EEG Neurofeedback Research

Arns, M., de Ridder, S., Strehl, U., Breteler, M., Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD: The effects on attention, impulsivity and hyperactivity: A meta-analysis. Clinical EEG and Neuroscience; 40(3). 180-189. In order to study the treatment of the children with attention deficit hyperactivity disorder (ADHD), the integrated visual and auditory continuous performance test (IVA-CPT) was clinically applied to evaluate the effectiveness of electroencephalogram (EEG) biofeedback training. Of all the 60 children with ADHD aged more than 6 years, the effective rate of EEG biofeedback training was 91.6% after 40 sessions of EEG biofeedback training. Before and after treatment by EEG biofeedback training, the overall indexes of IVA were significantly improved among predominately inattentive, hyperactive, and combined subtype of children with ADHD (P<0.001). It was suggested that EEG biofeedback training was an effective and vital treatment on children with ADHD. 

Beauregard, M., & Levesque, J. (2006). Functional magnetic resonance imaging investigation of the effects of neurofeedback training on the neural bases of selective attention and response inhibition in children with attention-deficit/hyperactivity disorder. Applied Psychophysiology & Biofeedback, 31(1), 3-20. Two functional magnetic resonance imaging (fMRI) experiments were randomly assigned to the Experimental (EXP) group whereas the other five children were randomly assigned to the Control (CON) week before the beginning of NFT (Time 1) and 1 week after the end of NFT (Time 2), while they performed a “Counting Stroop” and CON groups. At Time 2, in both groups, the Counting Stroop task was associated with significant activation of the left activation were noted, in the EXP group, in the right ventrolateral prefrontal cortex, right ACcd, left thalamus, left caudate nucleus, and left substantia nigra. No significant activation of these brain regions was measured in CON subjects. These results suggest that NFT has the capacity to functionally normalize the brain systems mediating selective attention and response inhibition in AD/HD children.

Becerra J, Fernndez T, Harmony T, Caballero MI, Garcia F, Fernandez-Bouzas A, Santiago-Rodriguez E, Prado-Alcalá ¡ RA. (2006) “Follow-up study of learning disabled children treated with neurofeedback or placebo.” Clinical EEG & Neuroscience, 37 (3), 98-203. This report is a 2-year follow-up to a previous study describing positive behavioral changes and a spurt of EEG maturation with theta/alpha neurofeedback (NFB) training in a group of Learning Disabled (LD) children. In a control paired group, treated with placebo, behavioral changes were not observed and the smaller maturational EEG changes observed were easily explained by increased age. Two years later, the EEG maturational lag in Control Group children increased, reaching abnormally high theta Relative Power values; the absence of positive behavioral changes continued and the neurological diagnosis remained LD. In contrast, after 2 years EEG maturation did continue in children who belonged to the Experimental Group with previous neurofeedback training; this was accompanied by positive behavioral changes, which were reflected in remission of LD symptoms.

Breteler, M. H. M., Arns, M., Peters, S., Giepmans, I., & Verhoeven, L. (2010). Improvements in spelling after QEEG-based neurofeedback in dyslexia: A randomized controlled treatment study. Applied Psychophysiology & Biofeedback, 35(1), 5-11. Phonological theories of dyslexia assume a specific deficit in representation, storage and recall of phonemes. Various brain imaging techniques, including qEEG, point to the importance of a range of areas, predominantly the left hemispheric temporal areas. This study attempted to reduce reading and spelling deficits in children who are dyslexic by means of neurofeedback training based on neurophysiological differences between the participants and gender and age matched controls. Nineteen children were randomized into an experimental group receiving qEEG based neurofeedback (n = 10) and a control group (n = 9). Both groups also received remedial teaching. The experimental group improved considerably in spelling (Cohen’s d = 3). No improvement was found in reading. An in-depth study of the changes in the qEEG power and coherence protocols evidenced no frontal- central changes, which is in line with the absence of reading improvements. A significant increase of alpha coherence was found, which may be an indication that attentional processes account for the improvement in spelling. Consideration of subtypes of dyslexia may refine the results of future studies.

Egner, T., & Gruzelier, J. H. (2004). EEG biofeedback of low beta band components: Frequency-specific effects on variables of attention and event-related brain potentials. Clinical Neurophysiology, 115(1), 131-139. Objective: To test a common assumption underlying the clinical use of electroencephalographic (EEG) biofeedback training (neurofeedback), that the modulation of discreet frequency bands is associated with frequency-specific effects. Specifically, the proposal was assessed that enhancement of the low beta components sensorimotor rhythm (SMR: 12 — 15 Hz) and beta1 (15 — 18 Hz) affect different aspects of attentional processing. Methods: Subjects (n = 25) were randomly allocated to training with either an SMR or beta1 protocol, or to a non- neurofeedback control group. Subjects were assessed prior and subsequent to the training process on two tests of sustained attention. The neurofeedback participants were also assessed on target P300 event-related potential (ERP) amplitudes in a traditional auditory oddball paradigm. Results: Protocol-specific effects were obtained in that SMR training was associated with increased perceptual sensitivity prime’ (d0 ), and reduced omission errors and reaction time variability. Beta1 training was associated with faster reaction times and increased target P300 amplitude whereas no changes were evident in the control group. Conclusions: Neurofeedback training of SMR and beta1 band components led to significant and protocol-specific effects in healthy subjects. The data can be interpreted as indicating a general attention-enhancing effect of SMR training, and an arousal-enhancing effect of beta1 training.

