Neurofeedback and Psychology

Research Publications

Research & Publications

1. Sustained effects of neurofeedback in ADHD: A systematic review and meta-analysis

Van Doren, J., Arns, M., Heinrich, H., Vollebregt, M. A., Strehl, U., & Loo, S. K.

European Child & Adolescent Psychiatry (2018)

Abstract: Neurofeedback (NF) has gained increasing interest in the treatment of attention-deficit/hyperactivity disorder (ADHD). Given learning principles underlie NF, lasting clinical treatment effects may be expected. This systematic review and meta-analysis addresses the sustainability of neurofeedback and control treatment effects by considering randomized controlled studies that conducted follow-up (FU; 2–12 months) assessments among children with ADHD. PubMed and Scopus databases were searched through November 2017. Within-group and between-group standardized mean differences (SMD) of parent behavior ratings were calculated and analyzed. Ten studies met inclusion criteria (NF: ten studies, N = 256; control: nine studies, N = 250). Within-group NF effects on inattention were of medium effect size (ES) (SMD = 0.64) at post-treatment and increased to a large ES (SMD = 0.80) at FU. Regarding hyperactivity/impulsivity, NF ES were medium at post-treatment (SMD = 0.50) and FU (SMD = 0.61). Non-active control conditions yielded a small significant ES on inattention at post-treatment (SMD = 0.28) but no significant ES at FU. Active treatments (mainly methylphenidate), had large ES for inattention (post: SMD = 1.08; FU: SMD = 1.06) and medium ES for hyperactivity/impulsivity (post: SMD = 0.74; FU: SMD = 0.67). Between-group analyses also revealed an advantage of NF over non-active controls [inattention (post: SMD = 0.38; FU: SMD = 0.57); hyperactivity–impulsivity (post: SMD = 0.25; FU: SMD = 0.39)], and favored active controls for inattention only at pre-post (SMD = − 0.44). Compared to non-active control treatments, NF appears to have more durable treatment effects, for at least 6 months following treatment. More studies are needed for a properly powered comparison of follow-up effects between NF and active treatments and to further control for non-specific effects.

The research article can be accessed by clicking the link here: (https://doi.org/10.1007/s00787-018-1121-4)

 

 

2. Evaluation of neurofeedback in ADHD: The long and winding road

Arns, M., Heinrich, H., & Strehle, U.

Biological Psychology (2014)

Abstract: Among the clinical applications of neurofeedback, most research has been conducted in ADHD. As an introduction a short overview of the general history of neurofeedback will be given, while the main part of the paper deals with a review of the current state of neurofeedback in ADHD. A meta-analysis on neurofeedback from 2009 found large effect sizes for inattention and impulsivity and medium effects sizes for hyperactivity. Since 2009 several new studies, including 4 placebo-controlled studies, have been published. These latest studies are reviewed and discussed in more detail. The review focuses on studies employing (1) semi-active, (2) active, and (3) placebo-control groups. The assessment of specificity of neurofeedback treatment in ADHD is discussed and it is concluded that standard protocols such as theta/beta, SMR and slow cortical potentials neurofeedback are well investigated and have demonstrated specificity. The paper ends with an outlook on future questions and tasks. It is concluded that future controlled clinical trials should, in a next step, focus on such known protocols, and be designed along the lines of learning theory.

The research article can be accessed by clicking the link here: (https://doi.org/10.1016/j.biopsycho.2013.11.013).

 

 

3. EEG neurofeedback treatments in children with ADHD: an updated meta-analysis of randomized controlled trials

Micoulaud-Franchi, J. A., Geoffroy, P. A., Fond, G., Lopez, R.,  Bioulac, S., & Philip, P.

