Neurofeedback ADHD Treatment

Neurofeedback is a non-drug treatment for managing ADHD that trains people to shift their own brain waves. It targets patterns linked to attention, impulsivity, and hyperactivity, aiming to improve self-regulation. Parents often report gains, but the best-controlled trials suggest most benefit is not specific to the training.

This article explores the mechanisms behind neurofeedback, its effectiveness in treating ADHD based on current research, and important considerations for those interested in pursuing this treatment option.

What is neurofeedback?

Neurofeedback, also known as EEG biofeedback or neurotherapy, is a non-invasive treatment that aims to improve brain function through the self-regulation of brain activity.

It gives an individual real-time feedback on their brain activity, typically measured by electroencephalography (EEG). EEG records brain activity through scalp sensors. The aim is to teach people to shift brain wave patterns associated with attention, impulsivity, and hyperactivity.

Neurofeedback is increasingly used for children and adults with Attention Deficit Hyperactivity Disorder (ADHD), once called ADD. It is offered as an alternative or complement to medication.

How does neurofeedback therapy work?

The goal is to teach the individual to change their brain activity in a desired direction. For example, they might increase beta waves (associated with attention and focus) or decrease theta waves (associated with drowsiness and inattention).

A typical session lasts 30-60 minutes. The individual sits in front of a computer screen while the therapist monitors their brain activity. Each session follows four steps.

1. Measure: Electrodes on the scalp record brain wave activity.
2. Feed back: Specialized software processes the signal and presents it as visual or auditory feedback, such as a video game or moving graphs.
3. Reward: The therapist sets target thresholds, and the individual is rewarded when their brain activity meets them, for example by a game character moving faster or earning points.
4. Adjust: As the individual progresses, the therapist may change the thresholds and difficulty to keep the task challenging but achievable.

Over multiple sessions, typically 20-40, the individual learns to recognize and control their brain activity patterns. The aim is improved self-regulation and fewer ADHD-related difficulties.

How can neurofeedback be used to treat ADHD?

Neurofeedback can be used to treat ADHD by targeting specific brain wave patterns associated with the disorder.

Many children with ADHD show a higher theta/beta ratio, meaning more slow theta activity relative to fast beta activity, than other children. Not every child shows this pattern.

A meta-analysis of nine studies (1,253 children and adolescents with ADHD, 517 without) found the ratio is not a reliable diagnostic measure. A substantial subgroup does deviate, so it may have prognostic value. The difference between groups also narrowed in later studies.

This imbalance is thought to contribute to the inattention, impulsivity, and hyperactivity characteristic of ADHD.

During neurofeedback training for ADHD, the individual learns to decrease theta wave activity and increase beta wave activity. This happens in specific brain regions, such as the central and frontal lobes.

This works through operant conditioning. Brain wave patterns that earn positive feedback become more likely to recur.

Most neurofeedback for ADHD uses one of two protocols.

• Theta/beta ratio training: aims to decrease the ratio of theta to beta waves.
• Slow cortical potential (SCP) training: teaches the individual to regulate the excitability of their cortex, the brain’s outer layer.

A randomized trial of 102 children aged 8 to 12 compared 36 sessions of neurofeedback (one block of each protocol) with a computerized attention skills training. Parent and teacher ratings improved more with neurofeedback, and the two protocols gave comparable effects.

The effect size on the parent-rated total score was 0.60. The authors noted that the specificity of these effects still needed testing.

How effective is neurofeedback for ADHD?

Researchers have tested neurofeedback for ADHD in numerous studies. Results depend on who rates the child and whether the trial included a sham control, a placebo version of the training.

What Meta-Analyses Found

A meta-analysis found that neurofeedback had large effect sizes for reducing inattention and impulsivity symptoms and a medium effect size for hyperactivity. The authors concluded that neurofeedback could be considered an “efficacious and specific” treatment for ADHD.