Escolano, C., Navarro-Gil, M., Garcia-Campayo, J., Congedo, M. & Minqueez, j. (2014). The effects of individual upper alpha neurofeedback in ADHD: An open-label pilot study. Applied Psychophysiology and Biofeedback: early E-Pub Sept 9. Standardized neurofeedback (NF) protocols have been extensively evaluated in attention-deficit/hyperactivity disorder (ADHD). However, such protocols do not account for the large EEG heterogeneity in ADHD. Thus, individualized approaches have been suggested to improve the clinical outcome. In this direction, an open-label pilot study was designed to evaluate a NF protocol of relative upper alpha power enhancement in fronto-central sites. Upper alpha band was individually determined using the alpha peak frequency as an anchor point. 20 ADHD children underwent 18 training sessions. Clinical and neurophysiological variables were measured pre- and post-training. EEG was recorded pre- and post-training, and pre- and post-training trials within each session, in both eyes closed resting state and eyes open task-related activity. A power EEG analysis assessed long-term and within- session effects, in thetrained parameter and in all the sensors in the (1-30) Hz spectral range. Learning curves over sessions were assessed as well. Parents rated a clinical improvement in children regarding inattention and hyperactivity/impulsivity. Neurophysiological tests showed an improvement in working memory, concentration and impulsivity (decreased number of commission errors in a continuous performance test). Relative and absolute upper alpha power showed long-term enhancement in task-related activity, and a positive learning curve over sessions. The analysis of within-session effects showed a power decrease (“rebound” effect) in task-related activity, with no significant effects during training trials. We conclude that the enhancement of the individual upper alpha power is effective in improving several measures of clinical outcome and cognitive performance in ADHD. This is the first NF study evaluating such a protocol in ADHD. A controlled evaluation seems warranted due to the positive results obtained in the current study.

Fleischman, M. J., & Othmer, S. (2005). Case study: Improvements in IQ score and maintenance of gains following EEG biofeedback with mildly developmentally delayed twins. Journal of Neurotherapy, 9(4), 35-46.This study reports on the improvements in IQ scores and maintenance of the gains following EEG biofeedback with identical twin girls with mild developmental delay and symptoms suggestive of Attention Deficit Hyperactivity Disorder (ADHD). Full Scale IQ scores increased 22 and 23 points after treatment and were maintained at three follow-up retests over a 52-month period. ADHD symptom checklists completed by their mother showed a similar pattern of improvement and maintenance of gains. The extent of improvement is upported by anecdotal reports of behavioral changes. The results are discussed in the context of other studies of EEG biofeedback also showing improved intelligence following EEG biofeedback.

Foks, M. (2005). Neurofeedback training as an educational intervention in a school setting: How the regulation of arousal states can lead to improved attention and behavior in children with special needs. Educational & Child Psychology, 22(3), 67-77. The current choice of treatment for the remediation of attentional and behavioral difficulties among primary school children with special educational needs (SEN) is, increasingly, pharmacological. If-neurofeedback can regulate brain arousal states and thereby improve attention, behavior and readiness to learn, there may be a case for incorporating it into the special needs provision of mainstream primary schools, thus avoiding the use of potentially damaging stimulant medication as a means of controlling behavior and promoting inclusion. An experimental design was used, employing the TOVA test as a pre-/post-test measure of attention and the TOVA rating scale as parental pre/post measure of behavior, plus qualitative feedback as a post-treatment measure of attention/behavior. Results indicate that neurofeedback may make an important impact on emotions and affect of the SEN individual, leading to improved behavior and improved attentional capability; quality time spent on a no-failure task of any kind on a one-to-one basis may be beneficial to children with SEN, affecting their personal belief system and behavior; incorporating neurofeedback as part of the school-based special needs provision is feasible and practicable

Fuchs, T., Birbaumer, N., Lutzenberger, W., Gruzelier, J. H., & Kaiser, J. (2003). Neurofeedback treatment for attention deficit/hyperactivity disorder in children: A comparison with methylphenidate. Applied Psychophysiology and Biofeedback, 28, 1- 12. Clinical trials have suggested that neurofeedback may be efficient in treating attention-deficit/hyperactivity disorder (ADHD). We compared the effects of a 3-month electroencephalographic feedback program providing reinforcement contingent on the production of cortical sensorimotor rhythm (12—15 Hz) and beta1 activity (15—18 Hz) with stimulant medication. Participants were N = 34 children aged 8—12 years, 22 of which were assigned to the neurofeedback group and 12 to the methylphenidate group according to their parents’ preference. Both neurofeedback and methylphenidate were associated with improvements on all subscales of the Test of Variables of Attention, and on the speed and accuracy measures of the d2 Attention Endurance Test. Furthermore, behaviors related to the disorder were rated as significantly reduced in both groups by both teachers and parents on the IOWA-Conners Behavior Rating Scale. These findings suggest that neurofeedback was efficient inimproving some of the behavioral concomitants of ADHD in children whose parents favored a non-pharmacological treatment.

