DOCUMENT 3 FOI 24/25-1491
Research – Neuro-feedback therapy for ADHD
Is neuro feedback effective for treating people (13yo, pubescence age range) with ASD (level 2)? (update to 2019 research)
Is neuro feedback effective for treating people (13yo, pubescence age range) with ASD (level 2) and ADHD?
Is neuro feedback effective for treating people (13yo, pubescence age range) with ADHD? Brief Is it suitable for prolonged/ongoing treatment and in conjunction with other allied health treatments?
What are some side effects of neuro feedback treatment? i.e. increase in tics
Is there evidence in the published literature that neuro feedback therapy can effectively treat “paroxysmal activity on executive functioning, reduce anxiety, improve emotional self-regulation and language processing issues.”
Date 09/04/2021
Requester(s) Julie s22(1)(a)(ii) - irrelev - Senior Technical Advisor (TAB)
Researcher Jane s22(1)(a)(ii) - irrelev (Research Team Leader - TAB)
Cleared N/A
Please note:
The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.
The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.
2 Summary ……………………………………………………………………………………………………………………….. 2
3 What is neurofeedback therapy?………………………………………………………………………………………. 2
4 Neurofeedback in the treatment of autism spectrum disorder …………………………………………….. 4
5 Neurofeedback in the treatment of attention deficit hyperactivity disorder ………………………….. 9
6 References …………………………………………………………………………………………………………………… 15
Research – Neurofeedback therapy for children and adolescents with ASD or ADHD
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2 Summary
- Neurofeedback therapy for the treatment of ASD is not considered an evidence based practice. The few randomised controlled trials that do exist are of poor quality. Further large scale, high quality studies that include best practice treatments as a comparison group are required.
- Most commonly, studies include “high functioning” children with ASD and do not provide severity level. Therefore, results can only be generalised to that population group.
- Comorbid ADHD is not reliably assessed in current studies, possibly owing to the current exclusion criteria in the classification system that rule out coexisting ASD and ADHD. Few neurofeedback studies have focused on ADHD in individuals with ASD.
- Multiple meta-analyses have investigated the effectiveness of neurofeedback therapy for ADHD. They have found that neurofeedback is superior to ‘non-active’ control groups for reducing inattention and hyperactivity/impulsivity symptoms when parents provide self-reported assessments. When less biased examiners (teachers) perform assessments the results are more commonly non-significant a. Further high quality studies (better blinding, use of objective measures) comparing to current best practice treatment for ADHD are required b. Some authors have suggested that neurofeedback be used as a complimentary/combined treatment with stimulants c. Neurofeedback does not appear in any ADHD clinical practice guidelines or treatment recommendations
- No studies could be located which used neurofeedback therapy in conjunction with other allied health treatments
- Given that neurofeedback therapy is a non-invasive treatment, adverse events are unlikely. One study did look investigate this and reported no significant adverse effects or sleep problems after neurofeedback therapy [1]. a. No evidence of an increase in tics following neurofeedback therapy
- No consensus on protocol, intensity or duration of treatment
- There is no evidence that neurofeedback therapy can effectively treat “paroxysmal activity on executive functioning, reduce anxiety, improve emotional self-regulation and language processing issues.” a. There is only weak evidence of its effectiveness in reducing inattention and hyperactivity/impulsivity symptoms in those with ADHD
3 What is neurofeedback therapy?
Research – Neurofeedback therapy for children and adolescents with ASD or ADHD
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Neurofeedback is a kind of biofeedback, which utilises operant conditioning to teach self-
control of brain functions to subjects by measuring brain waves through
electroencephalography (EEG) or functional magnetic resonance imaging (fMRI) and
providing a feedback signal [2, 3]. Positive or negative feedback is produced for desirable or
undesirable brain activities, respectively. Various EEG components are extracted and fed to
subjects using online feedback loop in the form of audio, video or their combination.
Accordingly, electrophysiological components are separately demonstrated [2]. As an
illustration, the power of a signal in a frequency band can be shown by a varying bar graph.
During this procedure, the subject becomes aware of the changes occurring during training
and will be able to assess his/her progress in order to achieve optimum performance.
Neurofeedback treatment protocols mainly focus on the alpha, beta, delta, theta, and
gamma treatment or a combination of them such as alpha/theta ratio, beta/theta ratio, etc.
