Running head: NEUROFEEDBACK AND PEDIATRIC ADHD 1

Evidence Synthesis: Neurofeedback and Pediatric ADHD

Based on Fieldwork at Bilingual Behavior Services
Hayley J. Meredith and Joshua M. Hensley
Touro University Nevada






















NEUROFEEDBACK AND PEDIATRIC ADHD 2

Background
Currently, the most successful and widely used treatment for attention deficit
hyperactivity disorder (ADHD) is catecholaminergic stimulant medication (Lofthouse, Arnold,
Hersch, Hurt, & DeBeus, 2012). Unfortunately, a problem with pharmacotherapy is that an
unknown amount of families refuse to try the approved medications, even though some of their
children might benefit. Parents and families may be resistant to medicating their children
because of the negative publicity surrounding FDA-approved drugs and their boxed warning
about cardiovascular effects. Another established treatment for ADHD is behavioral treatment,
which is less effective than well-managed medication, but can sometimes help those who cannot
tolerate, fail to respond to, or refuse to try stimulants or other medications (Lofthouse et al.,
2012). However, the carefully crafted combination treatment is not available in most
communities. Overall, almost a third of children with ADHD do not fully benefit from
established treatments and other families will not even consider medication, the most effective
standard treatment. Therefore, additional complementary and/or alternative interventions are
critically needed.
Neurofeedback (NF), formerly called electroencephalographic biofeedback, focuses on
training of the brains electrical activity through biofeedback techniques and implementing these
skills in daily-life situations (Gevensleben et al., 2009). NF is thought to work through classical
or operant conditioning mechanisms of learning that train the brain to improve its self-regulation
by providing it with real-time video, audio, and tactile information about its electrical activity
measured from electrodes placed on the surface of the head.
Two training protocols are typically used with children with ADHD, training of slow
sensorimotor cortex potentials (SCPs) and theta/beta training. A training of SCPs is related to
NEUROFEEDBACK AND PEDIATRIC ADHD 3

phasic regulation of cortical excitability. Negative SCPs reflect increased excitation and occur
during states of behavioral or cognitive preparation. While positive SCPs indicate reduction of
cortical excitation of the underlying neural networks and appears during behavioral inhibition
(Gevensleben et al., 2009).
In 1976, Lubar and Shouse became the first to report on EEG and behavioral changes in a
hyperkinetic child following theta and beta NF (Lofthouse et al., 2012). The researchers targeted
the reduction of theta waves associated with an inattentive state and increased beta waves
associated with an attentive state. Higher beta frequencies are now associated with focusing on a
task or other situation requiring attention. The goal is to decrease theta frequencies and increase
beta frequencies of the EEG which parallels the childs alert and focused but relaxed state
(Gevensleben et al., 2009). Since the turn of the 21
st
century there has been a significant increase
in the clinical application of NF to several psychiatric and medical conditions and, to a lesser
extent the number of published research and dissertation studies.
Purpose & Hypothesis
Our research question was, Is neurofeedback a viable intervention for treating pediatric
ADHD? The title of the quantitative article we chose to review, Is neurofeedback an
efficacious treatment for ADHD? A randomised controlled clinical trial written by Gevensleben
et al. (2009), is self-explanatory in that it too is focused on determining if NF is an effective
treatment intervention for our desired population.
The effects of NF training for children with ADHD were evaluated in comparison to a
computerized attention skills training aiming to provide further information about the efficacy of
NF. Compared to other studies conducted, these researchers controlled for nonspecific effects,
like the fact that training is an attention-demanding task, and confounding variables such as
NEUROFEEDBACK AND PEDIATRIC ADHD 4

parental engagement. The control treatment was designed to parallel the NF treatment as closely
as possible with respect to unspecific factors, using larger sample sizes and a randomized group
assignment. The researchers hypothesized that improvements in the NF group would exceed the
training effects in the control group with respect to all ADHD symptom domains. They expected
comparable global effects for the two NF training protocols but were also interested to know
whether a distinct pattern may occur at the symptom level.
Participants and Study Design
This randomized control study is of the highest level of evidence, or level one. The
sample size was sufficient, and was calculated by the researchers to be large enough to ensure
sufficient statistical power to reveal at least moderate treatment effects. The researchers initially
accounted for the potential of a 5% drop-out rate with a sample size of over 100 participants.
From the 102 children with ADHD who were initially assessed and randomly assigned to a
training group, eight children had to be excluded. Five were excluded from the NF group and
three from the AST group. Three dropped out due to immediate need for medical treatment, two
because of organizational problems of the parents, one for loss of motivation, and two for
protocol violation. Consequently, 94 children were included in the analysis.
The participants consisted of patients that attended participating outpatient clinics and
had no urgent need for medication. The outpatient clinics were informed of the study. Parents
were then informed by local health professionals and applied to take part. The subjects were
randomly assigned to groups by the administering psychologist and were either placed in the
control group; assisted skills training (AST), or were placed in the NF group. The neurofeedback
group included 59 participants and the assisted skills training group consisted of 35 participants.
The demographics of the 59 that were in the neurofeedback group included 51 boys and 8
NEUROFEEDBACK AND PEDIATRIC ADHD 5