Gani C, Birbaumer N & Strehl U. (2008). Long term effects after feedback of slow cortical potentials and of theta-beta amplitudes in children with attention-deficit/hyperactivity disorder (ADHD). International Journal of Bioelectromagnetism, 10(4), 209-232. Though it had already been shown in the 1970s that neurofeedback improves attention, academic performance and social behavior in children with ADHD, it has not been considered as a standard therapy so far. This is mainly due to the small number of controlled studies fulfilling methodological standards – especially long-term data was not available so far. We are the first to present long term data of children undergoing neurofeedback training. 47 patients in the age of 8 – 12 years were randomly assigned to two different training groups. One group was trained to self-regulate slow cortical potentials (SCP), the other group tried to influence Theta- and Beta-amplitudes. Follow-up evaluation was carried out 6 months and more than 2 years after the last training session. Eleven children of the SCP group and 12 CHildren of the Theta/Beta group took part in three booster sessions. Parents rated behavioral symptoms as well as frequency and impact of problems. Attention was measured with the Testbatterie zur Aufmerksamkeitsprüfung (TAP). All improvements in behavior and attention that had been observed at previous assessments turned out to be stable. Yet another significant reduction of number of problems and significant improvement in attention was observed. EEG-self regulation skills were preserved. In each group, half of the children no longer met ADHD criteria. Neurofeedback appears to be an alternative or complement to traditional treatments. The stability of changes might be explained by normalizing of brain functions that are responsible for inhibitory control, impulsivity and hyperactivity.

Gevensleben H, Moll GH, Rothenberger A, Heinrich H. (2011). The usage of neurofeedback with children with ADHD: The method and its evaluation. Prax Kinderpsychol Kinderpsychiatr. 2011;60(8):666-76. Neurofeedback is a computer-based behavior training, which is gaining increasing interest in the treatment of children with attention-deficit/hyperactivity disorder (ADHD). This article gives an introduction to neurofeedback and summarizes the state of research, discussing inter alia methodical aspects (e. g., requirements to a control training). Evaluation studies conducted so far indicate clinical efficacy. Forexample, neurofeedback training was superior to a computerized attention training in a randomized controlled trial (medium effect size). Follow-up investigations suggest that treatment effects remain stable (at least six months). At the clinical level, comparable improvements could be obtained for the neurofeedback protocols theta/beta training and training of slow cortical potentials. Neurophysiological findings document different mechanisms of theta/beta training and slow cortical potential training Future studies should further elucidate the specificity of training effects related to the kind of training and certain disorders and address how to optimize and individualize neurofeedback training.

Ghaziri J, Tucholka A, Larue V, Blanchette-Sylvestre M, Reyburn G, Gilbert G, Lévesque J, Beauregard M. Neurofeedback Training Induces Changes in White and Gray Matter. Clin EEG Neurosci. 2013 Mar 26. The main objective of this structural magnetic resonance imaging (MRI) study was to investigate, using diffusion tensor imaging, whether a neurofeedback training (NFT) protocol designed to improve sustained attention might induce structural changes in white matter (WM) pathways, purportedly implicated in this cognitive ability. Another goal was to examine whether gray matter (GM) volume (GMV) might be altered following NFT in frontal and parietal cortical areas connected by these WM fiber pathways. Healthy university students were randomly assigned to an experimental group (EXP), a sham group, or a control group. Participants in the EXP group were trained to enhance the amplitude of their β1 waves at F4 and P4. Measures of attentional performance and MRI data were acquired one week before (Time 1) and one week after (Time 2) NFT. Higher scores on visual and auditory sustained attention were noted in the EXP group at Time 2 (relative to Time 1). As for structural MRI data, increased fractional anisotropy was measured in WM pathways implicated in sustained attention, and GMV increases were detected in cerebral structures involved in this type of attention. After 50 years of research in the field of neurofeedback, our study constitutes the first empirical demonstration that NFT can lead to microstructural changes in white and gray matter.

Hansen, L. M., Trudeau, D., & Grace, L. (1996). Neurotherapy and drug therapy in combination for adult ADHD, personality disorder, and seizure. Journal of Neurotherapy, 2(1), 6-14. This is a case report of an adult female patient with ADHD, temporal seizure disorder, and Borderline Personality Disorder treated with 30 weekly sessions of SMR neurofeedback and carbamazepine. Posttreatment measures showed improvements in T.O.V.A., self-report, and QEEG. Both neurofeedback and carbamazepine showed the most effect in early treatment. Progress continued after discontinuance of the drug. 

Kaiser, D. A., & Othmer, S. (2000). Effect of Neurofeedback on variables of attention in a large multi-center trial. Journal of Neurotherapy, 4(1), 5-15. Since the first reports of Neurofeedback treatment in ADHD in 1976 many studies have been carried out investigating 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 non-specific 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. Four randomized controlled trials have shown Neurofeedback to be superior to a (semi- active) control group, whereby the requirements for Level 4: Efficacious are fulfilled (Criteria for evaluating the level of evidence for efficacy established by the AAPB and ISNR). Three 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. 

Leins, U., Goth, G., Hinterberger, T., Klinger, C., Rumpf, M., & Strehl, U. (2007). Neurofeedback for children with ADHD: A comparison of SCP and theta/beta protocols. Applied Psychophysiology & Biofeedback, 32. 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 behavioral or cognitive outcome. 

