Are you a parent looking for information or help with Attention Deficit Hyperactivity Disorder or Oppostional Defiant Disorder? Are you considering using Ritalin, Dexedrine, Strattera, or Adderall? Are you looking for alternative treatments? Perhaps your child has a problem with learning disabilities, such as dyslexia or simple behavior issues. At this site you will find all the help you need on these topics, plus information on conduct disorder, social skills training, neurofeedback, parent counseling, relaxation training, dealing with school problems, discipline, and more.


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Added September 19, 2004

The Role of Neurofeedback in ADHD Treatment

Neurofeedback is probably the most interesting and promising treatment modality for ADHD in use today. The goal of the treatment is to teach a person to change the way his brain works, so that the person no longer functions like he has ADHD. That means that with neurofeedback your child could teach his brain not to have ADHD. Would such a thing interest you? We are now going to go into how it works.

What is Biofeedback?

Biofeedback is the use of instrumentation to mirror psychological and physiological processes of which the individual is not normally aware. These processes are usually considered involuntary. However, through biofeedback they may be brought under voluntary control. The person receives information about the status of his own biological state, and using this information, learns to gain control over involuntary biological functions.

Neurofeedback is a type of biofeedback that can be used to train ADHD children to change their brain wave patterns to be more like normal children. Using an electroencephalograph to monitor the brain waves and a system of positive reinforcement, the children learn how to make their brains become more attentive. The result is that there is a significant reduction in ADHD symptoms and improvements in behavior, relative to how well the children learn to control their own brain function.

How Does Neurofeedback Work?

Every normal person has five major types of brain wave patterns. Multiple patterns are present in the brain at any given time, but each area of the brain has a predominate pattern that reflects the persons current mental state. These patterns can be measured and recorded by an electroencephalogram (EEG). The EEG can be used to make a map of the person’s mental function. The five types of brain wave patterns are:

    Beta waves: These are fastest waves. When a person is attentive, his brain has a lot of beta waves.

    SMR waves: These are a subcategory of beta waves. These are the waves that occur in the sensorimotor cortex when a person is quietly focused to prepare for a physical challenge.

    Alpha waves: These waves are slower. These are the brain waves of relaxation.

    Theta waves: These waves are even slower. This is the brain wave pattern that a person has when he is daydreaming or almost at the point of falling asleep.

    Delta waves: These are the slowest brain waves. These are the brain waves of deep sleep.
When a normal child tries to read or concentrate, he increases the amount of beta waves in certain parts of his brain. ADHD children don’t do this. Instead of increasing beta waves, they increase theta waves, the daydreaming brain wave. That means that where other children are concentrating harder to complete a certain task, ADHD children are drifting off.

Does Neurofeedback Work?

The Claim

When an ADHD child is given a task requiring attention, instead of increasing beta waves, sometimes he increases theta waves, the day dreaming brain wave. These children have what is known as a high theta/beta ratio. Using neurofeedback, a technique was developed to train ADHD children to increase the beta/theta ratio.

This is how it works: Over a series of 40 or more neurofeedback sessions, children are gradually taught to inhibit the brains production of theta waves and increase the brains use of beta waves. A large number of children can learn to make these changes. As the children learn to adjust their brain wave patterns, they show an improvement in cognition, and a reduction in ADHD symptoms and behavior. This symptomatic improvement is similar to what we see when the children take stimulant medication. There is one significant difference, however.

When children take stimulants, the effects last a few hours. As the medicine wears off, the ADHD symptoms return. When children learn to control their brain waves using neurofeedback, the improvement in ADHD symptoms does not disappear. The child is better.

I’ll say it again differently. When a child completes his neurofeedback training and the treatment is successful, he now has a normal beta/theta ratio, and many or all of his ADHD symptoms disappear. This improvement is permanent. There have been follow-up studies over a decade. Any gains the child makes stays with him.

This means that when the treatment is successful, it probably works for life. This makes neurofeedback a very significant treatment. No other treatment makes a permanent change like this. All of this is extremely exciting, provided that it is true.

The Counterclaim

However, many ADHD researchers, most notably Russell Barkley, say it is not true. Barkley claims that there is little or no evidence that neurofeedback works at all. He maintains that the supporting research is sloppy and does not prove anything. In an interview, Barkley expressed his skepticism.

    “Case studies prove nothing because they’re totally uncontrolled. There’s an aura of medical intervention here. High technology in a medical environment has a high placebo effect…. It’s not the equipment. It’s the exercises, the mental exercises they are telling these kids to do. (Some kids may be getting better) with maturation alone…and some kids don’t have ADD.”
Another critic of neurofeedback is neurophysiologist, Sam Goldstein. Goldstein is not quite as negative as Barkley, but he echoes many of the same reservations.

