Meta-Analysis: Can Neurofeedback Effectively Treat ADHD?
“Should my family consider neurofeedback therapy for ADHD symptoms?” It’s a question many clinicians are asked. Studies are encouraging, but not conclusive. Here’s what professionals — and patients — need to know.
What Is Neurofeedback Treatment?
Neurofeedback training is an alternative therapy that uses real-time EEG data to help patients train their brains to improve focus, impulse control, and executive function.
Since the 1970s, patients with ADHD and other neurological disorders have used neurofeedback in hopes of training their brains. According to proponents, the demonstrated benefits are twofold:
- Brainwave alterations are measurable and appear to endure well beyond the therapy’s end.
- Brainwave improvements may lead to behavior improvements — most notably, sustained focus, diminished impulsivity, and reduced distractibility beyond the study environment.
The Science of Neurofeedback
Neurofeedback traces its roots to neuroplasticity — the concept that the brain is malleable and that with frequent, intense practice, patients may transform their brainwave activity. Over time, neurofeedback aims to help patients increase the ratio of high-frequency brain waves, leading to stronger attention and self-control.
Many ADHD brains generate an abundance of low-frequency delta or theta brain waves, and a shortage of high-frequency beta brain waves. Over 20 to 40 training sessions, neurofeedback works to reverse that ratio. The end goal is an activated, engaged brain, and an overall reduction in ADHD symptoms.
More specifically, neurofeedback therapy works to increase the brain’s capacity and predisposition for beta waves, which are associated with efficient information processing and problem solving. In contrast, when a high proportion of theta waves are present, patients complain of incomplete work, disorganization, and distractibility. Neurofeedback aims to diminish the frequency of delta and theta waves.
How Neurofeedback Works
Neurofeedback is a distinct type of biofeedback. Biofeedback is the process of learning how to change your own physiological activity using real-time monitoring of biological data like breathing rates, muscle activity, and heart function.
In neurofeedback training sessions, practitioners monitor a patient’s brain waves using scalp sensors. These sensors measure the brain’s activity and relay it so that the therapist and patient can see exactly when and how brain waves reach an optimal level. The participants work with the therapist to recognize when the brain is operating in its optimal zone then repeat and consciously sustain the behaviors that lead to this ideal brain state until they become second nature.
Each traditional neurofeedback therapy session lasts no more than 30 minutes, ideally. Many therapists use a baseline assessment of the patient’s natural brain wave patterns, and standard ADHD rating scales to continually reassess if neurofeedback sessions are creating improvements, then adjust treatment going forward.
Representative Neurofeedback Studies
The first studies and case reports on the efficacy of neurofeedback began to appear in 1976. Since then, dozens of studies with increasingly stronger research methodology have been published. Here is a summary of notable conclusions:
- Monastra, et al. (2002): 100 six- to 19-year-olds with ADHD were treated for one year with a combination of Ritalin, behavior therapy, and school accommodations. Half of parents also opted to include neurofeedback in the treatment plan. The youth receiving neurofeedback did better than did the other subjects on parent and teacher reports, and computerized attention tests. EEG scans showed that their brainwaves had normalized. After discontinuing medication, only the patients who received neurofeedback saw persistent results. This study is criticized because its participants were not randomly assigned to treatment groups.
- Levesque, et al. (2006): 20 eight- to 12-year-old children with ADHD were randomly assigned to receive 40 weekly neurofeedback treatment sessions, or to a waitlist control condition with no treatment. At the end of 40 weeks, the children who had received neurofeedback showed noteworthy improvement, as captured by parent ratings and laboratory measures. fMRI scans showed significant change in brainwave patterns for the treated children, but no change for control children. This study was limited by its small sample size.
- Gevensleben, et al. (2009): 102 eight- to 12-year-olds with ADHD were randomly chosen to receive neurofeedback or computerized attention training. Both groups received 36 active treatment sessions over 18 weeks. Researchers tried to keep parents and teachers from knowing which treatment the children received. This study sought to remedy shortcomings of previous research with a randomized control group, along with a larger sample size. At the end of the study, the children in the neurofeedback group showed 0.6 greater reductions in parent and teacher ratings of ADHD symptoms when compared to the computer-training group. Six months later, the differences remained, and parents of the children treated with neurofeedback reported fewer homework difficulties.
- Meisel et al. (2013): 23 seven- to 14-year-olds were randomly assigned treatment with methylphenidate or 40 neurofeedback sessions. Both groups showed significant and equivalent reductions in parent and teacher ratings of ADHD symptoms immediately after training ended, two months afterward — and the improvements persisted through a six-month follow-up. Teachers reported significant academic improvements in reading and writing skills for only the neurofeedback group, but it is not clear if teachers were blind to which group received which treatment.
Enough neurofeedback studies exist to complete meta-analyses of the data, which helps create a more reliable estimate of its impact in treating ADHD.
In 2012, researchers studied 14 randomized trials and calculated the following effect sizes for neurofeedback training: a 0.8 reduction in inattention and 0.7 reduction in hyperactivity for participants with ADHD. These are considered fairly robust results, though not as high as the approximate effect size of 1.0 that is typically associated with stimulant medications.
In 2016, researchers analyzed 13 randomized, controlled trials – some of which overlapped with the 2012 analysis – to determine how ratings varied between parents and teachers who probably knew which treatment the child was receiving and those who were blind. They concluded that raters who were not blind reported greater reduction in ADHD symptoms than did raters who were unaware of which patient received which treatment.
A Promising Complementary Therapy
Though most studies are not fully blind, the body of research cited above suggests that neurofeedback is a promising therapy for ADHD, but it should be considered a complement to medication and/or behavior therapy rather than a standalone treatment.
Existing research does suggest that neurofeedback can result in improved attention, diminished hyperactivity, and enhanced executive functions, including working memory, for some patients. However, some of the most important researchers in the ADHD field would argue that the efficacy of neurofeedback for ADHD has not been conclusively established. The bottom line is that research support for both simulant medication therapy and behavior therapy is stronger than it is for neurofeedback at the moment.
David Rabiner, Ph.D., and Ed Hamlin, Ph.D., are members of the ADDitude ADHD Specialist Panel.