Lenartowitz, A., Delorme, A., Walshaw, PD., Cho, AL., Bilder, RM., McGough, JJ., McCracken, JT., Makeaig, S & Loo, S. (2014). Electroencephalography Correlates of Spatial Working Memory Deficits in Attention-Deficit/Hyperactivity Disorder: Vigilance, Encoding, and Maintenance. Journal of Neuroscience:34(4). 1171-1182. In the current study we sought to dissociate the component processes of working memory (WM) (vigilance, encoding and maintenance) that may be differentially impaired in attention-deficit/ hyperactivity disorder (ADHD). We collected electroencephalographic (EEG) data from 52 CHildren with ADHD and 47 typically developing (TD) children, ages 7–14 years, while they performed a spatial Sternberg working memory task. We used independent component analysis and time-frequency analysis to identify midoccipital alpha (8 –12 Hz) to evaluate encoding processes and frontal midline theta (4 –7 Hz) to evaluate maintenance processes. We tested for effects of task difficulty and cue processing to evaluate vigilance. Children with ADHD showed attenuated alpha band event-related desynchronization (ERD) during encoding. This effect was more pronounced when task difficulty was low (consistent with impaired vigilance) and was predictive of memory task performance and symptom severity. Correlated with alpha ERD during encoding were alpha power increases during the maintenance period (relative to baseline), suggesting a compensatory effort. Consistent with this interpretation, midfrontal theta power increases during maintenance were stronger in ADH D and in high-load memory conditions. Furthermore, children with ADHD exhibited a maturational lag in development of posterior alpha power whereas age- related changes in frontal theta power deviated from the TD pattern. Last, subjects with ADHD showed age-independent attenuation of evoked responses to warning cues, suggesting low vigilance.Combined,thesethreeEEGmeasurespredicted diagnosis with 70% accuracy. We conclude that the interplay of impaired vigilance and encoding in ADHD may compromise maintenance and lead to impaired WM performance in this group. 

Levesque, J., Beauregard, M., & Mensour, B. (2006). Effect of neurofeedback training on the neural substrates of selective attention in children with attention-deficit/hyperactivity disorder: a functional magnetic resonance imaging study. Neuroscience Letters, 394(3), 216-221. Attention De cit Hyperactivity Disorder (AD/HD) is a neurodevelopmental disorder mainly characterized by impairments in cognitive functions. Functional neuroimaging studies carried out in individuals with AD/HD have shown abnormal functioning of the anterior cingulate cortex (ACC) during tasks involving selective attention. In other respects, there is mounting evidence that neurofeedback training (NFT) can significantly improve cognitive functioning in AD/HD children. In this context, the present functional magnetic resonance imaging (fMRI) study was conducted to measure the effect of NFT on the neural substrates of selective attention in children with AD/HD. Twenty AD/HD children— not taking any psychostimulant and without co-morbidity-participated to the study Fifteen children were randomly assigned to the Experimental (EXP) group (NFT), whereas the other children were assigned to the Control (CON) group (no NFT). Subjects from both groups were scanned 1 week before the beginning of the NFT (Time 1) and 1 week after the end of this training (Time 2), while they performed a Counting Stroop task. At Time 1, for both groups, the Counting Stroop task was associated with significant loci of activation in the left superior parietal lobule. No activation was noted in the ACC. At Time 2, for both groups, the counting Stroop task was still associated with significant activation of the left superior parietal lobule. This time, however, for the EXP group only there was a significant activation of the right ACC. These results suggest that in AD/HD children, NFT has the capacity to normalize the functioning of the ACC, the key neural substrate of selective attention. 

Linden, M., Habib, T., & Radojevic, V. (1996). A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback & Self-Regulation, 21(1), 35-49. Eighteen children with ADD/ADHD, some of whom were also LD, ranging in ages from 5 through 15 were randomly assigned to one of two conditions. The experimental condition consisted of 40 45-minute sessions of training in enhancing beta activity and suppressing theta activity, spaced over 6 months. The control condition, waiting list group, received no EEG biofeedback. No other psychological treatment or medication was administered to any subjects. All subjects were measured at pretreatment and at posttreatment on an IQ test and parent behavior rating scales for inattention, hyperactivity, and aggressive/defiant (oppositional) behaviors. At posttreatment the experimental group demonstrated a significant increase (mean of 9 points) on the K- Bit IQ Composite as compared to the control group (p <.05). The experimental group also significantly reduced inattentive behaviors as rated by parents (p < .05). The significant improvements in intellectual functioning and attentive behaviors might be explained as a result of the attentional enhancement affected by EEG biofeedback training. Further research utilizing improved data collection and analysis, more stringent control groups, and larger sample sizes are needed to support and replicate these findings. 

Lofthouse N, Arnold LE, Hersch S, Hurt E, DeBeus R. (2011). A review of neurofeedback for pediatric ADHD. Journal of Attention Disorders;16(5). 351-372. The aim of this paper was to review all randomized published trials and unpublished conference presentations on the neurofeedback (NF) treatment of pediatric ADHD, and their relevance, strengths, and limitations. METHOD: Via PsychInfo and Medline searches and contacts with NF researchers 14 studies were identified and reviewed. RESULTS: The majority were conducted from 1994 to 2010, with 5- to 15-year-olds, usually male and White with the combined type of ADHD. Most studies used theta/beta NF with a unipolar-electrode placement at Cz and demonstrated, where reported, an overall ADHD mean effect size of d = 0.69, a medium effect. Main study strengths, within some studies, include use of randomization, treatment control conditions, Diagnostic and Statistical Manual of Mental Disorders criteria, evidence-based assessment of ADHD, standard treatment outcome measures, multi-domain assessment, and, for some studies, moderate sample size, some type of blind and the identification of medication as a concomitant treatment. Main study limitations (and directions for future research) include the lack of adequate blinding of participants, raters and NF trainers, a sham-NF/blinded control treatment condition, post treatment follow-up, generalizability, specific details about delivery of NF, identification and control of comorbidity, and the identification, measurement, and control of concomitant treatments and potential side effects. CONCLUSION: Based on the results and methodologies of published studies, this review concludes that NF for pediatric ADHD can be currently considered as “probably efficacious.” 