    “The older studies are not well done…There are a number of possible explanations. One is, it works. Two, its a placebo. Three is, there’s some mechanism operating that we don’t understand…. I would like these guys to do more research, and I support their application for research grants.”
How valid are these complaints? How valid are the claims of the supporters of neurofeedback?

The Evidence

Neurofeedback has been used successfully in the treatment of epilepsy and drug rehabilitation. It has some very impressive results in both of these areas. This already lends a great deal of credibility to the field. It changes the question we ask. We don’t have to ponder if this is a genuine treatment modality. We see that it is. The question is whether its efficacy also extends to the treatment of ADHD.

Neurofeedback for ADHD has been actively studied and used clinically for over three decades, and there is much to say in its favor. There are numerous studies showing its effectiveness. There are many children who have been gone through neurofeedback and are now functioning normally.

What about the criticism? In many cases it is valid. The experiments were not well done and they do not prove conclusively that neurofeedback works. However, all the studies point in the same direction. There are no studies suggesting that neurofeedback is ineffective. In addition, none of the critics have produced evidence that neurofeedback doesn’t work. The most they claim is that the modality is still unproven.

The Down Side

There are problems with neurofeedback.

The treatment takes a long time- at least 40 sessions. Each session can cost up to $100. Naturally, insurance does not cover it. So, this fairly expensive treatment comes directly out of your pocket. However, there are ways around this expense.

Neurofeedback requires the child to be motivated to complete the full treatment. If the child gets bored, the treatment won’t work as well.

The child has to be at the right age for the treatment. If he is too young, he will not be able to do what he needs to do. As he gets older, it may become boring for him. Also, the older the patient gets, the harder it is to make the EEG changes. Adults have a more difficult time getting good results with this treatment than children.

Finally, this treatment does not work for everybody. I have not seen any hard data on what the percentages are. The leading proponents claim that the success rate is greater than 90%.

Is this true? Probably not. One therapist told me that he feels it might help only about 50% of the patients. The trouble is that you don’t know whom it is going to help until you are very far into the program. It make take over twenty sessions before you know things are not going well. That is a lot of money and time invested in a treatment that may not work.

There is one other concern that no one else is going to tell you. This is my personal concern. It seems to me that a treatment that is so powerful that it can permanently change the way the brain functions may have some very significant adverse effects if misapplied. It is not clear to me that we know so much about brain function that we can monkey around with it and get it perfectly right every time.

Now admittedly, there is no report of any harmful affects. Any damage must be small enough that it is possible to overlook it. It might be something as subtle as a decrease in creativity.

On the other hand, who is going to report it? The scientists who feel neurofeedback works and have invested their lives and businesses in it have a very good reason not to look too rigorously for negative effects.

The major opponents of neurofeedback certainly will not claim there is a potential for harm. They would have to admit that neurofeedback does something first, which is contrary to their platform that it is ineffective.

So the only one who will even suggest the possibility that neurofeedback may be dangerous is someone like myself, who has no personal stake in whether or not it works. If I have to start selling pencils on the street next week, it is not going to be because of what is happening in the world of neurofeedback.

What You Should Do

There is enough evidence that supports the efficacy of neurofeedback that I feel it is worth the time and the risk. As far as the cost, neurofeedback is less than half of what you will spend for your child’s first semester at Yale or Princeton. And if it works, you might be sending your child there.

Also, as I describe in How to Help the Child You Love, there are ways you can greatly reduce the cost. You may be able to save as much as $3000. I was able to have both of my ADHD children treated for less than $800. So, the price is not as big a factor as it sounds.

So the question is not whether or not you should investigate neurofeedback, but how you should approach it. It is my perception that there is a great deal of variability in the field. That means that there are some neurofeedback providers that are excellent and some fall somewhat short of excellent. You must choose your provider carefully.

Conclusion

EEG biofeedback is not a “cure” for ADHD. Nevertheless, there is an increasing body of evidence that it leads to “normalization” of behavior and can enhance the long-term academic performance, social functioning, and overall life adjustment of your ADHD child.

It would be wonderful if we could have solid experimental evidence whether or not neurofeedback works in ADHD. That is out of our hands. However, if I had an AHDH child, which I do, and knowing the evidence available, which I do, I would not wait around for another decade or so, which I didn’t, until enough evidence accumulated to confirm the efficacy of neurofeedback before I would try it on my child, which I did.

The main thing to remember is, just don’t pick anyone. You must have a way to determine who is good. You can use the approach I outline in How to Help the Child You Love. You can use a different approach. You have to have a way of finding who in your area is good and whom you should avoid.


Anthony Kane, MD

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