girls aged 9-11 years. This groups IQs ranged from 93-119. Of the 59, 39 were diagnosed with
the combined type (inattentive and hyperactive) and 20 were of the inattentive type. Only 5 of
the 59 were taking medication at time of study. The study also listed their associated disorders
that coincided with ADHD and these included conduct disorder (10), emotional disorder (3), tic
disorder (3), and dyslexia (12).
Of the 35 that were placed in the control group or AST 26 were male and 9 were female
and the age of this group spanned from 9 years to 10.5 years. 27 of the 35 were diagnosed as
having the combined type and 8 were of the inattentive type and just 2 were reported as being
medicated. The associated disorders included conduct disorder (7), emotional disorder (3), and
dyslexia (10).
Control Group
Researchers chose AST as a control condition, with both trainings being conceived as
similarly as possible by participants and families. Both training programs were designed as
similarly as possible concerning the setting and the demands placed upon the participants.
Treatment of both groups entailed computer-game-like tasks that demanded attention,
development of strategies for focusing ones attention and practicing of acquired strategies at
home and in school.
The training programs were administered by the same clinical psychologists with the
support of a student assistant who were instructed to take a neutral attitude concerning the effects
of the individual training programs. The children and their parents were blind to group
assignment. Subjects were randomly assigned to the groups by the administering psychologist.
Both treatments were introduced to the parents and children as experimental, but promising
treatment modules for ADHD. Parents were explicitly not informed about the treatment
NEUROFEEDBACK AND PEDIATRIC ADHD 6

condition of their child and, as a rule, did not enter the room during treatment.
Measures Used
The measures or assessments utilized in this study consisted of parent and teacher ratings.
These measures were conducted at three different stages of the study: pre-training, intermediate
(middle of training), and post-training. Measures included five different assessments or ratings
and were completed by the parents of the participating children. Three of which were completed
by the participants respective teachers and all five were completed by the parents. The five
measurements or assessments used included the FBB-HKS (a German ADHD rating scale), a
German Rating Scale for Oppositional Defiant/Conduct disorders (FBB-SSV), the Strength and
Difficulties Questionnaire (SDQ), the Home Situations Questionnaire (HSQD), and the
Homework Problem Checklist (HPC-D). The HSQ-D and HPC-D were solely completed by the
parents.
The reliability and validity of the six outcome measures used for this study were not
discussed. The FBB-HKS was the primary outcome measure used, and is a 20-item
questionnaire, completed by teachers and parents, related to DSM-IV and ICD-10 criteria for
ADHD and hyperkinetic disorders. The FBB-HKS total score of the parents constituted the
primary outcome measure of the study.
Interventions
Two different types of interventions were utilized in order to treat the symptoms of
ADHD. These included NF and AST. Assisted skills training was used as a control group. This
intervention was based on Skillies, an award winning German learning software program that
provides visual and auditory perception exercises that are meant to increase vigilance, sustained
attention, and reactivity. The neurofeedback intervention is a system that uses electrodes to
NEUROFEEDBACK AND PEDIATRIC ADHD 7

monitor the electrical activity of the brain. The electrodes are placed directly on the participants
skulls in order to read and modulate theta and beta waves specifically.
Statistical Analysis
One sided t-tests were applied in order to analyze the training effects for the between
group comparisons (NF vs AST). Change scores (post training scores minus pre-training scores)
for both the parent and teacher ratings were used as the primary outcome measure in which a
standard t-test and a one-tailed analysis were performed. Two sided t-tests were also performed
whereby the pre-training measures of the NF group versus the pre-training measures of the AST
group were compared using evaluations of the treatments completed by the parents (placebo
scales).
Findings
Behavior ratings by both parents and teachers were significant and supported a
superiority of the neurofeedback training in decreasing symptoms of ADHD as compared to
AST. The results of the FBB-SSV, the SDQ, the HSQ, and HPC indicated that not only does
neurofeedback have positive effects with ADHD, but also affected accompanying problems of
social adaptation. 52% responded positively of the 59 in the NF group as opposed to the control
group (AST) which saw just 29% respondance. These results indicate that neurofeedback is a
viable treatment option for parents who do not want their kids to be put on medication and or for
those who may not respond well to medication.
These results supported the hypothesis in that the neurofeedback group saw greater
improvements in ADHD symptoms as compared to the placebo (AST) group. Although AST has
been shown to also have profound benefits in children with ADHD, neurofeedback outperformed
AST in this study. Thusly, neurofeedback is a more viable treatment option and can be especially
NEUROFEEDBACK AND PEDIATRIC ADHD 8