Loo, S., & Barkley, R. (2005). Clinical utility of EEG in attention deficit hyperactivity disorder. Applied Neuropsychology, 12(2), 64-76. Electrophysiological measures were among the first to be used to study brain processes in children with attention deficit hyperactivity disorder (ADHD; Diagnostic and Statistical Manual of Mental Disorders [4th ed.], American Psychiatric Association, 1994) and have been used as such for over 30 years (see Hastings & Barkley, 1978, for an early review). More recently, electroencephalography (EEG) has been used both in research to describe and quantify the underlying neurophysiology of ADHD, but also clinically in the assessment, diagnosis, and treatment of ADHD. This review will first provide a brief overview of EEG and then present some of the research findings of EEG correlates in ADHD. Then, the utility of EEG in making an ADHD diagnosis and predicting stimulant response will be examined. Finally, and more controversially, we will review the results of the most recent studies on EEG biofeedback (neurofeedback) as a treatment for ADHD and the issues that remain to be addressed in the research examining the efficacy this therapeutic approach. 

Lubar, J. O., & Lubar, J. F. (1984). Electroencephalographic biofeedback of SMR and beta for treatment of attention deficit disorders in a clinical setting. Biofeedback & Self-Regulation, 9, 1-23. Six children were provided with long-term biofeedback and academic treatment for attention deficit disorders. Their symptoms were primarily learning disabilities, and, in some cases, there were varying degrees of hyperkinesis. The training consisted of two sessions per week for ten to 27 months, with a gradual phase-out. Feedback was provided for either increasing 12- 15 Hz SMR or 16-20 beta activity. Inhibit circuits were employed for SMR or beta when either gross movement excessive EMG, or theta (4-8 HZ) activity was present. Treatment also consisted of combining the biofeedback with academic training, including reading, arithmetic and spatial tasks to improve their attention. All children increased SMR or beta and decreased slow EEG and EMG activity. Changes could be seen in their power spectra after training in terms of increased beta and decreased slow activity. All six children demonstrated considerable improvement in their schoolwork in terms of grades or achievement test scores. None of the children are currently on any medications for hyperkinetic behavior. The results indicate that EEG biofeedback training, if applied comprehensively, can be highly effective in helping to remediate children who are experiencing attention deficit disorders. 

Lubar, J. F., Swartwood, M. O., Swartwood, J. N., & O’Donnell, P. H. (1995). 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. Biofeedback & Self- Regulation, 20(1), 83-99. 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. Post training changes in EEG activity, T.O.V~I. 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. VM. 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. Out findings corroborate and extend previous research, indicating that neurofeedback training can be an appropriate and efficacious treatment for children with ADHD. 

Monastra, V. J., Monastra, D. M., & George, S. (2002). The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Applied Psychophysiology & Biofeedback, 27(4), 231-249. One hundred children, ages 6– 19, who were diagnosed with attention-deficit/hyperactivity disorder (ADHD), either inattentive or combined types, participated in a study examining the effects of Ritalin, EEG biofeedback, and parenting style on the primary symptoms of ADHD. All of the patients participated in a 1- year, multimodal, outpatient program that included Ritalin, parent counseling, and academic support at school (either a 504 Plan or an IEP). Fifty-one of the participants also received EEG biofeedback therapy. Post treatment assessments were conducted both with and without stimulant therapy. Significant improvement was noted on the Test of Variables of Attention (TOVA; L. M. Greenberg, 1996) and the Attention Deficit Disorders Evaluation Scale (ADDES; S. B. McCarney, 1995) when participants were tested while using Ritalin. However, only those who had received EEG biofeedback sustained these gains when tested without Ritalin. The results of a Quantitative Electroencephalographic Scanning Process (QEEG-Scan; V. J. Monastra et al., 1999) revealed significant reduction in cortical slowing only in patients who had received EEG biofeedback. Behavioral measures indicated that parenting style exerted a significant moderating effect on the expression of behavioral symptoms at home but not at school. 

Rasey, H. W., Lubar, J. E., McIntyre, A., Zoffuto, A. C., & Abbott, P. L. (1996). EEG biofeedback for the enhancement of attentional processing in normal college students. Journal of Neurotherapy, 1(3), 15-21. College students diagnosed as free of any neurological or attention deficit disorder received EEG biofeedback to enhance beta (16-22 HZ) activity while simultaneously inhibiting high theta and low alpha (6-10 Hz) activity in order to evaluate improvements in attentional measurers. Following short-term treatment (mean number of sessions = 20), subjects were evaluated as either learners or non-learners based upon standard pre- and post-treatment neurofeedback measurers. Attention quotients taken from pre- and post-treatment measurements using the Integrated Visual and Auditory Continuous Performance Test (IVA) identified significant improvements in attentional measures in learners, while non-learners showed no significant improvements. Results suggest that some “normal” young adults can learn to increase EEG activity associated with improved attention. Twenty sessions, however, even for this population may represent the lower limit for achieving significant improvement. 

Shin, D. I., Lee, J. H., Lee, S. M., Kim, I. Y., & Kim, S. I. (2004). Neurofeedback training with virtual reality for inattention and impulsiveness. Cyberpsychology & Behavior, 7(5), 519-526. In this research, the effectiveness of neurofeedback, along with virtual reality (VR), in reducing the level of inattention and impulsiveness was investigated. Twenty-eight male participants, aged 14-18, with social problems, took part in this study. They were separated into three groups: a control group, a VR group, and a non-VR group. The VR and non-VR groups underwent eight sessions of neurofeedback training over 2 Weeks, while the control group just waited during the same period. The VR group used a head-mounted display (HMD) and a head tracker, which let them look around the virtual world. Conversely, the non-VR group used only a computer monitor with a fixed viewpoint. All participants performed a continuous performance task (CPT) before and after the complete training session. The results showed that both the VR and non-VR groups achieved better scores in the CPT after the training session, while the control group showed no significant difference. Compared with the other groups, the VR group presented a tendency to get better results, suggesting that immersive VR is applicable to neurofeedback for the rehabilitation of inattention and impulsiveness. 

