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ABSTRACT Since the first reports of neurofeedback treatment in Attention Deficit Hyperactivity Disorder (ADHD) in 1976, many studies have investigated the effects of neurofeedback on different symptoms of ADHD such as inattention, impulsivity and hyperactivity. This technique is also used by many practitioners, but the question as to the evidence-based level of this treatment is still unclear. In this study selected research on neurofeedback treatment for ADHD was collected and a meta-analysis was performed.

Both prospective controlled studies and studies employing a pre- and post-design found large effect sizes (ES) for neurofeedback on impulsivity and inattention and a medium ES for hyperactivity. Randomized studies demonstrated a lower ES for hyperactivity suggesting that hyperactivity is probably most sensitive to nonspecific treatment factors.

Due to the inclusion of some very recent and sound methodological studies in this meta-analysis, potential confounding factors such as small studies, lack of randomization in previous studies and a lack of adequate control groups have been addressed, and the clinical effects of neurofeedback in the treatment of ADHD can be regarded as clinically meaningful. Three randomized studies have employed a semi-active control group which can be regarded as a credible sham control providing an equal level of cognitive training and client-therapist interaction. Therefore, in line with the AAPB and ISNR guidelines for rating clinical efficacy, we conclude that neurofeedback treatment for ADHD can be considered “Efficacious and Specific” (Level 5) with a large ES for inattention and impulsivity and a medium ES for hyperactivity.

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Place of EEG Biofeedback for ADHD by Hirshberg LM Expert Review Neurotherapeutics, 7(4), 315-319 Although methodological weaknesses limited early research into electroencephalograpic (EEG) biofeedback (EBF) for treatment of attention-deficit/hyperacticity disorder (ADHD), recent stronger randomized controlled trials have provided substantial, but not yet conclusive, empirical support. Additional support is found in research on functional magnetic resonance imaging (fMRI) feedback and brain-computer interface (BCI) models which involve feedback-guided learning to achieve control over neural activation.

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EEG Biofeedback in the Treatment of Attention Deficit Hyperactivity Disorder (abs.) by Friel PN< Alternative Medicine Review, Volume 12, #2, June, 2007, pp146-151 Electroencephalogram (EEG) biofeedback, also known as neurofeedback, is a promising alternative treatment for patients with attention deficit/hyperactivity disorder (AD/HD). EEG biofeedback therapy rewards scalp EEG frequencies that are associated with relaxed attention, and suppresses frequencies associated with under- or over-arousal.

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Electroencephalographic Biofeedback in the Treatment of Attention-Deficit/Hyperactivity Disorder by Monastra VJ, Lynn S, Linden M, Lubar JF, Gruzelier J, LaVaque TJ Historically, pharmacological treatments for attention-deficit/hyperactivity disorder (ADHD) have been considered to be the only type of interventions effective for reducing the core symptoms of this condition. However, during the past three decades, a series of case and controlled group studies examining the effects of EEG biofeedback have reported improved attention and behavioral control, increased cortical activation on quantitative electroencephalographic examination, and gains on tests of intelligence and academic achievement in response to this type of treatment.

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Electroencephalographic Biofeedback (Neurotherapy) as a Treatment for Attention Deficit Hyperactivity Disorder: Rationale and Empirical Foundation (abs.) by Monastra VJ During the past three decades, electroencephalographic (EEG) biofeedback has emerged as a nonpharmacologic treatment for attention-deficit/hyperactivity disorder (ADHD). This intervention was derived from operant conditioning studies that demonstrated capacity for neurophysiologic training in humans and other mammals and targets atypical patterns of cortical activation that have been identified consistently in neuroimaging and quantitative EEG studies of patients diagnosed with ADHD.

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Treatment of Attention Deficit Hyperactivity Disorder with Neurotherapy (abs.) by Nash JK Significant public health concerns exist regarding our current level of success in treating ADHD. Medication management is very helpful in 60-70% of patients. Side effects, lack of compliance and the fact that stimulant medications cannot be given late in the day limit the benefits largely to school hours.