[2]. Table 1 below provides an overview of common brainwaves, frequencies and
characteristics.
Table 2. Specific brainwaves with their characteristics
Common Frequency brainwave General characteristics range (Hz) frequency
Sleep, repair, complex problem solving, unawareness, deep- Delta 1–4 unconsciousness
Creativity, insight, deep states, unconsciousness, optimal Theta 4–8 meditative state, depression, anxiety, distractibility
Alpha 8–13 Alertness and peacefulness, readiness, meditation, deeply-relaxed
Lower alpha 8–10 Recalling
Research – Neurofeedback therapy for children and adolescents with ASD or ADHD
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Table 2. Specific brainwaves with their characteristics
Common Frequency brainwave General characteristics range (Hz) frequency
Upper alpha 10–13 Optimize cognitive performance
SMR
(sensorimotor 13–15 Mental alertness, physical relaxation
rhythm)
Thinking, focusing, sustained attention, tension, alertness, Beta 15–20 excitement
High beta 20–32 Intensity, hyper alertness, anxiety
32–100 or Learning, cognitive processing, problem solving tasks, mental Gamma 40 sharpness, brain activity, organize the brain
4 Neurofeedback in the treatment of autism spectrum disorder
There are very few high quality studies that investigate the use of neurofeedback therapy for children and adolescents with ASD (Table 2). A recent systematic review found that 19/20 studies which investigated neurofeedback therapy obtained positive results [3]. However, they provided not critical analysis of the included studies.
The limitations of the studies include:
- Small sample sizes (ranging from n = 10 to 28) meaning results should be interpreted with caution
- Lack of criterion standard diagnostic instruments
- No clear guidance as to how many sessions of neurofeedback are needed for optimal results (ranged from 5 to 69 sessions)
Research – Neurofeedback therapy for children and adolescents with ASD or ADHD
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- No firm agreement on optimal treatment protocols
- Studies restricted to individuals with ASD with an IQ above 70 (‘high-functioning ASD’); this selection bias does not allow for the generalization of current findings
- Insufficient control interventions - no studies compared to best practice treatments
A further systematic review concluded that existing evidence does not support neurofeedback as a treatment that can be recommended for ASD core symptoms [4]. They also suggest that studies with outcomes in favour of neurofeedback might be showing an improvement in comorbid ADHD symptoms rather than a true improvement in core ASD symptoms.
Research – Neurofeedback therapy for children and adolescents with ASD or ADHD
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Table 2. Literature Review - ASD
Level & Quality of Author Aim/Objective Methods Results evidence
Is neurofeedback 20 studies (n = 443) met the inclusion MODERATE van Hoogdalem, Feijs Systematic Review (NF) an effective criteria (3 RCT, 13 non-randomised & 4 [3] alternative Methods designed in experimental). Lacked quality assessment of treatment in children accordance with Preferred included studies. The with ASD? Reporting Items for Systematic Selected studies were heterogeneous authors take positive Reviews and Meta-Analyses in their design and methodology. The findings at face value and (PRISMA) statement NF therapy protocol as well as the don’t criticise further. 3/4 of duration, frequency, and number of the included RCTs are not Eligibility criteria sessions varied between studies. blinded and all have small • NF as a treatment for ASD in samples. children (<18 years) Results qualitatively presented. • Diagnosis for autism had to Sample sizes of all included be diagnosed by DSM-III-R, 19/20 studies found some form of studies were quite small DSM-IV, or DSM-5 positive result. Various studies also (ranging from n = 10 to n = guidelines reported that specific functions 28) meaning results should • Peer reviewed improved while other functions did be interpreted with caution. • Experimental in design with not, or even became worse. a control group Socialisation appears to improve most Lack of qualitatively good consistently. studies, which makes it hard Excluded to draw strong conclusions • Adults Long term effects
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Table 2. Literature Review - ASD
Level & Quality of Author Aim/Objective Methods Results evidence
• Other disorders such as 2 RCTs looked at longitudinal effects. No clear guidance as to how ADHD, learning disorders, One found significant maintenance in many sessions of NF are intellectual disability social behaviour and executive function needed for optimal results • Case studies and book at 12 months. The other study showed (ranged from 5 to 69 chapters that NF did not significantly reduced sessions). ASD symptoms. No quality assessment of No firm agreement on included studies. Non-invasive, no side effects optimal treatment protocols. Holtmann, Steiner To review current LOW Literature review Qualitative interpretation of individual [4] studies on the studies provided along with effectiveness of Other than listing the databases • Studies don’t use corresponding percentage