Steiner, NJ., Frenette, EC., Rene, KM., Brennan, RT & Perrin, EC. (2014). In-school neurofeedback training for ADHD: Sustained improvements from a randomized control trial. Pediatrics:133. 483. OBJECTIVE: To evaluate sustained improvements 6 months after a 40- session, in-school computer attention training intervention using neurofeedback or cognitive training (CT) administered to 7- to 11-year-olds with attention-deficit/hyperactivity disorder (ADHD). METHODS: One hundred four children were randomly assigned to receive neurofeedback, CT, or a control condition and were evaluated 6 months post intervention. 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). Analysis of variance assessed community-initiated changes in stimulant medication. RESULTS: Parent response rates were 90% at the 6-month follow-up. Six months post intervention, 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 post intervention ratings only on Conners 3- P Executive Functioning (ES = 0.18) and 2 BRIEF subscales. 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). 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. Pediatrics 2014;133:483– 492 

Steiner, NJ., Frenette, EC., Rene, KM., Brennan, RT & Perrin, EC. (2014). Neurofeedback and cognitive attention training for children with attention-deficit hyperactivity disorder in schools. J Dev Behav Peadiatr:35(1). 18-27. OBJECTIVE: To evaluate the efficacy of 2 Computer attention training systems administered in school for children with attention-deficit hyperactivity disorder (ADHD). METHOD: Children in second and fourth grade with a diagnosis of ADHD (n = 104) were randomly assigned to neurofeedback (NF) (n = 34), cognitive training (CT) (n = 34), or control (n = 36) conditions. A 2-point growth model assessed change from pre-post intervention on parent reports (Conners 3- Parent [Conners 3-P]; Behavior Rating Inventory of Executive Function [BRIEF] rating scale), teacher reports (Swanson, Kotkin, Agler, M-Flynn and Pelham scale [SKAMP]; Conners 3- Teacher [Conners 3-T]), and systematic classroom observations (Behavioral Observation of Students in Schools [BOSS]). Paired t tests and an analysis of covariance assessed change in medication. RESULTS: Children who received NF showed significant improvement compared with those in the control condition on the Conners 3-P Attention, Executive Functioning and Global Index, on all BRIEF summary indices, and on BOSS motor/verbal off-task behavior. Children who received CT showed no improvement compared to the control condition. Children in the NF condition showed significant improvements compared to those in the CT condition on Conners 3-P Executive Functioning, all BRIEF summary indices, SKAMP Attention, and Conners 3-T Inattention subscales. Stimulant medication dosage in methylphenidate equivalencies significantly increased for children in the CT (8.54 mg) and control (7.05 mg) conditions but not for those in the NF condition (0.29 mg). CONCLUSION: Neurofeedback made greater improvements in ADHD symptoms compared to both the control and CT conditions. Thus, NF is a promising attention training treatment intervention for children with ADHD. 

Strehl, U., Leins, U., Goth, G., Klinger, C., Hinterberger, T., and Birbaumer, N. (2006). Self-regulation of slow cortical potentials: A new treatment for children with attention deficit/hyperactivity disorder. Pediatrics, 118, 1530-1540. We investigated the effects of self-regulation of slow cortical potentials for children with attention-deficit/hyperactivity disorder. Slow cortical potentials are slow event-related direct-current shifts of the electroencephalogram. Slow cortical potential shifts in the electrical negative direction reflect the depolarization of large cortical cell assemblies, reducing their excitation threshold. This training aims at regulation of cortical excitation thresholds considered to be impaired in children with attention-deficit/hyperactivity disorder. Electroencephalographic data from the training and the 6-month follow-up are reported, as are changes in behavior and cognition. Twenty-three children with attention-deficit/hyperactivity disorder aged between 8 and 13 years received 30 sessions of self-regulation training of slow cortical potentials in 3 phases of 10 sessions each. Increasing and decreasing slow cortical potentials at central brain regions was fed back visually and auditorily. Transfer trials without feedback were intermixed with feedback trials to allow generalization to everyday-life situations. In addition to the neurofeedback sessions, children exercised during the third training phase to apply the self-regulation strategy while doing their homework. For the first time, electroencephalographic data during the course of slow cortical potential neurofeedback are reported. Measurement before and after the trials showed that children with attention-deficit/hyperactivity disorder learn to regulate negative slow cortical potentials. After training, significant improvement in behavior, attention, and IQ score was observed. The behavior ratings included Diagnostic and Statistical Manual of Mental Disorders criteria, number of problems, and social behavior at school and were conducted by parents and teachers. The cognitive variables were assessed with the Wechsler Intelligence Scale for Children and with a computerized test battery that measures several components of attention. All changes proved to be stable at 6 months’ follow-up after the end of training. Clinical outcome was predicted by the ability to produce negative potential shifts in transfer sessions without feedback. 

