title: Self-reported efficacy of neurofeedback treatment in a clinical randomized controlled study of ADHD children and adolescents Multimodal treatment in children and adolescents with attention-deficit/hyperactivity disorder: a 6-month follow-up Real‐time fMRI neurofeedback in adolescents with attention deficit hyperactivity disorder Behavioral Effects of Neurofeedback Compared to Stimulants and Physical Activity in Attention-Deficit/Hyperactivity Disorder: A Randomized Controlled Trial. A randomized controlled trial into the effects of neurofeedback, methylphenidate, and physical activity on EEG power spectra in children with ADHD. Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports An RCT into the effects of neurofeedback on neurocognitive functioning compared to stimulant medication and physical activity in children with ADHD Effects of neurofeedback versus stimulant medication in attention-deficit/hyperactivity disorder: a randomized pilot study. Additive effects of neurofeedback on the treatment of ADHD: A randomized controlled study. A Randomized Controlled Trial Investigating the Effects of Neurofeedback, Methylphenidate, and Physical Activity on Event-Related Potentials in Children with Attention-Deficit/Hyperactivity Disorder. Reprint of “Neurofeedback and standard pharmacological intervention in ADHD: A randomized controlled trial with six-month follow-up” A randomised controlled trial of combined EEG feedback and methylphenidate therapy for the treatment of ADHD. Neurocognitive effects of neurofeedback in adolescents with ADHD: a randomized controlled trial. Young adult outcomes in the follow‐up of the multimodal treatment study of attention‐deficit/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression
abstract: Background Many non-pharmacological treatments for children and adolescents with attention-deficit/hyperactivity disorder ( ADHD ) have been attempted , but reports indicate that most are ineffective . Although neurofeedback ( NF ) is a treatment approach for children with ADHD that remains promising , a variety of appropriate measures have been used in reporting and evaluating its effect . Objective To report the self-evaluations of NF treatment by children and adolescents with ADHD . Methods R and omized controlled trial in 91 children and adolescents with ADHD , aged less than 18 years ( mean , 11.2 years ) participated in a 30-session program of intensive NF treatment .  Participants were r and omized and allocated by sequentially numbered sealed envelopes into three groups : methylpheni date ( MPH ) as an active control group , and two trial groups NF with MPH , and NF alone .  ADHD core symptoms and school performance were given on a scale of 1 to 10 using a self-reporting question naire , and the changes in these scores after treatment were used as the self-reported evaluation . Basic statistical methods ( descriptive , analyses of variance , exact χ2 test , and paired t-test ) were used to investigate the baseline data . Changes in ADHD core symptoms and treatment effects were investigated using a general linear model for repeated measures . Results Eighty participants completed the treatment study and 73 ( 91 % ) responded sufficiently on the self-reporting question naires . The treatment groups were comparable in age , sex , and cognition as well as in the baseline levels of core ADHD symptoms . All treatments result ed in significant improvements regarding attention and hyperactivity ( P<0.001 ) , and did not differ from each other in effectiveness . However , a significant treatment effect in school performance was observed ( P=0.042 ) , in which only the NF group showed a significant improvement . Conclusion The self-reported improvements in ADHD core symptoms and school performance shortly after treatment indicate NF treatment being promising in comparison with medication , suggesting NF as an alternative treatment for children and adolescents who do not respond to MPH , or who suffer side effects . Further long-term follow-up is needed Abstract Background : Different treatment approaches aim ed at reducing attention-deficit/hyperactivity disorder ( ADHD ) core symptoms are available . However , factors such as intolerance , side-effects , lack of efficacy , high new technology costs , and placebo effect have spurred on an increasing interest in alternative or complementary treatment . Aim : The aim of this study is to explore efficacy of multimodal treatment consisting of st and ard stimulant medication ( methylpheni date ) and neurofeedback ( NF ) in combination , and to compare it with the single treatment in 6-month follow-up in ADHD children and adolescents . Methods : This r and omized controlled trial with 6-month follow-up comprised three treatment arms : multimodal treatment ( NF + MED ) , MED alone , and NF alone .  