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Review of the Literature Regarding the Efficacy of Neurofeedback in the Treatment of Attention Deficit Hyperactivity Disorder by Lingenfelter JE The following is a review of the most recent literature regarding the efficacy of EEG Neurofeedback in the treatment of attention deficit hyperactivity disorders.

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Update on Attention-Deficit/Hyperactivity Disorder (abs.) by Campbell Daley K In her recent paper, Update on Attention-Deficit/Hyperactivity Disorder, published in Current Opinion in Pediatrics, Katie Campbell Daley reviewed the research and practice standards on treatment of ADHD.

Dr. Campbell is on the staff of the Department of Medicine, Children’s Hospital Boston and in the Department of Pediatrics of the Harvard Medical School. Her conclusion: “Overall, these findings support the use of multi-modal treatment, including medication, parent/school counseling, and EEG biofeedback, in the long term management of ADHD, with EEG biofeedback in particular providing a sustained effect even without stimulant treatment… Parents interested in non-psychopharmacologic treatment can pursue the use of complementary and alternative therapy. The therapy most promising by recent clinical trials appears to be EEG biofeedback.” read full text read full text

Research Papers

Comparisons of Neurofeedback with Stimulant Medication:

Neurofeedback Treatment for Attention Deficit/Hyperactivity Disorder in Children: A Comparison with Methylphenidate (abs.) Fuchs T, Birbaumer N, Lutzenberger W, Gruzelier J. H., & Kaiser J Clinical trials have suggested that neurofeedback may be efficient in treating attention-deficit/hyperactivity disorder (ADHD). We compared the effects of a 3-month electroencephalographic feedback program providing reinforcement contingent on the production of cortical sensorimotor rhythm (12-15 Hz) and betal activity (15-18 Hz) with stimulant medication.

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The Effectiveness of Neurofeedback and Stimulant Drugs in Treating AD/HD: Part I. Review of Methodological Issues (abs.) by Rossiter T.R. The paper examines major criticisms of AD/HD (Attention Deficit/Hyperactivity Disorder) neurofeedback research using T. R. Rossiter and T. J. La Vaque (1995) as an exemplar and discusses relevant aspects of research methodology.

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The Effectiveness of Neurofeedback and Stimulant Drugs in Treating AD/HD: Part II. Replication. (abs.) by Rossiter T.R. This study replicated T. R. Rossiter and T. J. La Vaque (1995) with a larger sample, expanded age range, and improved statistical analysis. Thirty-one ADIHD patients who chose stimulant drug (MED) treatment were matched with 31 patients who chose a neurofeedback (EEG) treatment program.

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A Comparison of EEG Biofeedback and Psychostimulants in Treating Attention Deficit/Hyperactivity Disorders by Rossiter TR and La Vaque TJ

The study compared treatment programs with EEG biofeedback or stimulants as their primary components. An EEG group (EEG) was matched with a stimulant group (MED) by age, IQ, gender and diagnosis. The Test of Variables of Attention (TOVA) was administered pre and post treatment. read full text  

The Effects of Stimulant Therapy, EEG Biofeedback, and Parenting Style on the Primary Symptoms of Attention-Deficit/Hyperactivity Disorder by Monastra VJ, Monastra DM, George S

One hundred children, ages 6-19, who were diagnosed with attention-deficit/hyperactivity disorder (ADHD), either inattentive or combined types, participated in a study examining the effects of Ritalin, EEG biofeedback, and parenting style on the primary symptoms of ADHD. read full abstract

Neurofeedback for ADHD using Slow Cortical Potentials:

Is Neurofeedback an Efficacious Treatment for ADHD? A Randomised Controlled Clinical Trial (abs.) by Gevensleben H, Holl B, Albrecht B, Vogel C, Schlamp D, Kratz O, Studer P, Rothenberger A, Moll GH, Heinrich H