Studer, P., Kratz, O., Gevensleben, H., Rothenberger, A., Moll, GH., Hautzinger, M & Heinrich, H. (2014). Frontiers in Human Neuroscience:24(8) 555. Neurofeedback (NF) is being successfully applied, among others, in children with attention deficit/hyperactivity disorder (ADHD) and as a peak performance training in healthy subjects. However, the neuronal mechanisms mediating a successful NF training have not yet been sufficiently uncovered for both theta/beta (T/B), and slow cortical potential (SCP) training, two protocols established in NF in ADHD. In the present, randomized, controlled investigation in adults without a clinical diagnosis (n = 59), the specificity of the effects of these two NF protocols on attentional processes and motor system excitability were to be examined, focusing on the underlying neuronal mechanisms. Neurofeedback training consisted of 10 double sessions, and self-regulation skills were analyzed. Pre- and post-training assessments encompassed performance and event-related potential measures during an attention task, and motor system excitability assessed by transcranial magnetic stimulation. Some NF protocol-specific effects have been obtained. However, due to the limited sample size medium effects did not reach the level of significance. Self-regulation abilities during negativity trials of the SCP training were associated with increased contingent negative variation amplitudes, indicating improved resource allocation during cognitive preparation. Theta/beta training was associated with increased response speed and decreased target-P3 amplitudes after successful theta/beta regulation suggested reduced attentional resources necessary for stimulus evaluation. Motor system excitability effects after theta/beta training paralleled the effects of methylphenidate. Overall, our results are limited by the non-sufficiently acquired self- regulation skills, but some specific effects between good and poor learners could be described. Future studies with larger sample sizes and sufficient acquisition of self-regulation skills are needed to further evaluate the protocol-specific effects on attention and motor system excitability reported. 

Tansey, M. A. (1985). Brainwave signatures–An index reflective of the brain=s functional neuroanatomy: Further findings on the effect of EEG sensorimotor rhythm biofeedback training on the neurologic precursors of learning disabilities. International Journal of Psychophysiology, 3, 85-89. Eight boys, ages 7 years 11 months to 15 years 3 months, were provided with long-term–symptom duration– sensorimotor rhythm biofeedback training for the remediation of their learning disabilities. Concurrently, the simultaneous recording of five frequency bands of brainwave activity (5 Hz, 7 Hz, 10 Hz, 12 Hz and 14 Hz), from one active electrode equidistant from reference and ground, was intended to provide a glimpse of the ‘brainwave signature’ reflective of the dynamic and synergistic processes involved in such cerebro-neural activation and the brain’s global response to such an alteration in the sensorimotor subnetwork. Overall, the main effect of this procedure, for the biofeedback and subsequent conditioning of increased 14 Hz neural discharge patterns over the central Rolandic cortex in a clinical office setting, seems to be to increase bilateral sensorimotor transactions resulting in substantive remediation of the learning disabilities of the recipients of such training–by way of internally exercising of, and/or recruitment of additional neural activation within, the sensorimotor subnetwork/matrix. Observation of the changing brainwave signatures showed a tendency for decreased slow wave activity concomitant with increases in fast wave activity, for cases with a Full Scale I.Q. within the range of 76 and 85; with those cases with a Full Scale I.Q. within the range of 102 and 116 exhibiting increased amplitudes over most of the monitored bands, but with the increases being much less at the slower frequencies. It is noteworthy that those four subjects with either a significant Verbal greater than Performance, or Performance greater than Verbal, I.Q. Score discrepancy exhibited no less than a 40% greater increase in the lower of the two I.Q. scores; indicating that this SMR training procedure also resulted in an increased symmetry in the interhemispheric interactions reflective of the higher cortical functions for these no longer learning disabled boys. 

Tansey, M. A. (1993). Ten-year stability of EEG biofeedback results for a hyperactive boy who failed fourth grade perceptually impaired class. Biofeedback & Self-Regulation, 18, 33-44. Ten years ago, the first successful application of a clinical, private- practice based, EEG 14-Hz biofeedback training regimen for the treatment of learning disorders was performed by the author. After the 10-year-old boy, with presenting symptomatology including a developmental reading disorder, hyperactivity, and an educational classification of perceptually impaired, continued symptom free for a period of two years, his case was submitted for publication. Ten years after his termination from successful treatment, his ongoing normal social and academic functioning is noted and his EEG brainwave signature examined and compared with a population of 24 “used-to-be” learning disabled, one-half of which had a pretreatment state including the educational classification of perceptually impaired. This 10-year follow-up confirms the long-term stability of the results of this EEG 14-Hz biofeedback regimen. Current findings on recent medical research identifying a major cerebral locus of dysfunction for hyperkinesis and how it supports the electrode placements of this clinical office setting regimen is also discussed. 

Tansey, M. A., & Bruner, R. L. (1983). EMG and EEG biofeedback training in the treatment of 10-year old hyperactive boy with a developmental reading disorder. Biofeedback & Self-Regulation, 8(1), 25-37. The serial application of electromyographic (EMG) and sensorimotor (SMR) biofeedback training was attempted with a 10-year-old boy presenting a triad of symptoms: an attention deficit disorder with hyperactivity, developmental reading disorder, and ocular instability. Symptom elimination was achieved, for all three aspects of the triad, following the procedure of first conditioning a decrease in EMG- monitored muscle tension and then conditioning increases in the amplitude of sensorimotor rhythm over the Rolandic cortex. The learned reduction of monitored EMG levels was accompanied by a reduction in the child’s motoric activity level to below that which had been achieved by past administration of Ritalin. In addition, the attention deficit disorder with hyperactivity was no longer diagnosable following the EMG biofeedback training. The learned increase in the amplitude of monitored SMR was accompanied by remediation of the developmental reading disorder and the ocular instability. These results remained unchanged, as ascertained by follow-ups conducted over a 24-month period subsequent to the termination of biofeedback training. 