A total of 130 ADHD children/adolescents participated , and 62 % completed the study .  ADHD core symptoms were recorded pre-/post-treatment , using parents ’ and teachers ’ forms taken from Barkley ’s Defiant Children : A Clinician ’s Manual for Assessment and Parent Training , and a self-report question naire . Results : Significant ADHD core symptom improvements were reported 6 months after treatment completion by parents , teachers , and participants in all three groups , with marked improvement in inattention in all groups . However , no significant improvements in hyperactivity or academic performance were reported by teachers or self-reported by children/adolescents , respectively , in the three groups . Changes obtained with multimodal treatment at 6-month follow-up were comparable to those with single medication treatment , as reported by all participants . Conclusions : Multimodal treatment using combined stimulant medication and NF showed 6-month efficacy in ADHD treatment . More research is needed to explore whether multimodal treatment is suitable for ADHD children and adolescents who showed a poor response to single medication treatment , and for those who want to reduce the use of stimulant medication Abstract Attention Deficit Hyperactivity Disorder ( ADHD ) is associated with poor self‐control , underpinned by inferior fronto‐striatal deficits . Real‐time functional magnetic resonance neurofeedback ( rtfMRI‐NF ) allows participants to gain self‐control over dysregulated brain regions . Despite evidence for beneficial effects of electrophysiological‐NF on ADHD symptoms , no study has applied the spatially superior rtfMRI‐NF neurotherapy to ADHD . A r and omized controlled trial tested the efficacy of rtfMRI‐NF of right inferior prefrontal cortex ( rIFG ) , a key region that is compromised in ADHD and upregulated with psychostimulants , on improvement of ADHD symptoms , cognition , and inhibitory fMRI activation . To control for region‐specificity , an active control group received rtfMRI‐NF of the left parahippocampal gyrus ( lPHG ) . Thirty‐one ADHD boys were r and omly allocated and had to learn to upregulate their target brain region in an average of 11 rtfMRI‐NF runs over 2 weeks . Feedback was provided through a video‐clip of a rocket that had to be moved up into space . A transfer session without feedback tested learning retention as a proximal measure of transfer to everyday life . Both NF groups showed significant linear activation increases with increasing number of runs in their respective target regions and significant reduction in ADHD symptoms after neurotherapy and at 11‐month follow‐up . Only the group targeting rIFG , however , showed a transfer effect , which correlated with ADHD symptom reductions , improved at trend level in sustained attention , and showed increased IFG activation during an inhibitory fMRI task . This proof‐of‐concept study demonstrates for the first time feasibility , safety , and shorter‐ and longer‐term efficacy  of rtfMRI‐NF of rIFG in adolescents with ADHD . Hum Brain Mapp 38:3190–3209 , 2017 . © 2017 The Authors Human Brain Mapping Published by Wiley Periodicals , OBJECTIVE The efficacy of neurofeedback as a treatment for attention-deficit/hyperactivity disorder ( ADHD ) , and whether neurofeedback is a viable alternative for stimulant medication , is still an intensely debated subject . The current r and omized controlled trial compared neurofeedback to ( 1 ) optimally titrated methylpheni date and ( 2 ) a semi-active control intervention , physical activity , to account for nonspecific effects . METHODS A multicenter 3-way parallel-group study with balanced r and omization was conducted . Children with a DSM-IV-TR diagnosis of ADHD , aged 7 - 13 years , were r and omly allocated to receive neurofeedback ( n = 39 ) , methylpheni date ( n = 36 ) , or physical activity ( n = 37 ) over a period of 10 - 12 weeks . Neurofeedback comprised theta/beta training on the vertex ( Cz ) . Physical activity consisted of moderate to vigorous intensity exercises . Neurofeedback and physical activity were balanced in terms of number ( ~30 ) and duration of sessions . A double-blind pseudor and omized placebo-controlled crossover titration procedure was used to determine an optimal dose in the methylpheni date intervention . Parent and teacher ratings on the Strengths and Difficulties Question naire ( SDQ ) and Strengths and Weaknesses of ADHD Symptoms and Normal Behavior ( SWAN ) were used to assess intervention outcomes . Data collection took place between September 2010 and March 2014 . RESULTS Intention-to-treat analyses revealed an improvement in parent-reported behavior on the SDQ and the SWAN Hyperactivity/Impulsivity scale , irrespective of received intervention ( ηp² = 0.21 - 0.22 , P ≤ .001 ) , whereas the SWAN Inattention scale revealed more improvement in children who received methylpheni date than neurofeedback and physical activity ( ηp² = 0.13 , P ≤ .001 ) . Teachers reported a decrease of ADHD symptoms on all measures for methylpheni date , but not for neurofeedback or physical activity ( range of ηp² = 0.14 - 0.29 , P < .001 ) . CONCLUSIONS The current study found that optimally titrated methylpheni date is superior to neurofeedback and physical activity in decreasing ADHD symptoms in children with ADHD . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT01363544 BACKGROUND The clinical and neurophysiological effects of neurofeedback ( NF ) as treatment for children with ADHD are still unclear . This r and omized controlled trial ( RCT ) examined electroencephalogram ( EEG ) power spectra before and after NF compared to methylpheni date ( MPH ) treatment and physical activity ( PA ) - as semi-active control group - during resting and active ( effortful ) task conditions to determine whether NF can induce sustained alterations in brain function . METHODS Using a multicentre three-way parallel group RCT design , 112 children with a DSM-IV diagnosis of ADHD , aged between 7 and 13 years , were initially included . NF training consisted of 30 sessions of theta/beta training at Cz over a 10-week period . PA training was a semi-active control group , matched in frequency and duration . Methylpheni date was titrated using a double-blind placebo controlled procedure in 6 weeks , followed by a stable dose for 4 weeks . EEG power spectra measures during eyes open ( EO ) , eyes closed ( EC ) and task ( effortful ) conditions were available for 81 children at pre- and postintervention ( n = 29 NF , n = 25 MPH , n = 27 PA ) . CLINICAL TRIALS REGISTRATION Train Your Brain ? Exercise and Neurofeedback Intervention for ADHD , https:// clinical trials.gov/show/;NCT01363544 , Ref . No. NCT01363544 . RESULTS Both NF and MPH result ed in comparable reductions in theta power from pre- to postintervention during the EO condition compared to PA ( ηp ( 2 ) = .08 and .12 ) . For NF , greater reductions in theta were related to greater reductions in ADHD symptoms . During the task condition , only MPH showed reductions in theta and alpha power compared to PA ( ηp ( 2 ) = .10 and .12 ) . CONCLUSIONS This study provides evidence for specific neurophysiological effects after theta/beta NF and MPH treatment in children with ADHD . However , for NF these effects did not generalize to an active task condition , potentially explaining reduced behavioural effects of NF in the classroom Background A r and omized and controlled clinical study was performed to evaluate the use of neurofeedback ( NF ) to treat  attention-deficit/hyperactivity disorder ( ADHD ) in children and adolescents . Methods The ADHD population was selected from an outpatient clinic for Child and Adolescent Mental Health in Norway . Ninety-one of the 275 children and adolescents ranging in age from 6 to 18 years ( 10.5 years ) participated in 30 sessions of an intensive NF program . The reinforcement contingency was based on the subjects ’ production of cortical beta1 activity ( 15–18 Hz ) . The ADHD participants were r and omized into three groups , with 30 in the NF group , 31 controls in a group that was given methylpheni date , and 30 in a group that received NF and methylpheni date .  ADHD core symptoms were reported by parents using the parent form of the Clinician ’s Manual for Assessment by Russell A. Barkley . Results Ninety-one children and adolescents were effectively r and omized by age , sex , intelligence and distribution of ADHD core symptoms . The parents reported significant effects of the treatments , but no significant differences between the treatment groups were observed . Conclusions NF was as effective as methylpheni date at treating the attentional and hyperactivity symptoms of ADHD , based on parental reports . Trial registration Current Controlled Trials Neurofeedback ( NFB ) is a potential alternative treatment for children with ADHD that aims to optimize brain activity . Whereas most studies into NFB have investigated behavioral effects , less attention has been paid to the effects on neurocognitive functioning . The present r and omized controlled trial ( RCT ) compared neurocognitive effects of NFB to ( 1 ) optimally titrated methylpheni date ( MPH ) and ( 2 ) a semi-active control intervention , physical activity ( PA ) , to control for non-specific effects . Using a multicentre three-way parallel group RCT design , children with ADHD , aged 7–13 , were r and omly allocated to NFB ( n = 39 ) , MPH ( n = 36 ) or PA ( n = 37 ) over a period of 10–12 weeks . NFB comprised theta/beta training at CZ . The PA intervention was matched in frequency and duration to NFB . MPH was titrated using a double-blind placebo controlled procedure to determine the optimal dose . Neurocognitive functioning was assessed using parameters derived from the auditory oddball- , stop-signal- and visual spatial working memory task . Data collection took place between September 2010 and March 2014 . Intention-to-treat analyses showed improved attention for MPH compared to NFB and PA , as reflected by decreased response speed during the oddball task [ ηp2 = 0.21 , p < 0.001 ] , as well as improved inhibition , impulsivity and attention , as reflected by faster stop signal reaction times , lower commission and omission error rates during the stop-signal task ( range ηp2 = 0.09–0.18 , p values < 0.008 ) . Working memory improved over time , irrespective of received treatment ( ηp2 = 0.17 , p < 0.001 ) . Overall , stimulant medication showed superior effects over NFB to improve neurocognitive functioning . Hence , the findings do not support theta/beta training applied as a st and -alone treatment in children with ADHD OBJECTIVE The purpose of this pilot study was to compare the effects of 30 sessions of neurofeedback ( NF ) with stimulant medication on attention-deficit/hyperactivity disorder ( ADHD ) patients . METHODS Thirty-two medication-naïve ADHD patients , ages 7 - 16 , from a neuropsychiatric clinic , were r and omized to NF ( n=16 ) or drug treatment ( n=16 ) . Other actions , such as parent management training , information , or support in school were given as needed , with no differences between the groups . All participants were assessed before treatment on two rating scales , each with parent and teacher forms . In addition , quantitative electroencephalogram ( QEEG ) and event-related potentials ( ERPs ) , which included behavioral data from a go/no go test were administered . NF training took place in the clinic over a period of 7 - 11 months , and was followed by a repeat of the same assessment tools . The mean time interval between pre- and postassesment was not significantly different in the two groups . The 18 symptoms of ADHD ( American Psychiatric Association , Diagnostic and Statistical Manual of Mental Disorders , 4th ed . ( DSM-IV ) ) were used as the primary outcome measure . RESULTS Analysis of covariance revealed a significant difference between the groups at evaluation in favor of medication , with a large effect size . This picture was confirmed by other outcome measures . The QEEG spectral power in the theta and beta b and s did not change in either group . In ERP , the P3 no go component increased significantly in 8 of 12 patients who had a clinical ly relevant medication effect , but did not increase in the medication nonresponders or the NF group . CONCLUSIONS Our study supports effects for stimulants , but not for NF . Effects of NF may require thorough patient selection , frequent training sessions , a system for excluding nonresponders , and active transfer training . The P3 no go ERP component may be a marker for treatment response Neurofeedback ( NF ) has been identified as a " possibly efficacious " treatment in current evidence -based review s ; therefore , more research is needed to determine its effects . The current study examined the potential additive effect of NF for children diagnosed with ADHD beginning a medication trial first . Thirty-six children ( 6 - 12 years ) with a DSM-IV-TR diagnosis of ADHD were r and omly assigned to an NF with medication ( NF condition ) or a medication only condition . Children in the NF group attended 20 twice-weekly sessions . Outcome measures included individual cognitive performance scores ( ADS , K-WISC-III ) , ADHD rating scores completed by their parents ( ARS , CRS ) and brainwave indices of left and right hemispheres before and after NF treatment . Significant additive treatment effect in any of the symptom variables was found and a reduction of theta waves in both the right and left hemispheres was recorded in NF condition participants . However our r and omized controlled study could not demonstrate superior effects of combined NF on intelligent functioning compared to the medication treatment only . This study suggested any possible evidence of positive and additive treatment effects of NF on brainwaves and ADHD symptomatology OBJECTIVE Electroencephalographic ( EEG ) neurofeedback ( NF ) is considered a nonpharmacological alternative for medication in attention-deficit/hyperactivity disorder ( ADHD ) . Comparisons of the