible for attention, executive function, and organization — is impaired in people with ADHD. In this new trial, researchers studied the activation of the right inferior frontal cortex (rIFC) by neurofeedback training. Medication — a first-line treatment — activates or normalizes the IFC in many patients, but not all. 2 Side effects are also commonly reported.
“Functional MRI neurofeedback, which enables self-regulation of brain activation in specific regions or networks by providing feedback of brain activity in real time, could be a novel alternative to pharmacological treatment,” the researchers wrote.
Participants were asked to complete a series of 15 “runs” over multiple visits and four one-hour fMRI-NF scans. Each run presented a video of a rocketeer flying in space. Its speed and direction (up or down) represented brain activity and increased or decreased activation of the rIFC, respectively. Participants in the sham group were shown neurofeedback from the last active participant instead of their own.
Compared to the sham group, the active fMRI-NF group showed improved activation in the rIFC across all sessions. But contrary to the study’s hypothesis, researchers found no improvement in ADHD-RS scores — their primary outcome measure. In other words, parents did not report an improvement in ADHD symptoms among children receiving fMRI-NF.
Additionally, the sham group showed comparatively less irritability and motor inhibition in the post-treatment assessment. Among subjects receiving fMRI-NF, researchers observed neither “progressively increasing upregulation across sessions or runs, nor correlations between changes in rIFC activation and ADHD-RS scores, nor transfer of learning, indicating no progressive training effects.”
“The findings do not suggest that fMRI-NF of rIFC is an effective treatment for ADHD,” the researchers wrote.
Editorial research by ADDitude similarly found neurofeedback ineffective at addressing ADHD symptoms over time, as reported by parents. In a 2017 survey of 2,495 caregivers, less than one-third of those who had tried NF found it effective. They rated it less effective than exercise, medication, behavioral therapy, and ADHD coaching or counseling, but more effective than mindfulness meditation or nutrition changes, at addressing ADHD symptoms.
The cost of treatment was cited as a common reason for neurofeedback’s small adoption rate; 29% of caregivers said they had not tried non-medication ADHD treatment options because of price or lack of insurance coverage.
New Study Limitations
Researchers relied on clinical, cognitive, and fMRI measures during seven participant visits between 2018 and 2020. This included baseline assessments, fMRI interventions, post-treatment assessment, and six-month follow up. Researchers had no direct interaction with participants but were unblinded to administer treatment.
This double-blind study expanded on a single-blind, proof-of-concept study conducted in 2017, which was limited by small sample sizes and no control group. However, the new research was limited by an all-male participant group (between ages 10 to 18), the majority (approximately 65%) of whom were active medication users. The study was ended prematurely due to COVID lockdowns.
“Future studies should investigate whether fMRI-NF of alternative regions of interest or networks implicated in ADHD may be more effective in improving clinical and cognitive problems.”
The results are nonetheless effective in informing parents and clinicians of the most effective treatment options on the market for children with ADHD.
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1Lam, S. L., Criaud, M., Lukito, S., Westwood, S. J., Agbedjro, D., Kowalczyk, O. S., Curran, S., Barret, N., Abbott, C., Liang, H., Simonoff, E., Barker, G. J., Giampietro, V., & Rubia, K. (2022). Double-Blind, Sham-Controlled Randomized Trial Testing the Efficacy of fMRI Neurofeedback on Clinical and Cognitive Measures in Children With ADHD. The American journal of psychiatry, 179(12), 947–958. https://doi.org/10.1176/appi.ajp.21100999
2Rubia, K., Alegria, A. A., Cubillo, A. I., Smith, A. B., Brammer, M. J., & Radua, J. (2014). Effects of stimulants on brain function in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Biological psychiatry, 76(8), 616–628. https://doi.org/10.1016/j.biopsych.2013.10.016