Review
Neurofeedback for Attention-Deficit/Hyperactivity Disorder: Meta-Analysis of Clinical and Neuropsychological Outcomes From Randomized Controlled Trials

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Objective

We performed meta-analyses of randomized controlled trials to examine the effects of neurofeedback on attention-deficit/hyperactivity disorder (ADHD) symptoms and neuropsychological deficits in children and adolescents with ADHD.

Method

We searched PubMed, Ovid, Web of Science, ERIC, and CINAHAL through August 30, 2015. Random-effects models were employed. Studies were evaluated with the Cochrane Risk of Bias tool.

Results

We included 13 trials (520 participants with ADHD). Significant effects were found on ADHD symptoms rated by assessors most proximal to the treatment setting, that is, the least blinded outcome measure (standardized mean difference [SMD]: ADHD total symptoms = 0.35, 95% CI = 0.11−0.59; inattention = 0.36, 95% CI = 0.09−0.63; hyperactivity/impulsivity = 0.26, 95% CI = 0.08−0.43). Effects were not significant when probably blinded ratings were the outcome or in trials with active/sham controls. Results were similar when only frequency band training trials, the most common neurofeedback approach, were analyzed separately. Effects on laboratory measures of inhibition (SMD = 0.30, 95% CI = −0.10 to 0.70) and attention (SMD = 0.13, 95% CI = −0.09 to 0.36) were not significant. Only 4 studies directly assessed whether learning occurred after neurofeedback training. The risk of bias was unclear for many Cochrane Risk of Bias domains in most studies.

Conclusion

Evidence from well-controlled trials with probably blinded outcomes currently fails to support neurofeedback as an effective treatment for ADHD. Future efforts should focus on implementing standard neurofeedback protocols, ensuring learning, and optimizing clinically relevant transfer.

Section snippets

Method

The EAGG protocol was originally registered on the International Prospective Register of Systematic Reviews (PROSPERO; http://www.crd.york.ac.uk/PROSPERO, protocol number: CRD42011001393). As in previous work,4, 5 the original protocol was adapted to take account of the broader scope of this systematic review/meta-analysis. Most crucially, given that the scope of this analysis included neuropsychological measures, the mandatory requirement for studies to have ADHD symptoms-related outcomes no

Results

A total of 13 trials24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 met entry criteria. Figure 1 presents the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) selection flowchart. Table S1, available online, provides a list of excluded papers with reasons for exclusion. Retained studies included a total of 520 participants with ADHD. Table 1 gives information about the characteristics of the retained trials. Table 2 summarizes results of all analyses. There were

Discussion

The rationale for the use of neurofeedback for ADHD rests on the idea that promoting normalization or self-regulation of brain activity will translate into improved cognitive and behavioral control that is deficient in individuals with ADHD. A previous meta-analysis17 based on a limited number of trials (n = 8) was inconclusive with regard to the efficacy of neurofeedback for ADHD symptoms. Although there were moderate but highly significant effects (SMD = 0.59; 95% CI = 0.31−0.87) for ADHD

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    European ADHD Guidelines Group (EAGG) Members: Phil Asherson, MBBS, MRPsych, PhD, Tobias Banaschewski, MD, PhD, Daniel Brandeis, PhD, Jan Buitelaar, MD, PhD, David Coghill, MD, Samuele Cortese, MD, PhD, David Daley, PhD, Marina Danckaerts, MD, PhD, Ralf W. Dittmann, MD, PhD, Manfred Döpfner, PhD, Maite Ferrin, MD, PhD, Chris Hollis, MD, PhD, Martin Holtmann, MD, PhD, Eric Konofal, MD, PhD, Michel Lecendreux, MD, Aribert Rothenberger, MD, Paramala Santosh, MD, PhD, Joseph A. Sergeant, PhD, Emily Simonoff, MD, Edmund J. Sonuga-Barke, PhD, Cesar Soutullo, MD, HansChristoph Steinhausen, MD, PhD, Jim Stevenson, PhD, Argyris Stringaris, MD, PhD, MRCPsych, Eric Taylor, MD, Saskia van der Oord, PhD, Ian Wong, PhD, and Alessandro Zuddas, MD.

    Support for meetings and analyses was received from Brain Products GMBH, Janssen-Cilag, Eli Lilly and Co., Medice, Shire, and Vifor. No honoraria were received, and funders had no input into the review and meta-analysis process or the writing of the paper.

    Drs. Cortese and Ferrin are joint first authors.

    Disclosure: Dr. Cortese has received grant or research support from the Solent National Health Service (NHS) Trust, UK. He has received honorarium and travel expenses from the Association for Child and Adolescent Mental Health (ACAMH), UK. Dr. Ferrin was invited to participate to give a workshop on “Behavioural Interventions in ADHD” at the Meeting of Minds, Stockholm 2015, organized by Shire. Dr. Brandeis has served as an unpaid scientific advisor for a European Union (EU)-funded neurofeedback trial. Dr. Holtmann has served in an advisory or consultancy role for Medice and Shire, and has received conference attendance support or was paid for public speaking by Eli Lilly and Co., Medice, Neuroconn, and Shire. Dr. Daley has provided educational talks for Eli Lilly and Co. and Shire, has attended an advisory board for Eli Lilly and Co., has received support for educational travel from Eli Lilly and Co., Shire, and HP Pharma, and research funding from Shire. He has received royalties from the sale of a self-help version of the New Forest Parenting Programme. Dr. Santosh has received research funding from the EU (FP7 Programme) and the National Institute for Health Research (NIHR). He is a director and shareholder of HealthTracker, Ltd., UK, and HighStreet Medical Dental, Gillingham, UK. Dr. Simonoff has received grant funding from the following sources: NIHR; Autism Speaks; European Innovative Medicines Initiative; Wellcome Trust; South London and Maudsley Charitable Foundation; Biomedical Research Centre Nucleus Pilot Funding; NIHR Evaluation, Trials and Coordinating Centre (NETSCC). Dr. Stringaris has received grant or research support from the Guy’s and St. Thomas’ Charity, the Wellcome Trust, NIHR, and University College London for a joint project with Johnson and Johnson. He has received royalties from Cambridge University Press for The Maudsley Reader in Phenomenological Psychiatry and Oxford University Press for Disruptive Mood: Irritability in Children and Adolescents. Dr. Sonuga-Barke has received research funding and conference support from Shire Pharma; has received speaker fees from Shire Pharma, Janssen-Cilag, and Medice; has received book royalties from Oxford University Press and Jessica Kingsley; has served as a consultant to Shire Pharma, Neurotech Solutions, Aarhus University, Copenhagen University, and KU Leuven. Dr. Stevenson and Mr. Aggensteiner report no biomedical financial interests or potential conflicts of interest.

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