By Dr. Adi Jaffe, P.hD., Co-Founder and Executive Director of Alternatives Behavioral Health
Make no mistake, the prevalence of ADHD among youth is rising, and fast. The CDC estimates that between 2003 and 2011, the percentage of kids diagnosed with the disorder increased from 7.8% to 11%. It’s not entirely clear what’s driving the surge. More accurate recognition, overdiagnosis, and mobile device overload have all been floated as theories. While the debate over the root causes is sure to roll on, there’s another pressing cause for concern: increasing use of stimulants like Adderall and Ritalin as treatments. A 2011 study by the NIH found that the percentage of all children prescribed a stimulant rose from 2.4% in 1996 to 3.5% in 2008. While in the short-run stimulants appear to be well tolerated and the risk of adverse effects is low, their long-term effects are less clear (Clavenna & Bonati, 2016). A recent study suggests that long-term use of stimulants by kids with ADHD may not improve the severity of symptoms later in life and may also suppress height. And while the hypothesis that stimulant use in youth increases the risk of substance abuse in adulthood has largely been debunked, the jury is still out on the overall long-term safety of the drugs. On that account, there’s an urgent need for non-pharmacological treatments of ADHD in kids, and one you have probably never heard of looks especially promising: neurofeedback.
What is Neurofeedback?
Neurofeedback is best understood by way of the brain’s electrical activity. Our brains produce electrical activity, often called brainwaves, whenever our 100 billion brain cells communicate. Different brainwaves are associated with different mental states and are categorized by their frequency. For example, the faster “beta” waves are associated with alertness and energy. By contrast, “theta” waves are much slower and predominate during sleep. While the brain produces every type of brainwave all the time, functioning problems arise when there are excesses or deficiencies in activity in certain regions. In the case of ADHD, there is an excess of theta waves in the prefrontal cortex, a brain region associated with self-regulation, planning, and focus (it’s also the area of the brain that stimulants act on by increasing production of dopamine and norepinephrine there). Having too much slow wave activity like theta means that function in the prefrontal cortex is inhibited, leading to problems in focus and impulse control that underpin the disorder’s three different types. This suggests that somehow normalizing the brainwaves in the prefrontal cortex might alleviate ADHD symptoms and improve overall function, which is where neurofeedback comes into play.
During neurofeedback, brainwaves serve as the input (hence: “neuro”) that is altered with positive or negative reinforcement (hence: “feedback.”) Training should start with a qEEG analysis, often called “brain mapping,” that reads your brainwave activity and compares it with a database of thousands of people with normal activity. Any significant deviations from the norm, either of excess or deficiency, are highlighted and serve as the basis of neurofeedback training. For example, the prefrontal cortex’s excess theta seen in ADHD would show up as an irregularity and lay the groundwork for a training program in which the theta is trained “down” while other waves are trained “up.” The “brain map” will also assure that the training will be tailored to the brain’s unique signature.
During a training session, brainwaves are measured in real-time with EEG technology by attaching electrodes to the scalp, which then, in a completely harmless and non-invasive way, relay the brain activity to a computer program. The program represents the activity with a training game so that any brainwave production we are trying to encourage, such as lowered theta in the prefrontal cortex, is reinforced with positive feedback. For example, in a popular Pac-Man-like training game, producing less theta would make the character move faster and score more points, whereas producing too much theta would slow the character down.
Over time, the brain learns to produce more of the desired activity by virtue of this positive or negative feedback (a principle known as “operant conditioning”) so that your performance in the game improves session by session. Since neurofeedback is is an involuntary process, meaning you exert very little direct effort during training, you need not do any more than show up, relax, and pay attention to what’s happening in the game. Exactly how the brain is able to automatically recalibrate itself over time is still somewhat of a mystery and hotly debated among neurofeedback researchers. Nonetheless, its benefits are real. Most people who do neurofeedback see positive changes after around 20 sessions, and these changes in brain function are sustainable—unlike those that come through stimulant medications.