neurofeedback as a searched there are no criterion standard changes/descriptive statistics. method of treatment descriptions on the eligibility diagnostic instruments of the core criteria, data collection or Studies with outcomes in favour of • Neurofeedback should symptoms of ASD. quality assessment methods neurofeedback might be showing an be compared with best used. improvement in comorbid ADHD practice ASD symptoms rather than a true interventions in order to Authors state that ‘all available improvement in core ASD symptoms. determine its efficacy data on neurofeedback in ASD and effectiveness and in comorbid ASD ⁄ ADHD Lack of blinding in controlled studies, • Unknown whether are reviewed’. This cannot be therefore effects might be biased by determined without a search neurofeedback adds rater expectations (i.e. parents). strategy or methods. therapeutic value to existing methods Authors find that existing evidence • Studies restricted to does not support neurofeedback as a individuals with ASD with
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Table 2. Literature Review - ASD
Level & Quality of Author Aim/Objective Methods Results evidence
treatment that can be recommended an IQ above 70 (‘high- for ASD core symptoms. functioning ASD’); this selection bias does not allow for the generalization of current findings
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5 Neurofeedback in the treatment of attention deficit hyperactivity disorder
The delivery of neurofeedback therapy for children and adolescents with ADHD has been researched extensively over the past two decades (Table 3). Evidence from meta-analyses of RCTs show that most studies compare neurofeedback to a ‘non-active’ control group (described as control group conditions without enough proven efficacy to reduce ADHD symptoms – such as sham neurofeedback, wait list, electromyographic biofeedback, and physical activity) and not to current best practice such as stimulants/medication.
• The majority of meta-analyses (in the <18 year old cohort) find that neurofeedback is superior to ‘non-active’ control groups for reducing inattention and hyperactivity/impulsivity symptoms [5-7].
However, the above finding needs to be interpreted in relation to the below limitations
- Pre-post-test comparisons are calculated using measures performed by proximal evaluators (often parents). When ‘possibly blind’ evaluations are used (usually teachers) the magnitude of positive effect is often much smaller or non-significant. There is less bias when using a teachers subjective assessment rather than parent report
- This substantial variation in results depending on who provides the evaluation means conclusions about the effectiveness of neurofeedback therapy are fragile/weak
- The magnitude of effect sizes that support the efficacy of neurofeedback at present are small (<0.5)
Neurofeedback compared to stimulants shows that stimulants are more effective, even when parents are used to make the evaluations [7, 8].
Although current evidence on neurofeedback for ADHD is considered weak positive, it is suggested that neurofeedback be used as a complimentary/combined treatment with stimulants.
At this stage, neurofeedback does not appear in any ADHD clinical practice guidelines or treatment recommendations in the USA, Canada, UK or Spain (Aus guidelines currently being developed).
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Table 3. Literature Review - ADHD
Level & Quality of Author Aim/Objective Methods Results evidence
Summarise and review Meta-analysis 7 meta-analyses were reviewed and HIGH Riesco-Matías, the results of previous 17 studies were incorporated into the Yela-Bernabé [7] meta-analyses and Inclusion criteria new meta-analysis. There is less bias when present the results of a • Meta-analytic methodology using a teacher’s new meta-analysis of used to summarize the effect All meta-analyses that calculated the subjective assessment randomized controlled of studies effects of neurofeedback applied to rather than parent report. ADHD neurofeedback • RCTs published in peer- inattention symptoms and/or Therefore, this substantial trials. reviewed journals hyperactivity-impulsivity symptoms variation in results • Sample: primary ADHD versus the effect of non-active control depending on who diagnosis (DSM or ICD) condition groups and used most- provides the evaluation • Mean age < 18 years old proximal evaluator data (often means conclusions are • standard EEG-NF theta/beta parents) obtained significant effect ‘fragile’. ratio training, standard SCP or sizes in favour of neurofeedback. SMR, and theta training; Current evidence on • Validated scale pre–post No meta-analysis has found effective neurofeedback for ADHD neurofeedback treatment for is considered weak treatment measurements of at hyperactivity-impulsivity symptoms positive. least one of the core ADHD when possibly blind ratings (often symptoms (inattention, teacher ratings) have been used. Only New RCTs that establish hyperactivity, impulsivity, one meta- analysis was in favour of links between ADHD hyperactivity-impulsivity) symptom measurements,
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Table 3. Literature Review - ADHD
Level & Quality of Author Aim/Objective Methods Results evidence