behavioral efficacy of NF and medication have produced inconsistent results . EEG measures can provide insight into treatment mechanisms , but have received little consideration . In this r and omized controlled trial ( RCT ) , effects of NF were compared with methylpheni date ( MPH ) , and physical activity ( PA ) in children with ADHD on event-related potential ( ERP ) indices of response inhibition , which are involved in ADHD psychopathology . METHODS Using a multicenter three way parallel group RCT design , 112 children with a Diagnostic and Statistical Manual of Mental Disorders , 4th ed . ( DSM-IV ) ( American Psychiatric Association 1994 ) diagnosis of ADHD , between 7 and 13 years of age , were initially included .  NF training consisted of 30 sessions of theta/beta training at Cz over a 10 week period . PA training was a semiactive control group , matched in frequency and duration . MPH was titrated using a double-blind placebo controlled procedure in 6 weeks , followed by a stable dose for 4 weeks . ERP measures of response inhibition , N2 and P3 , were available for 81 children at pre- and postintervention ( n = 32 NF , n = 25 MPH , n = 24 PA ) . RESULTS Only the medication group showed a specific increase in P3 amplitude compared with NF ( partial eta-squared [ ηp(2 ) ] = 0.121 ) and PA ( ηp(2 ) = 0.283 ) , which was related to improved response inhibition . Source localization of medication effects on P3 amplitude indicated increased activation primarily in thalamic and striatal nuclei . CONCLUSIONS This is the first study that simultaneously compared NF with stimulant treatment and a semiactive control group . Only stimulant treatment demonstrated specific improvements in brain function related to response inhibition . These results are in line with recent doubts on the efficacy and specificity of NF as treatment for ADHD . CLINICAL TRIALS REGISTRATION Train Your Brain ? Exercise and Neurofeedback Intervention for ADHD , https:// clinical trials.gov/show/NCT01363544 , Ref . No. NCT01363544 The present study is a r and omized controlled trial that aims to evaluate the efficacy of Neurofeedback compared to st and ard pharmacological intervention in the treatment of attention deficit/hyperactivity disorder ( ADHD ) . The final sample consisted of 23 children with ADHD ( 11 boys and 12 girls , 7 - 14 years old ) . Participants carried out 40 theta/beta training sessions or received methylpheni date .  Behavioral rating scales were completed by fathers , mothers , and teachers at pre- , post-treatment , two- , and six-month naturalistic follow-up . In both groups , similar significant reductions were reported in ADHD functional impairment by parents ; and in primary ADHD symptoms by parents and teachers . However , significant academic performance improvements were only detected in the Neurofeedback group . Our findings provide new evidence for the efficacy of Neurofeedback , and contribute to enlarge the range of non-pharmacological ADHD intervention choices . To our knowledge , this is the first r and omized controlled trial with a six-month follow-up that compares Neurofeedback and stimulant medication in ADHD PURPOSE To evaluate the efficacy of combined methylpheni date and EEG feedback treatment for children with ADHD . METHODS Forty patients with ADHD were r and omly assigned to the combination group ( methylpheni date therapy and EEG feedback training ) or control group ( methylpheni date therapy and non-feedback attention training ) in a 1:1 ratio using the double-blind method . These patients , who met the DSM-IV diagnostic criteria and were aged between 7 and 16 years , had obtained optimal therapeutic effects by titrating the methylpheni date dose prior to the trial . The patients were assessed using multiple parameters at baseline , after 20 treatment sessions , after 40 treatment sessions , and in 6-month follow-up studies . RESULTS Compared to the control group , patients in the combination group had reduced ADHD symptoms and improved in related behavioural and brain functions . CONCLUSION The combination of EEG feedback and methylpheni date treatment is more effective than methylpheni date alone . The combined therapy is especially suitable for children and adolescents with ADHD who insufficiently respond to single drug treatment or experience drug side effects OBJECTIVE Neurofeedback aims to reduce symptoms of attention-deficit/hyperactivity disorder ( ADHD ) , mainly attention problems . However , the additional influence of neurofeedback over treatment as usual ( TAU ) on neurocognitive functioning for adolescents with ADHD remains unclear . METHOD By using a multicenter parallel r and omized controlled trial ( RCT ) design , male adolescents with