That 2009 analysis also included simple before-and-after studies. Randomized studies showed a smaller effect on hyperactivity, suggesting it is probably most sensitive to non-specific treatment factors.

Another meta-analysis pooled five randomized trials (263 children) that compared neurofeedback with sham feedback or a comparison training.

Parents, who probably knew which treatment their child received, rated overall ADHD, inattention, and hyperactivity-impulsivity as improved.

Teachers were less likely to know. Their ratings improved for inattention only, a small effect (standardized mean difference of -0.30). The benefits may therefore not generalize to every setting.

A more recent meta-analysis asked whether the gains last. It pooled ten randomized trials in children (256 of them given neurofeedback), with follow-up assessments 2 to 12 months after treatment.

Parent-rated inattention gains held up. Compared with non-active control conditions, neurofeedback stayed ahead for at least six months.

Medication, mainly methylphenidate, produced larger gains in inattention. The authors called for more studies that control for non-specific effects.

Blinded and Sham-Controlled Trials

The evidence is not all positive.

A 2016 meta-analysis pooled 13 randomized trials (520 children and adolescents). The results split by how well the raters were blinded, meaning unaware of which treatment each child received.

• Least blinded ratings: a small improvement (standardized mean difference of 0.35 for total ratings), from assessors closest to the treatment.
• Probably blinded ratings: no significant effect.
• Sham or active controls: no significant effect in trials with these comparison groups.
• Laboratory measures: no significant effect on attention or inhibition tasks.

The authors concluded that well-controlled trials with probably blinded outcomes currently fail to support neurofeedback as an effective treatment for ADHD.

A double-blind trial tested theta/beta training directly. Arnold and colleagues (2021) randomized 144 children aged 7 to 10 with moderate or severe ADHD and a high theta/beta ratio. Children received real training or a control of equal length, intensity, and appearance. The control used pre-recorded EEG.

• End of treatment: both groups improved, with no specific effect of the training.
• 13 months: still no specific effect.
• 25 months: parent-rated inattention did not differ between groups (Neurofeedback Collaborative Group, 2023). Gains were large in both: effect sizes of 1.63 for neurofeedback and 1.42 for the control.

The authors concluded that most of the improvement was non-specific. At 25 months, outcomes looked comparable to those of the evidence-based treatments in the Multimodal Treatment Study of ADHD. The authors read this as a psychotherapeutic or behavioral effect.

Adults and Expert Disagreement

Adults show a similar picture.

A triple-blind trial randomized 118 adults with ADHD to 30 sessions of theta/beta neurofeedback, sham neurofeedback, or group therapy. All three improved equally (Schönenberg et al., 2017).

A secondary analysis of the children’s trial (Ging-Jehli et al., 2024) found one cognitive difference.

On a computerized attention test, neurofeedback improved how efficiently children processed auditory information more than the control did.

Researchers disagree about how to read this evidence. Arns and colleagues (2014) conclude that standard protocols have demonstrated specificity. Enriquez-Geppert and colleagues (2019) call neurofeedback a viable treatment alternative. The blinded trials above found otherwise.

Reviewers on both sides call for trials that check whether children actually learn to control their brain activity.

Neurofeedback Versus Medication and Therapy

A systematic review compared neurofeedback with stimulant medication, mainly methylphenidate, in eight randomized trials with children and adolescents.

Its stronger trials used probably blinded ratings, sham or semi-active controls, or carefully adjusted medication doses. The review’s findings fell into three groups.

• Stand-alone use: the stronger trials did not support theta/beta neurofeedback as a stand-alone treatment.
• Added to stimulants: neurofeedback gave extra benefit in some trials.
• Medication dose: some children took lower doses, and both of these effects held at six-month follow-up.

In a trial of 59 children assigned at random to neurofeedback, behavior therapy, or medication, behavior therapy brought the widest improvements. Medication gave the biggest gain in overall attention.