The extant research on neurofeedback as a treatment for youth ADHD looks strong. In a meta-analysis of 14 different studies comparing behavioral therapies for youth ADHD, neurofeedback training was found to be the most effective of the lot (Hodgson, Hutchinson, & Deonson, 2014). In another meta-analysis, the results of five studies showed that neurofeedback produced significant improvements in overall ADHD symptoms, especially in inattention, compared to other behavioral treatments (Micolaud-Franchi et. al, 2014).
A recent trial found promising results among elementary school children—a group that you’d think would have a hard time sitting still for neurofeedback training (Steiner et. al, 2013). A total of 104 children who had been diagnosed with ADHD were randomly assigned to do neurofeedback, something called “cognitive control,” or a control group in which they did nothing. After five months had passed, the children who did neurofeedback showed significantly greater improvements in ADHD symptoms and overall executive function than the other groups. What’s particularly intriguing about this study is that children in all the groups were allowed to continue their ADHD medications if need be, yet there were no significant differences in the outcomes between who was and was not on medication. This suggests that it’s possible to combine neurofeedback and medication if medication is still needed. One concern about this study, however, is that children underwent 40 sessions over the course of five months—a protocol potentially infeasible and unaffordable for some families. Nonetheless, an even more recent study found that children can experience meaningful reductions in ADHD symptoms in as few as 12 sessions (Nooner, Leaberry, Keith, & Ogle, 2016). This study also found that benefits were attainable by children who had been taking medications yet were asked to stop once training had begun.
Challenges & Remaining Questions
While neurofeedback does appear to be a promising nonpharmacological treatment for kids with ADHD, there are a number of concerns. Firstly, neurofeedback is time-consuming. Most people don’t experience significant benefits until they’ve finished at least 20 training sessions, and completing this many may not be realistic for some children. Secondly, since it requires at least 20 sessions, neurofeedback may be too costly for some families, especially since some insurance policies do not, unfortunately, cover it as well as they do pharmaceuticals. Finally, more needs to known about what Bard & Singh (2015) have dubbed the “ecology of brainwaves,” meaning, how changing brainwaves to improve one area of functioning might impact another. For example, in the case of ADHD-tailored training, if theta in the prefrontal cortex is decreased in the long run, it is not known how that might impact something like musical ability, of which theta plays an important role. Overall, in spite of neurofeedback’s potential, there’s much to be improved through more research and innovation.
At Alternatives, our behavioral health center in Los Angeles, we use neurofeedback training to not only treat addiction, ADHD, and anxiety, but also to improve cognitive performance in people who do not necessarily have a disorder. While our clients’ goals are often similar, whether it’s to drink less, feel less anxious, or improve focus, everyone’s brain is unique. It’s important to get the right diagnosis so that a client plays a role in their journey to improved functioning. As we often say, once we figure out how our “machine” functions we find that we can do quite a bit to adjust it and better our way of life.
Bárd, I., & Singh, I. (2015). Attention Deficit Hyperactivity Disorder: Improving Performance Through Brain–Computer Interface. Springer Netherlands.
Clavenna, A., & Bonati, M. (2016). Safety and Tolerability of Medications for ADHD. In Pharmacovigilance in Psychiatry (pp. 233-253). Springer International Publishing.
Hodgson, K., Hutchinson, A. D., & Denson, L. (2014). Nonpharmacological treatments for ADHD: A meta-analytic review. Journal of Attention Disorders, 18(4), 275-282.
Micolaud-Franchi, J. A., Geoffroy, P. A., Fond, G., Lopez, R., Bioulac, S., & Philip, P. (2014). EEG neurofeedback treatments in children with ADHD: An updated meta-analysis of randomized controlled trials. Frontiers in Human Neuroscience, 8(1), 1-7.
Nooner, K. B., Leaberry, K. D., Keith, J. R., & Ogle, R. L. (2016). Clinic outcome assessment of a brief course neurofeedback for childhood ADHD symptoms. Journal of Behavioral Health Services & Research, 1-9.
Steiner, N. J., Frenette, E. C., Rene, K. M., Brennan, R. T., & Perrin, E. C. (2014). In-school neurofeedback training for ADHD: Sustained improvements from a randomized control trial. Pediatrics, 133(3), 483-492.