For children with attention deficit/hyperactivity disorder (ADHD), a reduction of inattention, impulsivity and hyperactivity by neurofeedback (NF) has been reported in several studies. But so far, unspecific training effects have not been adequately controlled for and/or studies do not provide sufficient statistical power. To overcome these methodological shortcomings we evaluated the clinical efficacy of neurofeedback in children with ADHD in a multisite randomised controlled study using a computerised attention skills training as a control condition. read full text  

Annotation: Neurofeedback – Train Your Brain to Train Behaviour (abs.) by Heinrich H, Gevensleben H, Strehl U

Neurofeedback (NF) is a form of behavioural training aimed at developing skills for self-regulation of brain activity. Within the past decade, several NF studies have been published that tend to overcome the methodological shortcomings of earlier studies. This annotation describes the methodical basis of NF and reviews the evidence base for its clinical efficacy and effectiveness in neuropsychiatric disorders. read full text  

Neurofeedback for Children with ADHD: A Comparison of SCP with Theta/Beta Protocols (abs.) by Leins U, Goth G, Hinterberger T, Klinger C, Rumpf N, Strehl U

This study fills a niche in the research to date in that it compares two neurofeedback techniques that rely on very different challenges to the brain. The capacity for learned self-regulation was demonstrated once again with both techniques. Significantly, there was no difference between them in terms of cognitive and behavioral outcomes. Measured improvement in IQ was both statistically and clinically significant. Results held up over a six-month follow-up period. read full text  

Controlled Evaluation of a Neurofeedback Training of Slow Cortical Potentials in Children with Attention Deficit/Hyperactivity Disorder (ADHD) by Drechsler R, Straub M, Doehnert M, Heinrich H, Steinhausen H, Brandeis D

To evaluate the specificity of a neurofeedback training of slow cortical potentials, a twofold strategy was pursued: First, the efficacy of neurofeedback training was compared to a group training program for children with ADHD. Secondly, the extent of improvements observed in the neurofeedback group in relation to successful regulation of cortical activation was examined. Parents and teachers rated children’s behaviour and executive functions before and after treatment. In addition, children underwent neuropsychological testing before and after training. read abstract text read full text (pdf file)  

Biofeedback Produced Slow Brain Potentials and Task Performance by Lutzenberger W, Elbert T, Rockstroh B, Birbaumer N

Twenty subjects learned to control slow potential (SP) shifts of the brain by means of a biofeedback procedure. Depending upon the pitch of a signal tone, negative SP shifts had to be increased or reduced during intervals of 6 sec each. read full text  

Operant Conditioning of Left-Hemispheric Slow Cortical Potentials and Its Effect on Word Processing by Pulvermüller F, Mohr B, Schleichert H, Veit R

This study investigated whether language-related cognitive processes can be modified by learned modulation of cortical activity. read full text read full text

Foundational Studies on Neurofeedback for ADHD::

Attention Deficit Hyperactivity, Disorder: Neurological Basis and Treatment Alternatives by Barabasz A and Barabasz M

Recent research indicates a neurological basis for attention deficit disorder, specifically, right frontal lobe dysfunction. Traditional treatments for ADD/ADHD, such as stimulant drugs, behavior modification, and cognitive-behavior therapy have had limited, short-term success and many drawbacks. read full text (pdf)  

EEG Biofeedback: A New Treatment Option For ADD/ADHD by Alhambra MA M.D., Fowler TP, Alhambra AA M.D.

Attention Deficit Disorder is commonly treated with stimulant medications such as Ritalin (methylphenidate). However, this medication has short-term effects and numerous undesirable side effects including insomnia and loss of appetite. This study explores using EEG biofeedback, with its minimal side effects and long-term results, as an alternative to pharmacological treatments for ADD. read full text (pdf)  

Evaluation of the Effectiveness of EEG Neurofeedback Training for ADHD in a Clinical Setting as Measured by Changes in T.O.V.A. Scores, Behavioral Ratings, and WISC-R Performance (abs.) by Lubar JF, Swartwood MO, Swartwood JN, O’Donnell PH