Thompson, L., & Thompson, M. (1998). Neurofeedback combined with training in metacognitive strategies: Effectiveness in students with ADD. Applied Psychophysiology & Biofeedback, 23(4), 243-263. Seven autistic children diagnosed with autism spectrum disorders (ASD) received a neurofeedback treatment that aimed to improve their level of executive control. Neurofeedback successfully reduced children’s heightened theta/beta ration by inhibiting theta activation and enhancing beta activation over sessions. Following treatment children’s executive capacities were found to have improved greatly relative to pre- treatment assessment on a range of executive function tasks. Additional improvements were found in children’s social, communicative and typical behavior, relative to a waiting list control group. These findings suggest a basic executive function impairment in ASD that can be alleviated through specific neurofeedback treatment. Possible neural mechanisms that may underlie neurofeedback mediated improvement in executive functioning in autistic children are discussed. 

Williams, J. (2010). Does neurofeedback help reduce attention-deficit hyperactivity disorder? Journal of Neurotherapy; 14(4), 261-279. Introduction: Neurofeedback is an alternative treatment for Attention Deficit Hyperactivity Disorder (ADHD), but its efficacy is unknown. This narrative review examines rigorous studies conducted utilizing neurofeedback as a treatment for ADHD. Methods: Studies were located by searching the Web of Science and PsycINFO databases with the keywords ADHD or attention deficit hyperactivity disorder AND neurofeedback or EEG biofeedback or electroencephalogram biofeedback. Located studies were chosen for initial review if they met the following criteria: (a) randomized controlled trial or quasi-experiment, (b) ADHD diagnosis based on DSM criteria, (c) published at any time prior to March 2010, (d) English language, and (e) published in a peer-reviewed journal. Participants included children, adolescents, and adults diagnosed with ADHD. Results: Twelve articles reporting 9 different studies met the eligibility criteria and were included in the review. All 9 studies produced results that indicated significant improvements on either tests scores or behavioral conduct for individuals who were treated with neurofeedback for ADHD. Alternative treatments also demonstrated effectiveness. Conclusion: Neurofeedback may be an effective treatment for ADHD. Future research is needed with larger sample sizes, comparing the efficacy of neurofeedback with the efficacy of other ADHD treatments and comparing different neurofeedback protocols. 

Vernon, D., Egner, T., Cooper, N., Compton, T., Neilands, C., Sheri, A., & Gruzelier, J. (2003). The effect of training distinct neurofeedback protocols on aspects of cognitive performance. International Journal of Psychophysiology, 47, 75-85. The use of neurofeedback as an operant conditioning paradigm has disclosed that participants are able to gain some control over particular aspects of their electroencephalogram (EEG). Based on the association between theta activity (4-7 Hz) and working memory performance, and sensorimotor rhythm (SMR) activity (12-15 Hz) and attentional processing, we investigated the possibility that training healthy individuals to enhance either of these frequencies would specifically influence a particular aspect of cognitive performance, relative to a non-neurofeedback control-group. The results revealed that after eight sessions of neurofeedback the SMR-group were able to selectively enhance their SMR activity, as indexed by increased SMR/theta and SMR/beta ratios. In contrast, those trained to selectively enhance theta activity failed to exhibit any changes in their EEG. Furthermore, the SMR- group exhibited a significant and clear improvement in cued recall performance, using a semantic working memory task, and to a lesser extent showed improved accuracy of focused attentional processing using a 2-sequence continuous performance task. This suggests that normal healthy individuals can learn to increase a specific component of their EEG activity, and that such enhanced activity may facilitate semantic processing in a working memory task and to a lesser extent focused attention. We discuss possible mechanisms that could mediate such effects and indicate a number of directions for future research. 

Walker, J. E., & Norman, C. A. (2006). The neurophysiology of dyslexia: A selective review with implications for neurofeedback remediation and results of treatment in twelve consecutive patients. Journal of Neurotherapy, 10(1), 45-55. Dyslexia is a common and important problem in all industrial societies, with a prevalence rate of five to ten percent, for which no consistently effective treatment is available. Recent advances in imaging (morphometric MRI, functional MRI, PET, regional cerebral blood flow), as well as in neurophysiology (evoked potentials, QEEG, event-related desynchronization, coherence studies, magnetic source imaging, reading difference topography) have clarified our understanding of the normal circuitry involved in reading and differences seen in individuals who have trouble learning to read. These studies have important implications for the use of neurofeedback to help dyslexic individuals learn to read more easily. First, we obtained a QEEG and a reading difference topography. We then train down any abnormalities that are significantly increased and train up any abnormalities that are significantly decreased. Increasing 16–18 Hz activity at T3 (left mid-temporal area) has also proved quite helpful in improving reading speed and comprehension. These combined approaches have been helpful in all cases of dyslexia we have treated, dramatically so in some cases. Each of the 12 individuals treated improved by at least two grade levels after 30 to 35 sessions.

Xiong, Z., Shi, S., & Xu, H. (2005). A controlled study of the effectiveness of EEG biofeedback training on children with attention deficit hyperactivity disorder. Journal of Huazhong University of Science & Technology, 25(3), 368-370. In order to study the treatment of the children with attention deficit hyperactivity disorder (ADHD), the integrated visual and auditory continuous performance test (IVA-CPT) was clinically applied to evaluate the effectiveness of electroencephalogram (EEG) biofeedback training. Of all the 60 children with ADHD aged more than 6 years, the effective rate of EEG biofeedback training was 91.6% after 40 sessions of EEG biofeedback training. Before and after treatment by EEG biofeedback training, the overall indexes of IVA were significantly improved among predominately inattentive, hyperactive, and combined subtype of children with ADHD (P<0.001). It was suggested that EEG biofeedback training was an effective and vital treatment on children with ADHD.