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      Sustained effects of neurofeedback in ADHD: a systematic review and meta-analysis

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          Abstract

          Neurofeedback (NF) has gained increasing interest in the treatment of attention-deficit/hyperactivity disorder (ADHD). Given learning principles underlie NF, lasting clinical treatment effects may be expected. This systematic review and meta-analysis addresses the sustainability of neurofeedback and control treatment effects by considering randomized controlled studies that conducted follow-up (FU; 2–12 months) assessments among children with ADHD. PubMed and Scopus databases were searched through November 2017. Within-group and between-group standardized mean differences (SMD) of parent behavior ratings were calculated and analyzed. Ten studies met inclusion criteria (NF: ten studies, N = 256; control: nine studies, N = 250). Within-group NF effects on inattention were of medium effect size (ES) (SMD = 0.64) at post-treatment and increased to a large ES (SMD = 0.80) at FU. Regarding hyperactivity/impulsivity, NF ES were medium at post-treatment (SMD = 0.50) and FU (SMD = 0.61). Non-active control conditions yielded a small significant ES on inattention at post-treatment (SMD = 0.28) but no significant ES at FU. Active treatments (mainly methylphenidate), had large ES for inattention (post: SMD = 1.08; FU: SMD = 1.06) and medium ES for hyperactivity/impulsivity (post: SMD = 0.74; FU: SMD = 0.67). Between-group analyses also revealed an advantage of NF over non-active controls [inattention (post: SMD = 0.38; FU: SMD = 0.57); hyperactivity–impulsivity (post: SMD = 0.25; FU: SMD = 0.39)], and favored active controls for inattention only at pre-post (SMD = − 0.44). Compared to non-active control treatments, NF appears to have more durable treatment effects, for at least 6 months following treatment. More studies are needed for a properly powered comparison of follow-up effects between NF and active treatments and to further control for non-specific effects.

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          The online version of this article (10.1007/s00787-018-1121-4) contains supplementary material, which is available to authorized users.

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          Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments.

          Edmund Sonuga‐Barke, Daniel Brandeis, Samuele Cortese … (2013)
          Nonpharmacological treatments are available for attention deficit hyperactivity disorder (ADHD), although their efficacy remains uncertain. The authors undertook meta-analyses of the efficacy of dietary (restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation) and psychological (cognitive training, neurofeedback, and behavioral interventions) ADHD treatments. Using a common systematic search and a rigorous coding and data extraction strategy across domains, the authors searched electronic databases to identify published randomized controlled trials that involved individuals who were diagnosed with ADHD (or who met a validated cutoff on a recognized rating scale) and that included an ADHD outcome. Fifty-four of the 2,904 nonduplicate screened records were included in the analyses. Two different analyses were performed. When the outcome measure was based on ADHD assessments by raters closest to the therapeutic setting, all dietary (standardized mean differences=0.21-0.48) and psychological (standardized mean differences=0.40-0.64) treatments produced statistically significant effects. However, when the best probably blinded assessment was employed, effects remained significant for free fatty acid supplementation (standardized mean difference=0.16) and artificial food color exclusion (standardized mean difference=0.42) but were substantially attenuated to nonsignificant levels for other treatments. Free fatty acid supplementation produced small but significant reductions in ADHD symptoms even with probably blinded assessments, although the clinical significance of these effects remains to be determined. Artificial food color exclusion produced larger effects but often in individuals selected for food sensitivities. Better evidence for efficacy from blinded assessments is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms.
          Article 0 comments Cited 336 times – based on 0 reviews     Review now
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            The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study.

            Brooke S G Molina, Stephen P. Hinshaw, James M. Swanson … (2009)
            To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261). Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report. In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested. Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.
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              Comparing the efficacy of stimulants for ADHD in children and adolescents using meta-analysis.