a DSM-IV-TR diagnosis of ADHD ( mean age = 16.1 years ; range , 12 - 24 ) were r and omized to receive either a combination of TAU and neurofeedback ( n = 45 ) or TAU ( n = 26 ) . R and omization was computer generated and stratified by age group ( ages 12 through 15 , 16 through 20 , and 21 through 24 years ) . The neurofeedback intervention consisted of approximately 37 sessions over a period of 25 weeks of theta/sensorimotor rhythm training on the vertex ( Cz ) . Primary neurocognitive outcomes included performance parameters derived from the D2 Test of Attention , the Digit Span backward , the Stroop Color-Word Test and the Tower of London , all assessed preintervention and postintervention . Data were collected between December 2009 and July 2012 . RESULTS At postintervention , outcomes of attention and /or motor speed were improved , with faster processing times for both intervention conditions and with medium to large effect sizes ( range , ηp2 = .08-.54 ; P values < .023 ) . In both groups , no improvements for higher executive functions were observed . Results might partly resemble practice effects . CONCLUSIONS Although neurocognitive outcomes improved in all adolescents receiving treatment for ADHD , no additional value for neurofeedback over TAU was observed . Hence , this study does not provide evidence for using theta/sensorimotor rhythm neurofeedback to enhance neurocognitive performance as additional intervention to TAU for adolescents with ADHD symptoms . TRIAL REGISTRATION Trialregister.nl identifier : 1759 BACKGROUND The Multimodal Treatment Study ( MTA ) began as a 14-month r and omized clinical trial of behavioral and pharmacological treatments of 579 children ( 7 - 10 years of age ) diagnosed with attention-deficit/hyperactivity disorder (ADHD)-combined type . It transitioned into an observational long-term follow-up of 515 cases consented for continuation and 289 classmates ( 258 without ADHD ) added as a local normative comparison group ( LNCG ) , with assessment s 2 - 16 years after baseline . METHODS Primary ( symptom severity ) and secondary ( adult height ) outcomes in adulthood were specified . Treatment was monitored to age 18 , and naturalistic subgroups were formed based on three patterns of long-term use of stimulant medication ( Consistent , Inconsistent , and Negligible ) . For the follow-up , hypothesis-generating analyses were performed on outcomes in early adulthood ( at 25 years of age ) . Planned comparisons were used to estimate ADHD-LNCG differences reflecting persistence of symptoms and naturalistic subgroup differences reflecting benefit ( symptom reduction ) and cost ( height suppression ) associated with extended use of medication . RESULTS For ratings of symptom severity , the ADHD-LNCG comparison was statistically significant for the parent/self-report average ( 0.51 ± 0.04 , p < .0001 , d = 1.11 ) , documenting symptom persistence , and for the parent/self-report difference ( 0.21 ± 0.04 , p < .0001 , d = .60 ) , documenting source discrepancy , but the comparisons of naturalistic subgroups reflecting medication effects were not significant . For adult height , the ADHD group was 1.29 ± 0.55 cm shorter than the LNCG ( p < .01 , d = .21 ) , and the comparisons of the naturalistic subgroups were significant : the treated group with the Consistent or Inconsistent pattern was 2.55 ± 0.73 cm shorter than the subgroup with the Negligible pattern ( p < .0005 , d = .42 ) , and within the treated group , the subgroup with the Consistent pattern was 2.36 ± 1.13 cm shorter than the subgroup with the Inconsistent pattern ( p < .04 , d = .38 ) . CONCLUSIONS In the MTA follow-up into adulthood , the ADHD group showed symptom persistence compared to local norms from the LNCG . Within naturalistic subgroups of ADHD cases , extended use of medication was associated with suppression of adult height but not with reduction of symptom severity
target: When only trials are considered that include probably blinded ratings or those that are sham-NF or semi-active controlled or those that employed optimally titration procedures , the findings do not support theta/beta NF as a st and alone treatment for children or adolescents with ADHD .
  This review concludes that the present role of NF in treating children diagnosed with ADHD should be considered as complementary in a multimodal treatment approach , individualized to the needs of the child , and may be considered a viable alternative to stimulants for a specific group of patients .
background: This systematic review aim ed to evaluate the efficacy of neurofeedback ( NF ) compared to stimulant medication in treating children and adolescents with attention-deficit/hyperactivity disorder ( ADHD ) .