Front. Hum. Neurosci. 2014

Objective: We undertook a meta-analysis of published Randomized Controlled Trials (RCT) with semi-active control and sham-NF groups to determine whether Electroencephalogram-neurofeedback (EEG-NF) significantly improves the overall symptoms, inattention and hyperactivity/impulsivity dimensions for probably unblinded assessment (parent assessment) and probably blinded assessment (teacher assessment) in children with Attention Deficit Hyperactivity Disorder (ADHD). Data sources: A systematic review identified independent studies that were eligible for inclusion in a random effects meta-analysis. Data extraction: Effect sizes for ADHD symptoms were expressed as standardized mean differences (SMD) with 95% confidence intervals. Results: Five identified studies met eligibility criteria, 263 patients with ADHD were included, 146 patients were trained with EEG-NF. On parent assessment (probably unblinded assessment), the overall ADHD score (SMD = −0.49 [−0.74, −0.24]), the inattention score (SMD = −0.46 [−0.76, −0.15]) and the hyperactivity/impulsivity score (SMD = −0.34 [−0.59, −0.09]) were significantly improved in patients receiving EEG-NF compared to controls. On teacher assessment (probably blinded assessment), only the inattention score was significantly improved in patients receiving EEG-NF compared to controls (SMD = −0.30 [−0.58, −0.03]). Conclusions: This meta-analysis of EEG-NF in children with ADHD highlights improvement in the inattention dimension of ADHD symptoms. Future investigations should pay greater attention to adequately blinded studies and EEG-NF protocols that carefully control the implementation and embedding of training.

The research article can be accessed by clicking the link here: (https://doi.org/10.3389/fnhum.2014.00906).

 

 

4. EEG-neurofeedback for optimising performance. I: a review of cognitive and affective outcome in healthy participants.

 Gruzelier, J.H.

 Neurosci Biobehav Rev. 2014

Abstract: A re-emergence of research on EEG-neurofeedback followed controlled evidence of clinical benefits and validation of cognitive/affective gains in healthy participants including correlations in support of feedback learning mediating outcome. Controlled studies with healthy and elderly participants, which have increased exponentially, are reviewed including protocols from the clinic: sensory-motor rhythm, beta1 and alpha/theta ratios, down-training theta maxima, and from neuroscience: upper-alpha, theta, gamma, alpha desynchronisation. Outcome gains include sustained attention, orienting and executive attention, the P300b, memory, spatial rotation, RT, complex psychomotor skills, implicit procedural memory, recognition memory, perceptual binding, intelligence, mood and well-being. Twenty-three of the controlled studies report neurofeedback learning indices along with beneficial outcomes, of which eight report correlations in support of a meditation link, results which will be supplemented by further creativity and the performing arts evidence in Part II. Validity evidence from optimal performance studies represents an advance for the neurofeedback field demonstrating that cross fertilisation between clinical and optimal performance domains will be fruitful. Theoretical and methodological issues are outlined further in Part III.

 The research article can be accessed by clicking the link here: (https://doi.org/10.3389/fnhum.2014.00906).

 

 

5. Neurofeedback in ADHD: Further Pieces of the Puzzle

Gevensleben, H., Kleemeyer, M., Rothenberger, L. G., Studer, P., Flaig-Ro¨hr, A., Moll, G. H., Rothnberger, A., & Heinrich, H.

Brain Topography (2013)

Abstract: Among the different neuromodulation techniques, neurofeedback (NF) is gaining increasing interest in the treatment of children with attention-deficit/hyperactivity disorder (ADHD). In this article, a methodological framework is summarised considering the training as a neuro-behavioural treatment. Randomised controlled trials are selectively reviewed. Results from two smaller-scale studies are presented with the first study comprising a tomographic analysis over the course of a slow cortical potential (SCP) training and a correlational analysis of regulation skills and clinical outcome in children with ADHD. In the second study, ADHD-related behaviour was studied in children with tic disorder who either conducted a SCP training or a theta/low-beta (12–15 Hz) training (single-blind, randomised design). Both studies provide further evidence for the specificity of NF effects in ADHD.

Based on these findings, a refined model of the mechanisms contributing to the efficacy of SCP training is developed. Despite a number of open questions concerning core mechanisms, moderators and mediators, NF (theta/beta and SCP) training seems to be on its way to become a valuable and ethically acceptable module in the treatment of children with ADHD.

 The research article can be accessed by clicking the link here: (https://doi.org/10.1007/s10548-013-0285-y).

 

 

6. Nonpharmacological Treatments for ADHD: A Meta-Analytic Review

Hodgson, K., Hutchinson, A. D., & Denson, L.