              Jan Buitelaar, Jan Buitelaar (2010)
              Stimulants used to treat attention-deficit/hyperactivity disorder (ADHD) have been well researched, but comparisons among stimulants are hindered by the absence of direct comparative trials. The goal of this work was to compare the efficacy of methylphenidate and amfetamine formulations through a meta-analysis of double-blind placebo-controlled trials. We analyzed recent published literature on the stimulant therapy of ADHD to describe the variability of drug-placebo effect sizes. A literature search was conducted to identify double-blind, placebo-controlled studies of ADHD in children and adolescents published after 1979. Meta-analysis regression assessed the influence of medication type and study design features on medication effects. Twenty-three trials met criteria and were included in this meta-analysis. These trials studied 11 drugs using 19 different outcome measures of hyperactive, inattentive, or impulsive behavior. We found significant differences between amfetamine and methylphenidate products, even after correcting for study design features that might have confounded the results. Our analyses indicate that effect sizes for amfetamine products are significantly, albeit moderately, greater than those for methylphenidate. We found that most measures of effect from all studies were statistically significant. Our findings suggest that amfetamine products may be moderately more efficacious than methylphenidate products, even after controlling for potentially confounding study design features. This difference in effect size may be due to differences between amfetamine and methylphenidate in the molecular mechanisms involved in facilitating the dopaminergic neurotransmission.
              Article 0 comments Cited 116 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Martijn Arns:
                ORCID: http://orcid.org/0000-0002-0610-7613
                +31 24 7503505 , martijn@brainclinics.com
                Journal
                Journal ID (nlm-ta): Eur Child Adolesc Psychiatry
                Journal ID (iso-abbrev): Eur Child Adolesc Psychiatry
                Title: European Child & Adolescent Psychiatry
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Print): 1018-8827
                ISSN (Electronic): 1435-165X
                Publication date (Electronic): 14 February 2018
                Publication date PMC-release: 14 February 2018
                Publication date (Print): 2019
                Volume: 28
                Issue: 3
                Pages: 293-305
                Affiliations
                [1 ]ISNI 0000 0000 9935 6525, GRID grid.411668.c, Department of Child and Adolescent Mental Health, , University Hospital Erlangen, ; Erlangen, Germany
                [2 ]ISNI 0000000120346234, GRID grid.5477.1, Department of Experimental Psychology, , Utrecht University, ; Utrecht, The Netherlands
                [3 ]neuroCare Group, Munich, Germany
                [4 ]Research Institute Brainclinics, Bijleveldsingel 34, 6524 AD Nijmegen, The Netherlands
                [5 ]kbo-Heckscher-Klinikum, Munich, Germany
                [6 ]ISNI 0000 0004 0444 9382, GRID grid.10417.33, Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, , Radboud University Medical Centre, ; Nijmegen, The Netherlands
                [7 ]ISNI 0000 0001 2190 1447, GRID grid.10392.39, Institute for Medical Psychology, , University of Tuebingen, ; Tuebingen, Germany
                [8 ]ISNI 0000 0000 9632 6718, GRID grid.19006.3e, Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine, , University of California, ; Los Angeles, USA
                Author information
                http://orcid.org/0000-0001-9042-8948
                http://orcid.org/0000-0002-0610-7613
                http://orcid.org/0000-0002-8156-489X
                http://orcid.org/0000-0002-9108-0565
                Article
                Publisher ID: 1121
                DOI: 10.1007/s00787-018-1121-4
                PMC ID: 6404655
                PubMed ID: 29445867
                SO-VID: 9ffcfb95-1a05-4ffa-a811-c0f8da7dc323
                Copyright © © The Author(s) 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 5 October 2017
                Date accepted : 5 February 2018
                Categories
                Subject: Review
                Custom metadata
                issue-copyright-statement © Springer-Verlag GmbH Germany, part of Springer Nature 2019

                ScienceOpen disciplines: Clinical Psychology & Psychiatry
                Keywords: neurofeedback,eeg biofeedback,adhd,meta-analysis,sustainability,follow-up
                Data availability:
                ScienceOpen disciplines: Clinical Psychology & Psychiatry
                Keywords: neurofeedback, eeg biofeedback, adhd, meta-analysis, sustainability, follow-up

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