Exclusion criteria neurofeedback for inattention subjects’ learning after • <5 participants per group symptoms neurofeedback, and • Language other than English neurophysiological or Spanish Results of the updated meta-analysis measures could improve • Sample was shared with are in support of previous findings, the quality of the current another study included in the i.e. results are only effective when conclusions. current meta-analysis parents are providing ratings of • Insufficient data to calculate change/effectiveness, and these target effect sizes effects are small (<0.5) • No inclusion criteria
- NF v control group for inattention using most proximal evaluator: ES -0.33, 95% CI -0.56, -0.10
- NF v control group inattention using probably blind evaluator: ES -0.25, 95% CI -0.45, -0.04
- NF v control for hyperactivity/impulsivity symptoms using most proximal evaluator: ES -0.17, 95% CI -0.33, -0.02
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Table 3. Literature Review - ADHD
Level & Quality of Author Aim/Objective Methods Results evidence
- NF v control for hyperactivity/impulsivity symptoms using probably blind evaluator: ES -0.16, 95% CI -0.32, 0.01
- NF v stimulant control group using most proximal evaluator: ES 0.26, 95% CI 0.02, 0.51 Bussalb, Congedo To update the meta- HIGH Meta-Analysis 16 included RCTs (n = 706) [5] analysis performed by Cortese, Ferrin [6] and Inclusion criteria • ES in favour of NF efficacy as Although results are in evaluate the efficacy of being significant when clinical favour of NF when parents • studies have to assess NFB neurofeedback scales of ADHD are rated by are rating/self-reporting efficacy treatment for ADHD in parents (non-blind, p-value = effectiveness there is still • subjects must have received a children and adolescents. 0.0014), but not when they are the need for studies with diagnosis of ADHD based on rated by teachers (probably blind, placebo-controlled DSM, ICD-10 (67) criteria, or p-value = 0.27). intervention as well as by a qualified psychiatrist • The ES is significant according to carefully reported neuro- • be written in English, German, both raters for the subset of marker changes in relation Spanish, or French studies meeting the definition of to clinical response to be • include at least eight subjects “standard NF protocols (parents’ performed. in each group
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Table 3. Literature Review - ADHD
Level & Quality of Author Aim/Objective Methods Results evidence
• Aged below 25 years p-value = 0.0054; teachers’ p- value = 0.043, k = 4) • 3 main factors identified that Severity of ADHD symptoms have an impact on NF efficacy: assessed by parents (most 1) more intensive treatment, but proximal) or teachers (probably not treatment duration blinded). Measured using clinical 2) teachers report a lower scales such as the ADHD-RS which improvement compared to is a self-reported questionnaire. parents 3) Using high-quality EEG Extensive explanation of meta- equipment improves the analysis methods provided. effectiveness of treatment. Sensitivity analysis and regression models conducted.
Yan, Wang [8] To perform a systematic Systematic review and meta- 18 RCTs included (778 individuals MODERATE review and meta-analysis analysis with ADHD in the NF arm and 757 in of head-to-head RCTs the MPH group) Differences in the dose of comparing the effects of PRISMA guidelines followed. drugs, the number of methylphenidate (MPH - At the study first endpoint, MPH was feedbacks, which may Ritalin) and NF in terms Eligibility significantly more efficacious than NF introduce some bias in the of efficacy on ADHD core • children/adolescents <18 on ADHD core symptoms (ADHD statistical analyses. symptoms (combined, years) and/or adults ≥18 years symptoms combined: SMD=−0.578, • RCTs only
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Table 3. Literature Review - ADHD
Level & Quality of Author Aim/Objective Methods Results evidence
inattention and • diagnosis of ADHD according 95% CI (−1.063 to –0.092)) and on Inclusion of different hyperactivity/impulsivity) to the DSM or ICD-10 two rating scales to assess the • ADHD defined based on scores neuropsychological parameters core symptoms of ADHD. above cut-off point on any (inattention:−0.959 (-1.711 to – validated ADHD measure, as in 0.208); inhibition:−0.469 (-0.872 to In future studies, risk of previous meta-analyses –0.066)). bias should be reduced, in particular, blinding of Interventions Dropouts were significantly lower in outcome assessments. Trials comparing head to head NF NF versus MPH (OR=0.412, 0.186 to and MPH. Both fixed dose and 0.913). At this stage there is still flexible dose designs. Multimodal some uncertainty around treatments were excluded to At the study follow-up, MPH was results due to study avoid confounding factors. superior to NF in some outcomes, but quality. Results should be results were inconsistent across interpreted with caution. Only validated ADHD rating scales raters (parents and teachers). were included to determine treatment effectiveness. High risk of bias across studies due to concerns of allocation concealment. This may have contributed to placebo effects, which may affect the results.
