In-School Neurofeedback Training for ADHD: Sustained improvements from a randomized control trial - Steiner et. al. - 2014 - Article

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with core symptoms of inattention, hyperactivity, and/or impulsivity and has a prevalence of 9.5% for 4-to 17-year-olds in the United States. Executive functioning is typically impaired in children with ADHD, affecting their academic achievement. Computer Attention Training is used to decrease ADHD symptoms and improve executive functioning skills. Two types of CompAT interventions were evaluated in the current study: neurofeedback and cognitive training (CT). Neurofeedback trains users to monitor and change their brainwave patterns, leading to behavioral changes. CT uses specifically designed exercises to train attention, working memory, and impulsivity through ongoing feedback to reinforce correct responses.

Methods

Participants

Students with ADHD attending 1 of 19 public elementary suburban or urban schools in the Greater Boston area were eligible to participate in the randomized trial. Inclusion criteria in-cluded the following:

1. Child in secondor fourth grade

2. Clinical diagnosis of ADHD made by the child’s clinician

3. Ability to speak and understand English well enough to follow the protocol

One hundred four children were randomly assigned to receive neurofeedback, CT, or a control condition and were evaluated 6 months postintervention.

Interventions

Participants received in-school 45-minute intervention sessions 3 times per week, monitored by a trained research assistant (RA), for 40 sessions over 5 months.

Primary Outcome Measures

Outcome measures included parent reports of ADHD symptoms and executive functioning, medication use, and systematic classroom observations of behavior. All outcome measures were obtained pre- and postintervention, and 6 months later. A 3-point growth model assessed change over time across the conditions on the Conners 3–Parent Assessment Report (Conners 3-P), the Behavior Rating Inventory of Executive Function Parent Form (BRIEF), and a systematic double-blinded classroom observation (Behavioral Observation of Students in Schools).

Data Analysis

Because this study investigated whether the 2 CompAT interventions are superior to community treatment alone, and whether neurofeedback is superior to CT, the randomized controlled trial is considered a superiority trial and analyses are presented with 1-tailed tests. The central focus of the analyses was to evaluate whether the observed changes in core ADHD symptoms between the startand end of the treatment period were sustained at the 6-month follow-up. Comparisons between neurofeedback and CT were undertaken using multivariate general linear hypothesis tests. Paired t tests were conducted to evaluate stimulant medication differences in methylphenidate equivalencies within randomization conditions between pre-intervention and the 6-month follow-up. An analysis of covariance was conducted to evaluate medication dosage differences among the randomization conditions at 6-month follow-up. 

Results

Of the 104 children in the study, 102 completed the intervention. Of these, only 4 did not complete the 6-month follow-up assessment. At baseline, 95% of participants showed clinically significant scores on the DSM,
Fourth Edition, ADHD Inattention and/or ADHD Hyperactive-Impulsive subscales. At baseline, 49% of participants were taking medication.

Growth Model Analysis

Parent-Reported Measures

Six months postintervention, neurofeedback participants maintained significant gains on Conners 3-P (Inattention effect size [ES] = 0.34, Executive Functioning ES = 0.25, Hyperactivity/Impulsivity ES = 0.23) and BRIEF subscales including the Global Executive Composite (ES = 0.31), which remained significantly greater than gains found among children in CT and control conditions. Children in the CT condition showed delayed improvement over immediate postintervention ratings only on Conners 3-P Executive Functioning (ES = 0.18) and 2 BRIEF subscales.

Classroom Observation

There were no differences found between neurofeedback and CT conditions on classroom observation measures. 

Medication Analysis

At the 6-month follow-up, neurofeedback participants maintained the same stimulant medication dosage, whereas participants in both CT and control conditions showed statistically and clinically significant increases
(9 mg [P = .002] and 13 mg [P , .001], respectively).

Discussion

The outcomes of the analyses are promising, as children in the  neurofeedback condition reported sustained improvements 6 months after the intervention, compared with those in the control condition. In the CT condition, areas of executive functioning that did not show statistically significant change immediately after the intervention showed a significant change by the 6-month follow-up assessment compared with the control condition. The inclusion of the systematic classroom observations provided a valid double-blinded representation of the children’s behavior in the classroom. This study used multiple sources and types of data including questionnaires from parents, systematic classroom observations of behavior, and medication.

Conclusions

Neurofeedback participants made more prompt and greater improvements in ADHD symptoms, which were sustained at the 6-month follow-up, than did CT participants or those in the control group. This finding suggests that neurofeedback is a promising attention training treatment for children with ADHD.