A study with three component parts was performed to assess the effectiveness of Neurofeedback treatment for Attention Deficit/Hyperactivity Disorder (ADHD). The subject pool consisted of 23 children and adolescents ranging in age from 8 to 19 years with a mean of 11.4 years who participated in a 2- to 3-month summer program of intensive Neurofeedback training. read full text  

A Controlled Study of the Effects of EEG biofeedback on Cognition and Behavior of Children with Attention Deficit Disorder and Learning Disabilities (abs.) by Linden M, Habib T, Radojevic V

Eighteen children with ADD/ADHD, some of whom were also LD, ranging in ages from 5 through 15 were randomly assigned to one of two conditions. The experimental condition consisted of 40 45-minute sessions of training in enhancing beta activity and suppressing theta activity, spaced over 6 months. read full text  

Electroencephalographic Biofeedback of SMR and Beta for Treatment of Attention Deficit Disorders in a Clinical Setting (abs.) by Lubar JO and Lubar JF

Six children were provided with long-term biofeedback and academic treatment for attention deficit disorders. Their symptoms were primarily specific learning disabilities, and, in some cases, there were varying degrees of hyperkinesis. The training consisted of two sessions per week for 10 to 27 months, with a gradual phase-out. read full text  

EEG Biofeedback for the Enhancement of Attentional Processing in Normal College Students by Rasey HW B.A., Lubar JF Ph.D., McIntyre A Ph.D., Zoffuto AC B.S., Abbott PL B.A.

College students diagnosed as free of any neurological or attention deficit disorder received EEG biofeedback to enhance beta (16-22 hertz) activity while simultaneously inhibiting high theta and low alpha (6-10 hertz) activity in order to evaluate improvements in attentional measures. read full text (pdf)  

Effect of Neurofeedback on Variables of Attention in a Large Multi-Center Trial (abs.) by Kaiser DA Ph.D. and Othmer S Ph.D.

Neurofeedback studies have been criticized for including small numbers of subjects. The effect of SMR-beta Neurofeedback training on the Test of Variables of Attention was evaluated in more than 1,000 subjects from thirty-two clinics. read full text (pdf)  

Neocortical Dynamics: Implications for Understanding the Role of Neurofeedback and Related Techniques for the Enhancement of Attention by Lubar JF Ph.D.

This presentation will consist of two parts. The first portion will provide both the scientific basis and a model for understanding neocortical dynamics and the EEG. The second portion will show how EEG biofeedback and related methodologies that modify the EEG and behavior can be explained by neocortical dynamics. read full text (pdf)  

EEG and Behavioral Changes in a Hyperkinetic Child Concurrent with Training of the Sensorimotor Rhythm (SMR): A Preliminary Report by Lubar JF and Shouse MN

Reduced seizure incidence coupled with voluntary motor inhibition accompanied conditioned increases in the sensorimotor rhythm (SMR), a 12- 14 Hz rhythm appearing over rolandic cortex. read full text  

Operant Conditioning of EEG Rhythms and Ritalin in the Treatment of Hyperkinesis by Shouse MN and Lubar JF

Enhanced voluntary motor inhibition regularly accompanies conditioned increases in the sensorimotor rhythm (SMR), a 12–14-Hz Rolandic EEG rhythm in cats. read full text  

EEG Biofeedback in the Schools: The Use of EEG Biofeedback to Treat ADHD in a School Setting by Boyd WD and Campbell SE

Six middle school students diagnosed with attention deficit/hyperactivity disorder were selected for sensorimotor rhythm (SMR) training with EEG biofeedback. The subjects were evaluated following a 72-hour drug-free period with the WISC-III Digit Span subtest and the Test of Variables of Attention (TOVA). read full text (pdf)  

Event Related Potentials of Subgroups of Children with Attention Deficit Hyperactivity Disorder and the Implications for EEG Biofeedback by Linden M Ph.D., Gevirtz R Ph.D., Isenhart R, Fisher T

This study examines differences in Event Related Potentials (ERPs) and Reaction Times (RT’s) among two subgroups of Attention Deficit Disorder children: Attention Deficit-Hyperactivity Disorder (ADHD children with attentional and hyperactive behavior problems), and Mixed (ADHD and OD children with attentional and aggressive behavior problems). read full text (pdf)  

Improved Neuronal Regulation in ADHD: An Application of Fifteen Sessions of Photic-Driven EEG Neurotherapy by Patrick GJ R.N. Ph.D.