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Revision History
Cleared Research Revision Revised by Date HPE No. Summary of Revision by Register No.
Complete Jane Jane 09/04/2021 2021/180 NED19/195669 This document has been update of s22(1)(a)(ii) - irre s22(1)(a)(ii) - irre and completely revised. The literature and 2019/0038 initial document did not inclusion of conduct a comprehensive treatment for review of the literature or ASD and ADHD critically analyse any of the included papers. Most information was not peer reviewed and taken from website sources. This version now includes literature on the effectiveness of neurofeedback therapy for ASD and ADHD in children and adolescents.
6 References
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Lansbergen MM, van Dongen-Boomsma M, Buitelaar JK, Slaats-Willemse D. ADHD and EEG-
neurofeedback: a double-blind randomized placebo-controlled feasibility study. Journal of neural transmission [Internet]. 2011; 118(2):[275-84 pp.]. Available from: https://link.springer.com/content/pdf/10.1007/s00702-010-0524-2.pdf. 2. Marzbani H, Marateb HR, Mansourian M. Neurofeedback: A Comprehensive Review on System Design, Methodology and Clinical Applications. Basic Clin Neurosci [Internet]. 2016; 7(2):[143-58 pp.]. Available from: https://pubmed.ncbi.nlm.nih.gov/27303609. 3. van Hoogdalem LE, Feijs HME, Bramer WM, Ismail SY, van Dongen JDM. The effectiveness of neurofeedback therapy as an alternative treatment for autism spectrum disorders in children: A systematic review. Journal of Psychophysiology [Internet]. 2020:[No Pagination Specified-No Pagination Specified pp.]. 4. Holtmann M, Steiner S, Hohmann S, Poustka L, Banaschewski T, Bolte S. Neurofeedback in autism spectrum disorders. Developmental Medicine & Child Neurology. 2011;53(11):986-93. 5. Bussalb A, Congedo M, Barthélemy Q, Ojeda D, Acquaviva E, Delorme R, et al. Clinical and Experimental Factors Influencing the Efficacy of Neurofeedback in ADHD: A Meta-Analysis. Frontiers in Psychiatry [Internet]. 2019 2019-February-18; 10(35). Available from: https://www.frontiersin.org/article/10.3389/fpsyt.2019.00035. 6. Cortese S, Ferrin M, Brandeis D, Holtmann M, Aggensteiner P, Daley D, et al. Neurofeedback for Attention-Deficit/Hyperactivity Disorder: Meta-Analysis of Clinical and Neuropsychological Outcomes From Randomized Controlled Trials. Journal of the American Academy of Child & Adolescent Psychiatry [Internet]. 2016 2016/06/01/; 55(6):[444-55 pp.]. Available from: https://www.sciencedirect.com/science/article/pii/S0890856716300958.
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Riesco-Matías P, Yela-Bernabé JR, Crego A, Sánchez-Zaballos E. What Do Meta-Analyses
Have to Say About the Efficacy of Neurofeedback Applied to Children With ADHD? Review of Previous Meta-Analyses and a New Meta-Analysis. Journal of Attention Disorders [Internet]. 2021; 25(4):[473-85 pp.]. Available from: https://journals.sagepub.com/doi/abs/10.1177/1087054718821731. 8. Yan L, Wang S, Yuan Y, Zhang J. Effects of neurofeedback versus methylphenidate for the treatment of ADHD: systematic review and meta-analysis of head-to-head trials. Evidence Based Mental Health [Internet]. 2019; 22(3):[111 p.]. Available from: http://ebmh.bmj.com/content/22/3/111.abstract.
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