Journal of Attention Disorders (2012)

Abstract:Objective: The authors replicated and expanded on Fabiano et al.’s meta-analysis of behavioral treatments for ADHD, systematically comparing the efficacy of 7 nonpharmacological interventions. Method: A total of 14 controlled treatment studies conducted post-1994—evaluating behavior modification, neurofeedback therapy, multimodal psychosocial treatment, school-based programs, working memory training, parent training, and self-monitoring—were identified, primarily by searching electronic English-language databases. The results were meta-analyzed: mean-weighted effect sizes

for the treatment outcomes of 625 participants (382 treatment, 243 controls) were calculated, and moderator analyses examined contributions of gender, ADHD subtype, and treatment “dosage” to outcome. Results: Behavior modification and neurofeedback treatments were most supported by this evidence. Interventions were generally more efficacious for girls, and least efficacious for the “combined” ADHD subtype. The authors found no dose or age effects. Conclusion: Based on the small, published literature, this study supports some nonpharmacological interventions for ADHD, and indicates directions for more evaluation research into psychological treatments.

 The research article can be accessed by clicking the link here: (https://doi.org/10.1177/1087054712444732).

 

 

7. The Effects of QEEG-Informed Neurofeedback in ADHD: An Open-Label Pilot Study

Arns, M., Drinkenburg, W., & Kenemans, J. L.

Appl. Psychophysiol. Biofeedback (2012)

 Abstract: In ADHD several EEG biomarkers have been described before, with relevance to treatment outcome to stimulant medication. This pilot-study aimed at personalizing neurofeedback treatment to these specific sub-groups to investigate if such an approach leads to improved clinical outcomes. Furthermore, pre- and post-treatment EEG and ERP changes were investigated in a sub-group to study the neurophysiological effects of neurofeedback. Twenty-one patients with ADHD were treated with QEEG-informed neurofeedback and post-treatment effects on inattention (ATT), hyperactivity/impulsivity (HI) and comorbid depressive symptoms were investigated. There was a significant improvement forboth ATT, HI and comorbid depressive complaints after QEEG-informed neurofeedback. The effect size for ATT was 1.78 and for HI was 1.22. Furthermore, anterior individual alpha peak frequency (iAPF) demonstrated a strong relation to improvement on comorbid depressive complaints. Pre- and post-treatment effects for the SMR neurofeedback sub-group exhibited increased N200 and P300 amplitudes and decreased SMR EEG power post-treatment. This pilot study is the first study demonstrating that it is possible to select neurofeedback protocols based on individual EEG biomarkers and suggests this results in improved treatment outcome specifically for ATT, however these results should be replicated in further controlled studies. A slow anterior iAPF at baseline predicts poor treatment response on comorbid depressive complaints in line with studies in depression. The effects of SMR neurofeedback resulted in specific ERP and EEG changes.

 The research article can be accessed by clicking the link here: (https://doi.org/10.1007/s10484-012-9191-4).

 

 8. Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta-analysis.

Arns, M., de Ridder, S., Strehl, U., Breteler, M., & Coenen A.

Clin EEG Neurosci. 2009

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.

The research article can be accessed by clicking the link here: (https://doi.org/10.1177/155005940904000311).

 

9. Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial

Gevensleben, H., Holl, B., Albrecht, B., Vogel, C., Schlamp, D., Kratz, O., Studer, P., Rothenbrger, A., Moll, G.H., & Heinrich, H.

The Journal of Child Psychology and Psychiatry. 2009

Abstract

Background:  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. Methods:  102 children with ADHD, aged 8 to 12 years, participated in the study. Children performed either 36 sessions of NF training or a computerised attention skills training within two blocks of about four weeks each (randomised group assignment). The combined NF treatment consisted of one block of theta/beta training and one block of slow cortical potential (SCP) training. Pre-training, intermediate and post-training assessment encompassed several behaviour rating scales (e.g., the German ADHD rating scale, FBB‐HKS) completed by parents and teachers. Evaluation (‘placebo’) scales were applied to control for parental expectations and satisfaction with the treatment. Results:  For parent and teacher ratings, improvements in the NF group were superior to those of the control group. For the parent-rated FBB‐HKS total score (primary outcome measure), the effect size was .60. Comparable effects were obtained for the two NF protocols (theta/beta training, SCP training). Parental attitude towards the treatment did not differ between NF and control group. Conclusions:  Superiority of the combined NF training indicates clinical efficacy of NF in children with ADHD. Future studies should further address the specificity of effects and how to optimise the benefit of NF as treatment module for ADHD.

 

The research article can be accessed by clicking the link here: (https://doi.org/10.1111/j.1469-7610.2008.02033.x).