beneficial in cases where medication may not be appropriate.
Findings in Relation to Previous Research
The findings support previous research that has been done on neurofeedback in that its
use as an intervention tool has positive effects on the symptoms associated with ADHD.
However, this was the first randomized controlled trial on neurofeedback in children with ADHD
that has indicated clinical efficacy with sufficient statistical power.
Clinical Implications
Behavior ratings by parents and teachers revealed an advantage of the NF training in
decreasing ADHD symptomatology. These ratings indicate that NF effects are substantial and of
practical importance. The results confirm findings of previous NF studies even under strict
control conditions. Positive effects do not appear to be restricted to core ADHD symptoms, but
also affected accompanying problems of social adaptation.
Strengths, Limitations and Weaknesses
This study posed three major strengths. One, this was the first randomized controlled trial
on NF in children with ADHD indicating clinical efficacy with sufficient statistical power.
Second, populations of participating individuals were clearly identified. All patients fulfilled
DSM-IV criteria for ADHD and Children with comorbid disorders other than conduct disorder,
emotional disorders, tic disorder and dyslexia were excluded from the study. Third, the
researchers included two NT protocols, theta beta training and SCP training, into the NT training
group treatment program.
In order to avoid confounding variables, the researchers withheld from some basal
elements to enhance effectiveness, such as combination treatment with cognitive learning
strategies and involvement of parents and teachers. Due to these restrictions of the training
NEUROFEEDBACK AND PEDIATRIC ADHD 9

setting, it may not be appropriate to indirectly compare the efficacy of NF based on these results
with RCTs of other treatment approaches, and is therefore a limitation to the study.
Due to these limitations, three weaknesses of the study can be exposed. One, several
participants appeared unable to distinguish the regulation and transfer strategies of the SCP vs.
the theta/beta protocol, but that information was not assessed systematically. Two, dup to the
non-blind design it is possible that additional factors not considered in the study could have
affected the results. Finally, the expectations, comprehension and effort may have been different
between the children of the two groups, even though both trainings were paralleled.
Implications for Future Research
The researchers state that clinical, psychosocial factors as well as neuropsychological and
physiological parameters should be investigated as they may predict the outcome of NF training.
Thus, it could be possible to establish criteria that indicate which cases NF could be beneficial as
well as identify factors that require attention during training. Further studies are needed not only
to replicate the findings, but also to control for factors not covered in this study. Further
isolation of specific effects of NF and how to optimize NF training, and taking the long-term
outcome should be taken into account. Further research should show how to combine NF
optimally with the addition of cognitive behavioral and social intervention strategies, parental
counseling, and medication within the framework of a multimodal treatment setting. Overall,
future studies should further address the specificity of effects and how to optimize the benefit of
NF as treatment for ADHD.
Conclusion
As a therapist I would consider NF for my pediatric clients with ADHD based on the
results of this article. The single-blind design of the study eliminated subjective bias like the
NEUROFEEDBACK AND PEDIATRIC ADHD 10

placebo effect, from the results. I would use NF as a complementary or alternative intervention
based on the needs of the individual.
This article does not directly support participation in occupation and the field of
occupational therapy. However, it recognizes the need for alternatives to pharmacotherapy in
treating children with ADHD. NF is an intervention that focuses on training by means of
biofeedback techniques and implementing these skills in daily-life situations, as well as helping
the child to reach their optimal level of arousal and thusly enabling the child to focus on tasks
that require attention. These are similar approaches and concepts used in occupational therapy,
and so it would be realistic for occupational therapists to practice NF treatment.
























NEUROFEEDBACK AND PEDIATRIC ADHD 11

References

Gevensleben, H., Holl, B., Albrecht, B., Vogel, C., Schlamp, D., Kratz, O., Studer, P.,
Rothenberger, A., Moll, G.H., Heinrich, H. (2009). Is neurofeedback an efficacious
treatment for ADHD? A randomised controlled clinical trial. Journal of Child Psychology
& Psychiatry, 50(7), 780789.

Lofthouse, N., Arnold, L. E., Hersch, S., Hurt, E., & DeBeus, R. (2012). A Review of
Neurofeedback
Treatment for Pediatric ADHD. Journal of Attention Disorders,16(5), 351-372. Retrieved
February 11, 2014, from http://jad.sagepub.com/content/16/5/351