This study tested a 15-session electroencephalograph (EEG) driven photic stimulation neural training procedure designed to enhance the regulation of brain wave activity and thus improve cognitive functioning in Attention Deficit Hyperactivity Disorder (ADHD) children. read full text (pdf)  

EEG Biofeedback for Attention Deficit Hyperactivity Disorder by Othmer S Ph.D. and Othmer SF B.A.

Attention Deficit Hyperactivity Disorder, (ADHD) is characterized by impulsivity, hyperactivity, and distractibility. These symptoms may be present in varying degrees. For example, hyperactivity may not necessarily be obtrusive in order to diagnose the condition. ADHD is not a disease. read full text  

Neurofeedback Combined with Training in Metacognitive Strategies: Effectiveness in Students with ADD (abs.) by Thompson L and Thompson M

A review of records was carried out to examine the results obtained when people with Attention Deficit Disorder (ADD) received 40 sessions of training that combined neurofeedback with the teaching of metacognitive strategies. read full text  

Efficacy of Neurofeedback on Adults with Attentional Deficit and Related Disorders by Kaiser DA

Attention Deficit Hyperactivity Disorder (ADHD) is a lifelong disorder that affects as many as one in every twenty adults. Whereas ADHD in childhood is commonly associated with poor school performance and academic achievement, in adulthood this disorder can be especially disruptive to social and vocational relationships. read full text (pdf)  

Neurotherapy and Drug Therapy in Combination for Adult ADHD, Personality Disorder and Seizure Disorder: A Case Report by Hansen LM B.S., Trudeau DL M.D., Grace DL Ph.D.

This is a case report of an adult female patient with ADHD, temporal seizure disorder, and Borderline Personality Disorder treated with 30 weekly sessions of SMR neurofeedback and carbamazepine. read full text (pdf)  

EEG Biofeedback Training and Attention-Deficit/Hyperactivity Disorder In an Elementary School Setting (abs.)by Carmody DP Ph.D., Radvanski DC B.S., Wadhwani S B.S., Sabo MJ Ph.D., Vergara L M.S.

EEG biofeedback was conducted on site in an elementary school. Method: An experimental group of eight children ages 8-10 completed 35-47 sessions of EEG biofeedback training over a six-month period. read full text (pdf)  

Neurofeedback Therapy of Attention Deficits In Patients with Traumatic Brain Injury by Keller I Ph.D.

Impairments of attention are a frequent and well documented consequence of head injury. The purpose of this study was to evaluate if Neurofeedback Therapy (NFT) can enhance remediation of attention deficits in patients with closed head injuries (CHI) who are still in the phase of spontaneous recovery. read full text (pdf)  

ADHD and Stuttering: Similar EEG Profiles Suggest Neurotherapy as an Adjunct to Traditional Speech Therapies by Ratcliff-Baird B Ph.D.

This study investigated differences in theta and alpha activity measured by electroencephalography (EEG) at frontal sites between stutterers and nonstutterers during focused attention tasks. read full text  

Neurofeedback for AD/HD: A Ratio Feedback Case Study and Tutorial by Rossiter T Ph.D.

The case study of a 13-year-old AD/HD male treated with neurofeedback is the subject matter for a tutorial on Ratio feedback. read full text (pdf)  

Electroencephalographic Biofeedback of SMR and Beta for Treatment of Attention Deficit Disorders in a Clinical Setting by Lubar JO and Lubar JF

Six children were provided with long-term biofeedback and academic treatment for attention deficit disorders. Their symptoms were primarily specific learning disabilities, and, in some cases, there were varying degrees of hyperkinesis. read full text

Neurofeedback as a Treatment for ADHD: A Methodological Review with Implications for Future Research by Vernon D Ph.D., Frick A MSc, Gruzelier J Ph.D.

