School-Based Neurofeedback Training for ADHD
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March 23, 2020
Neurofeedback for Children and Adolescents with Attention Deficit Hyperactivity Disorder (ADHD)
Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects 5% of children and adolescents [1]. Core symptoms include poor attention, hyperactivity and impulsivity, typically reported by teachers and parents [2].
While concern has been raised about both the overdiagnosis and overmedication of ADHD, other data indicate that a significant amount of cases each year remain undiagnosed [3], with consequences on adult life that may include poor academic performance, addictive behavior, and problematic interpersonal relationships, resulting altogether in unbalanced overall functioning [4, 5].
Most commonly, children and adolescents diagnosed with ADHD starting from age 6 years onward are treated with methylphenidate [6] a psychostimulant medication, mainly with the goal of improving attention and decreasing impulsivity.
It has been pointed out, however, that psychostimulant treatment has, in many cases, only short-term effects and that, in some patients, is associated with little or no changes in core symptoms. Further, psychostimulant treatment can induce both short-term and long term adverse effects, including fatigue, nausea and loss of appetite (short term) [1, 7] as well as cardiovascular effects and suppression of growth (long term) [8, 9]. Fearing these adverse effects, many parents choose to leave their children unmedicated, even after a diagnosis has been made [10].
In the attempt of finding a solution to these shortcomings, Neurofeedback or electroencephalogram (EEG) biofeedback, has been subject of research for a number of years now.
In general, there is agreement that, in the anterior regions of the brain of ADHD subjects, EEG absolute theta power is increased and absolute beta power decreased [11, 12]. Neurofeedback protocols aimed at reducing brain activity in the theta frequency band while increasing activity in the beta frequency band (or to decrease the theta/beta ratio), have been shown to improve attention. Further, neurofeedback protocols targeting frequencies in the range of 12–15 Hz have been shown to address hyperkinetic behavior.
Several studies have investigated the efficacy of neurofeedback as compared to placebo in the treatment of ADHD. In general, these studies show large effect sizes for neurofeedback on impulsivity and inattention, and medium to low effect sizes on hyperactivity. These results have led to the conclusion that neurofeedback can be considered “Efficacious and Specific”.
What Works Better for the Treatment of ADHD? Psychostimulants or Neurofeedback?
While several randomized neurofeedback control trials have been published in ADHD, only a few studies have compared the effects of neurofeedback with those of stimulants [13].
A recent review by Razoki [12] examined eight randomized control trials with children or adolescents with ADHD where the efficacy of neurofeedback treatment, either alone or in combination with stimulant treatment, was compared with stimulant medication.
Interestingly, in two studies, medication dosage was reduced when neurofeedback training was combined with the administration of methylphenidate, suggesting that neurofeedback should be considered when treating low responders to single-drug administration or children who exhibit adverse effects associated with the administration of stimulants [14, 15].
Conclusions
Neurofeedback for the treatment of children and adolescents with ADHD should be considered:
1) complementary to treatment with stimulants, with protocols tailored to the needs of the subject;
2) a viable alternative to pharmacotherapy in patients exhibiting low responses and/or who display significant adverse effects to stimulant treatment.
References
- Arlington, American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 5th ed. 2013: American Psychiatric Publishing.
- Gadow, K.D., J. Sprafkin, and E.E. Nolan, DSM-IVSymptoms in community and clinic preschool children. J Am Acad Child Adolesc Psychiatry, 2001. 40(12): p. 1383-92.
- Jensen, P.S., Current concepts and controversies in the diagnosis and treatment of attention deficit hyperactivity disorder. Curr Psychiatry Rep, 2000. 2(2): p. 102-9.
- Arnold, L.E., et al., Long-Term Outcomes of ADHD: Academic Achievement and Performance. J Atten Disord, 2020. 24(1): p. 73-85.
- Shaw, M., et al., A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment. BMC Med, 2012. 10: p. 99.
- Subcommittee on Attention-Deficit/Hyperactivity, D., et al., ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 2011. 128(5): p. 1007-22.
- Clavenna, A. and M. Bonati, Safety of medicines used for ADHD in children: a review of published prospective clinical trials. Arch Dis Child, 2014. 99(9): p. 866-72.
- Reddy, D.S., Current pharmacotherapy of attention deficit hyperactivity disorder. Drugs Today (Barc), 2013. 49(10): p. 647-65.
- Swanson, J.M., et al., Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression. J Child Psychol Psychiatry, 2017. 58(6): p. 663-678.
- Kropotov, J.D., et al., ERPs correlates of EEG relative beta training in ADHD children. Int J Psychophysiol, 2005. 55(1): p. 23-34.
- Arns, M., C.K. Conners, and H.C. Kraemer, A decade of EEG Theta/Beta Ratio Research in ADHD: a meta-analysis. J Atten Disord, 2013. 17(5): p. 374-83.
- Lazzaro, I., et al., Quantified EEG activity in adolescent attention deficit hyperactivity disorder. Clin Electroencephalogr, 1998. 29(1): p. 37-42.
- Arns, M., et al., Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta-analysis. Clin EEG Neurosci, 2009. 40(3): p. 180-9.
- Duric, N.S., et al., Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports. BMC Psychiatry, 2012. 12: p. 107.
- Li, L., et al., A randomised controlled trial of combined EEG feedback and methylphenidate therapy for the treatment of ADHD. Swiss Med Wkly, 2013. 143: p. w13838.
