By Will Boggs MD
NEW YORK - Children with ADHD show sustained improvements in symptoms six months after a 40-session, in-school neurofeedback training, according to results from a randomized trial.
"These results are suggestive that neurofeedback could be supportive at the very least as an adjunctive treatment to medication and for some patients even, instead of medication," Dr. Naomi J. Steiner from The Floating Hospital for Children at Tufts Medical Center in Boston told Reuters Health by email.
"Physicians have been trained to treat ADHD with medication and behavior therapy," Dr. Steiner said. "This study opens a road for a new way of looking at ADHD, a true shift from the traditional (medication/behavior therapy) approach, that takes into consideration the brain and its ability through brain plasticity to be trained."
Dr. Steiner and colleagues conducted the first in-school efficacy trial comparing neurofeedback, cognitive training, and control conditions in 98 children, ages 7 to 11, diagnosed with ADHD.
Neurofeedback provides children with immediate auditory and visual feedback regarding their level of attention during each computer-based exercise, thereby training them to monitor and change their brainwave patterns and, as a result, their behavior.
Cognitive training uses specific computer-based exercises to train attention, working memory, and impulsivity through ongoing feedback to reinforce correct responses.
Participants in the neurofeedback training showed significant improvements in the Conners 3-Parent Assessment Report (Conners 3-P) areas of inattention, executive functioning, and hyperactivity/impulsivity, on four of six general behavior subscales, all three summary measures, and seven of eight subscales of the Behavior Rating Inventory of Executive Function (BRIEF), compared with the controls.
In contrast, participants in the cognitive training showed significant improvements on only one of the five Conners 3-P subscales and on only two of eight BRIEF subscales, compared with controls, according to a report online February 17 in Pediatrics.
There were no significant differences between neurofeedback training and cognitive training on classroom observational measures, but there were significant improvements in the neurofeedback condition compared with the control condition.
At the six-month follow-up, the dosage of stimulant medication had not changed in the neurofeedback training group, whereas it had increased significantly in both the cognitive training and the control groups, although the differences between groups were not significant.
"There is still work that has to be done to mainstream neurofeedback in schools," Dr. Steiner said. "The study should be replicated at the middle and high school level."
"Dissemination should be looked at in terms of feasibility to administer neurofeedback within a whole district (in terms of defining which students should be included, even elements such as length of sessions and how many training session are required have to be looked at, training of the staff, implementation of protocol)," Dr. Steiner said.
"However it is important to note that the department of education recognizes the importance that attention and executive function have to support academic learning," Dr. Steiner added, "which is why this study was funded by the Department of Education."
Dr. Martijn Arns from Research Institute Brainclinics and Utrecht University, Nijmegen, The Netherlands, told Reuters Health by email that the effect sizes reported for neurofeedback in this study are lower then what his group found in a previous meta-analysis. "But given the sample size of the study," he said, "the adequate control group and the sustained effects after six months still demonstrate this is a promising avenue for the treatment of ADHD."
"Most likely the fact that neurofeedback was implemented in a school setting in a standardized way might explain the lower effects as compared to studies that employed neurofeedback in a clinical setting," Dr. Arns suggested. "On the other hand, it does demonstrate that such a treatment can be implemented in a school setting and future research could focus on further enhancing and maybe personalizing the effects of this treatment."
"It now is becoming clearer and clearer that neurofeedback is a viable treatment for ADHD with sustained effects," Dr. Arns concluded. "This should also change the way insurance companies and policy makers evaluate treatments."
Dr. Geir Ogrim from Ostfold Hospital Trust, Fredrikstad, Norway recently compared neurofeedback training with stimulant medication in treatment-naïve ADHD patients. Dr. Ogrim told Reuters Health, "This study is not about neurofeedback as an alternative to medication, but as an intervention that can supplement medication treatment, or be implemented before medication. In that case it is important that an evaluation of daily functioning is completed sometime after neurofeedback is finished."
Dr. Ogrim added, "The mean IQ of those enrolled was about 105-110. Was this study done with intelligent ADHD children from motivated families? Can we make generalizations?"
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