Attention deficit/hyperactivity disorder (ADHD) represents one of the most common psychiatric disorders in childhood, resulting in serious impairment across a variety of domains. read full text read full text  

Clinical Use of SMR-Beta Training on Post Traumatic Stress Disorder and Adult Attention Deficit Disorder: A Case Study by Putman JA

After 20 sessions of SMR- Beta training, the patient’s TOVA revealed dramatic improvement on all 4 scales (Std scores ranged from 83 to 110). Additionally, she was much less reactive and felt more emotionally “stable.” Her sleep patterns had improved a great deal as well. Although she was still having nightmares, they had become less frequent and had decreased in their intensity. Her depression lifted and she became considerably more animated and less irritable. Shortly after starting college, she reported that she was able to read whole chapters at a time without frustration or anxiety and was actually enjoying and retaining what she had read. She completed her first semester in college with a B average and has not used cocaine in over a year. read full text (pdf)  

The Effect of Interhemispheric EEG training using Sequential Protocols on ADD (abs.) by Putman JA

The purpose of this study was to examine the effect of EEG biofeedback using interhemispheric EEG training protocols on attention deficit disorders. Neurofeedback protocols included T3-T4, Fp1-Fp2, F3-F4 employing a wide range of reward frequencies. The training group was comprised of 33 males and females, age range from 7 to 62 who were being treated for a variety of different disorders. Changes in attentional ability were measured through the use of a continuous performance test (TOVA) which was administered prior to the start of EEG training and every 20 to 25 sessions thereafter. continue reading abstract (page 31)  

TOVA Results Following Inter-Hemispheric Bipolar EEG Training (abs.) by J.A.Putman; S.F.Othmer; S.Othmer; V.E.Pollock

This study examines recovery of attentional measures among a heterogeneous group of clients in a pre-and post-comparison using inter-hemispheric EEG training at homologous sites. A continuous performance test was used as an outcome measure. The client population was divided into three categories: (a) primarily attentional deficits, (b) primarily psychological complaints, and (c) both. read full text  

Related Research

Human Prefrontal and Sensory Cortical Activity During Divided Attention Tasks by Loose R, Kaufmann C, Auer DP, Lange KW

In our natural environment, the ability to divide attention is essential since we attend simultaneously to a number of sensory modalities, e.g., to visual and auditory stimuli. In this study, functional magnetic resonance imaging (fMRI) was used to study brain activation while a divided attention task was performed. read full text  

The Electroencephalogram in Attention Deficit-Hyperactivity Disorder: Emphasis on Epileptiform Discharges by Hughes JR, DeLeo AJ, Melyn MA

This study dealt with the electroencephalograms (EEGs) of 176 children with attention deficit-hyperactivity disorder (ADHD). Of special interest were the patients who had in their EEG some type of spike activity (spike group), in contrast with those without such activity (control group). read full text  

Event Related Potentials During Attention Tasks in VLBW Children with and without Attention Deficit Disorder by Potgieter S, Vervisch J, Lagae L

Children born prematurely have a higher incidence of attention deficit disorder with or without hyperactivity. We have used visual event related potentials to study possible brain dysfunctions that could explain this higher incidence. read full text  

Do Quantitative EEG Measures Differentiate Hyperactivity in Attention Deficit/Hyperactivity Disorder? by Stewart GA,Steffler DJ, Lemoine DE, Leps JD

Attention Deficit/Hyperactivity Disorder (AD/HD) can occur with or without hyperactivity. However, much of the existing research collapses both AD/HD and AD/HD without hyperactivity participants into the AD/HD category, possibly confounding the samples with a heterogeneous population comprised of people with different disorders. read full text  

Volumetric Asymmetries in Late-Onset Mood Disorders: An Attenuation of Frontal Asymmetry with Depression Severity. by Kumar A, Bilker W, Lavretsky H, Gottlieb G

The purpose of the study was to examine global and regional volumetric asymmetries in patients with late-onset mood disorders and non-depressed control subjects. read full text read full text