 

10. Distinct EEG effects related to neurofeedback training in children with ADHD: A randomized controlled trial

Gevensleben, H., Holl, B., Albrecht, B., Schlamp, D., Kratz, O., Studer, P., Wangler, S., Rothenberger, A., Moll, G.H., & Heinrich, H.

International Journal of Psychophysiology. 2009

 

Abstract: In a randomized controlled trial, neurofeedback (NF) training was found to be superior to a computerised attention skills training concerning the reduction of ADHD symptomatology (Gevensleben et al., 2009). The aims of this investigation were to assess the impact of different NF protocols (theta/beta training and training of slow cortical potentials, SCPs) on the resting EEG and the association between distinct EEG measures and behavioral improvements. In 72 (of initially 102) children with ADHD, aged 8–12, EEG changes after either a NF training (n = 46) or the control training (n = 26) could be studied. The combined NF training consisted of one block of theta/beta training and one block of SCP training, each block comprising 18 units of 50 minutes (balanced order). Spontaneous EEG was recorded in a two-minute resting condition before the start of the training, between the two training blocks and after the end of the training. Activity in the different EEG frequency bands was analyzed. In contrast to the control condition, the combined NF training was accompanied by a reduction of theta activity. Protocol-specific EEG changes (theta/beta training: decrease of posterior-midline theta activity; SCP training: increase of central-midline alpha activity) were associated with improvements in the German ADHD rating scale. Related EEG-based predictors were obtained. Thus, differential EEG patterns for theta/beta and SCP training provide further evidence that distinct neuronal mechanisms may contribute to similar behavioral improvements in children with ADHD.

 

The research article can be accessed by clicking the link here: (https://doi.org/10.1016/j.ijpsycho.2009.08.005).

 

11. Neurofeedback for Children with ADHD: A Comparison of SCP and Theta/Beta Protocols

Leins, U., Goth, G., Hinterberger, T., Klinger, C., Rump, N., & Strehl, U.

Applied Psychophysiology and Biofeedback. 2007

Abstract: Behavioral and cognitive improvements in children with ADHD have been consistently reported after neurofeedback-treatment. However, neurofeedback has not been commonly accepted as a treatment for ADHD. This study addresses previous methodological shortcomings while comparing a neurofeedback-training of Theta-Beta frequencies and training of slow cortical potentials (SCPs). The study aimed at answering (a) whether patients were able to demonstrate learning of cortical self-regulation, (b) if treatment leads to an improvement in cognition and behavior and (c) if the two experimental groups differ in cognitive and behavioral outcome variables. SCP participants were trained to produce positive and negative SCP-shifts while the Theta/Beta participants were trained to suppress Theta (4–8 Hz) while increasing Beta (12–20 Hz). Participants were blind to group assignment. Assessment included potentially confounding variables. Each group was comprised of 19 children with ADHD (aged 8–13 years). The treatment procedure consisted of three phases of 10 sessions each. Both groups were able to intentionally regulate cortical activity and improved in attention and IQ. Parents and teachers reported significant behavioral and cognitive improvements. Clinical effects for both groups remained stable six months after treatment. Groups did not differ in behavioural or cognitive outcome.

 

The research article can be accessed by clicking the link here: (https://doi.org/10.1007/s10484-007-9031-0).

 

12. 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

(This article is one of the most cited research papers, and it should be taken into consideration under the historical development of Neurofeedback)

Lubar, J.F., Swartwood, M.O., Swartwood, J.N., & O’Donnell.

Biofeedback and Self-regulation. 1995

Abstract: 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. Feedback was contingent on the production of 16–20 hertz (beta) activity in the absence of 4–8 hertz (theta) activity. Posttraining changes in EEG activity, T.O.V.A. performance, (ADDES) behavior ratings, and WISC-R performance were assessed. Part I indicated that subjects who successfully decreased theta activity showed significant improvement in T.O.V.A. performance; Part II revealed significant improvement in parent ratings following neurofeedback training; and Part III indicated significant increases in WISC-R scores following neurofeedback training. This study is significant in that it examines the effects of neurofeedback training on both objective and subjective measures under relatively controlled conditions. Our findings corroborate and extend previous research, indicating that neurofeedback training can be an appropriate and efficacious treatment for children with ADHD.

The research article can be accessed by clicking the link here: (https://doi.org/10.1007/BF01712768).