Neurofeedback improved response control and inattention on a computerized test but had a smaller effect on rating scales.

For comparison, a network meta-analysis of 133 double-blind trials (Cortese et al., 2018) tested the main ADHD medications. In children and adolescents, all of them beat placebo on clinicians’ ratings at about 12 weeks.

Methylphenidate came out first for young people, amphetamines for adults.

Where Neurofeedback Fits

Some reviewers still see a role for neurofeedback. They regard it as a complementary option in a wider treatment plan, particularly for children who respond poorly to medication or cannot tolerate it.

Further research is needed to establish the optimal neurofeedback protocols and treatment durations for different subgroups of individuals with ADHD.

As Sedgwick, Merwood and Asherson (2019) explain, successful adults with ADHD described traits such as hyper-focus (intense absorption in a task) and divergent thinking. They used these traits to compensate for their difficulties.

Most trials above measured ratings of inattention and hyperactivity-impulsivity, which is only one way to judge a treatment.

Environmental support is another route. Routines, reminders, and accommodations at home, school, or work can substantially improve quality of life, and some people frame support as asking what environment lets their brain work well.

Considerations and Side Effects

Neurofeedback is generally considered a safe and non-invasive treatment for ADHD. Several practical considerations and potential side effects still deserve attention.

• Time and cost: A typical course involves 20-40 sessions of 30-60 minutes each, a significant commitment for families.
• Uncertain benefit: Blinded trials show little specific effect (Cortese et al., 2016; Arnold et al., 2021), so families should weigh the time and cost against that uncertainty.
• Engagement: Neurofeedback needs active cooperation. Children with ADHD may find it hard to sit still and focus for long periods, which can reduce its effectiveness.
• Combined approaches: Some researchers have suggested pairing neurofeedback with cognitive-behavioral therapy or parent training, which teaches caregivers consistent routines and consequences, to improve outcomes.
• Side effects: Neurofeedback is generally well tolerated, with few reported adverse events. Some people experience mild fatigue, headaches, or sleep disturbances, but these are typically short-lived and resolve independently.
• Practitioner: Choose a qualified, experienced practitioner to minimize risk. Practice is not regulated (Enriquez-Geppert et al., 2019), so ask about training and protocols.

References

Arnold, L. E., Arns, M., Barterian, J., Bergman, R., Black, S., Conners, C. K., Connor, S., Dasgupta, S., deBeus, R., Higgins, T., Hirshberg, L., Hollway, J. A., Kerson, C., Lightstone, H., Lofthouse, N., Lubar, J., McBurnett, K., Monastra, V., Buchan-Page, K., . . . Williams, C. E. (2021). Double-blind placebo-controlled randomized clinical trial of neurofeedback for attention-deficit/hyperactivity disorder with 13-month follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 60(7), 841-855. https://doi.org/10.1016/j.jaac.2020.07.906

Arns, M., De Ridder, S., Strehl, U., Breteler, M., & Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta-analysis. Clinical EEG and neuroscience, 40(3), 180-189. https://doi.org/10.1177/155005940904000311

Arns, M., Heinrich, H., & Strehl, U. (2014). Evaluation of neurofeedback in ADHD: the long and winding road. Biological psychology, 95, 108-115. https://doi.org/10.1016/j.biopsycho.2013.11.013

Arns, M., Conners, C. K., & Kraemer, H. C. (2013). A decade of EEG theta/beta ratio research in ADHD: a meta-analysis. Journal of attention disorders, 17(5), 374-383. https://doi.org/10.1177/1087054712460087

Cortese, S., Ferrin, M., Brandeis, D., Holtmann, M., Aggensteiner, P., Daley, D., Santosh, P., Simonoff, E., Stevenson, J., Stringaris, A., Sonuga-Barke, E. J. S., & the European ADHD Guidelines Group. (2016). Neurofeedback for attention-deficit/hyperactivity disorder: meta-analysis of clinical and neuropsychological outcomes from randomized controlled trials. Journal of the American Academy of Child & Adolescent Psychiatry, 55(6), 444-455. https://doi.org/10.1016/j.jaac.2016.03.007

Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., Atkinson, L. Z., Tessari, L., Banaschewski, T., Coghill, D., Hollis, C., Simonoff, E., Zuddas, A., Barbui, C., Purgato, M., Steinhausen, H.-C., Shokraneh, F., Xia, J., & Cipriani, A. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 5(9), 727-738. https://doi.org/10.1016/S2215-0366(18)30269-4

Enriquez-Geppert, S., Smit, D., Pimenta, M. G., & Arns, M. (2019). Neurofeedback as a treatment intervention in ADHD: current evidence and practice. Current Psychiatry Reports, 21(6), Article 46. https://doi.org/10.1007/s11920-019-1021-4

Gevensleben, H., Holl, B., Albrecht, B., Vogel, C., Schlamp, D., Kratz, O., Studer, P., Rothenberger, A., Moll, G. H., & Heinrich, H. (2009). Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial. Journal of Child Psychology and Psychiatry, 50(7), 780-789. https://doi.org/10.1111/j.1469-7610.2008.02033.x

Ging-Jehli, N. R., Painter, Q. A., Kraemer, H. A., Roley-Roberts, M. E., Panchyshyn, C., Debeus, R., & Arnold, L. E. (2024). A diffusion decision model analysis of the cognitive effects of neurofeedback for ADHD. Neuropsychology, 38(2), 146-156. https://doi.org/10.1037/neu0000932

Micoulaud-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, 906. https://doi.org/10.3389/fnhum.2014.00906

Monastra, V. J., Lynn, S., Linden, M., Lubar, J. F., Gruzelier, J., & LaVaque, T. J. (2005). Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder. Applied Psychophysiology and Biofeedback, 30(2), 95-114. https://doi.org/10.1007/s10484-005-4305-x

Moreno-García, I., Meneres-Sancho, S., Camacho-Vara de Rey, C., & Servera, M. (2019). A randomized controlled trial to examine the posttreatment efficacy of neurofeedback, behavior therapy, and pharmacology on ADHD measures. Journal of Attention Disorders, 23(4), 374-383. https://doi.org/10.1177/1087054717693371

Neurofeedback Collaborative Group. (2023). Neurofeedback for attention-deficit/hyperactivity disorder: 25-month follow-up of double-blind randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 62(4), 435-446. https://doi.org/10.1016/j.jaac.2022.07.862

Razoki, B. (2018). Neurofeedback versus psychostimulants in the treatment of children and adolescents with attention-deficit/hyperactivity disorder: a systematic review. Neuropsychiatric Disease and Treatment, 14, 2905-2913. https://doi.org/10.2147/NDT.S178839

Schönenberg, M., Wiedemann, E., Schneidt, A., Scheeff, J., Logemann, A., Keune, P. M., & Hautzinger, M. (2017). Neurofeedback, sham neurofeedback, and cognitive-behavioural group therapy in adults with attention-deficit hyperactivity disorder: a triple-blind, randomised, controlled trial. The Lancet Psychiatry, 4(9), 673-684. https://doi.org/10.1016/S2215-0366(17)30291-2

Sedgwick, J. A., Merwood, A., & Asherson, P. (2019). The positive aspects of attention deficit hyperactivity disorder: a qualitative investigation of successful adults with ADHD. ADHD Attention Deficit and Hyperactivity Disorders, 11(3), 241-253. https://doi.org/10.1007/s12402-018-0277-6

Van Doren, J., Arns, M., Heinrich, H., Vollebregt, M. A., Strehl, U., & Loo, S. K. (2019). Sustained effects of neurofeedback in ADHD: a systematic review and meta-analysis. European child & adolescent psychiatry, 28(3), 293-305. https://doi.org/10.1007/s00787-018-1121-4