Efficacy of Neurofeedback, Behavior Therapy, And Medication on ADHD

Neurofeedback, behavior therapy, and pharmacological treatment are interventions used to manage attention-deficit hyperactivity disorder (ADHD) symptoms.

Neurofeedback trains individuals to regulate brain activity through real-time feedback. Behavior therapy teaches strategies to improve focus, organization, and impulse control through techniques like parent training and skill-building. Pharmacological treatment, typically stimulant medication, targets chemical imbalances to enhance attention and reduce hyperactivity.

Each approach has unique mechanisms of action, but all aim to alleviate ADHD symptoms and improve functioning.

Combining these therapies may provide complementary benefits, targeting neurological, behavioral, and physiological aspects of ADHD. Treatment plans should be individualized based on symptom presentation and patient preferences

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

Key Points

• The study compared the efficacy of neurofeedback (NF), behavior therapy (BT), and pharmacology (PH) treatments for ADHD in children ages 7-14 using pre-post assessments. The three treatments were all effective but had different effects.
• NF improved response control and attention, especially with visual stimuli. PH mainly improved overall attention. BT had the most widespread effects, improving response control, attention, and ADHD rating scales.
• PH was superior to NF and BT in improving overall attention on the IVA/CPT test. NF and BT each surpassed PH on a couple IVA/CPT measures. BT showed the greatest improvements on ADHD rating scales.
• The research provides guidance on the differential effects and benefits of ADHD treatments, but has limitations like small sample sizes. Further research is needed comparing the treatments.

Rationale

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in childhood that impairs functioning.

Pharmacological treatment with stimulants is frequently recommended but has drawbacks like adverse effects and lack of acceptance (Peterson, McDonagh, & Fu, 2008). Research has shown the efficacy of combining behavioral interventions with medication (Eiraldi, Mautone, & Power, 2012; Leung & Hung, 2008; Murray et al., 2008).

Non-pharmacological treatments like neurofeedback and behavioral therapy have also demonstrated effectiveness for ADHD (Arns, Heinrich, & Sthehl, 2014; Coates, Taylor & Sayal, 2015).

However, conclusions about the comparative effectiveness of neurofeedback, pharmacology, and behavior therapy remain controversial, with some considering neurofeedback an efficacious first-line treatment (Pigott & Cannon, 2014) and others still uncertain (Loo & Makeig, 2012).

One issue may be the different measures used to assess ADHD symptoms. This study aims to directly compare the efficacy of neurofeedback, pharmacology, and behavior therapy for ADHD using neuropsychological tests and rating scales completed by parents, teachers, and children.

Examining the differential effects can provide insight into which treatments may be most suitable.

Method

This randomized controlled trial compared neurofeedback, pharmacology, and behavior therapy treatments for ADHD.

Procedure

Children were randomly assigned to the neurofeedback, pharmacology, or behavior therapy treatment group.

The neurofeedback group received 40 theta/beta training sessions, which involved learning to modify brain wave activity by decreasing theta waves (associated with inattention) and increasing beta waves (associated with focused attention) through real-time feedback.

The pharmacology group received methylphenidate, a stimulant medication that increases dopamine and norepinephrine levels in the brain to improve attention and reduce impulsivity, as prescribed by a pediatrician.

The behavior therapy group received parent training, which taught parents strategies to reinforce positive behaviors and manage challenging ones; teacher training, which provided educators with tools to support the child’s academic and behavioral functioning; and individual cognitive therapy sessions, which helped children develop skills in problem-solving, emotional regulation, and self-control.

ADHD assessments occurred 1 week before treatment and after the 20-week treatment period.

Sample

The 59 participants were 7-14 years old (mean age 8.8) and 77% male. They met DSM-V criteria for ADHD and scored above cutoffs on parent and teacher ADHD rating scales.

Exclusionary criteria included comorbid disorders, contraindications for medication, and intellectual disability.

Measures

ADHD symptoms were assessed before and after treatment using the Integrated Visual and Auditory Continuous Performance Test (IVA/CPT), ADHD Rating Scales-IV completed by parents and teachers, and the Attention Deficit Disorders Evaluation Scale (ADDES) completed by parents.

Below are the specific measures used and what they are:

• IVA/CPT: A computerized test that evaluates attention and control of responses to auditory and visual stimuli. The results are presented in standardized scores with a mean of 100 and standard deviation of 15.
• ADHD RS-IV: An 18-item scale that comprises two subscales, inattention, and hyperactivity-impulsivity, and yields a total score. Higher scores indicate greater problems related to ADHD. The scale was completed by mothers and teachers separately.
• ADDES: A more extensive parent-rated scale used to evaluate inattentive and hyperactive/impulsive symptoms in a more comprehensive manner compared to the ADHD RS-IV. Mothers completed this scale to provide additional information about their child’s ADHD symptoms.

Statistical Analysis

Pre-post changes for each treatment were analyzed using paired t-tests or Wilcoxon tests. Between-treatment comparisons used ANOVA on pre-post change scores with Bonferroni-corrected post-hoc tests. Effect sizes were calculated using Cohen’s d.

Results

All three treatments led to significant pre-post improvements on most IVA/CPT and rating scale measures, with some differential effects:

• Neurofeedback improved 15/18 IVA/CPT measures, with larger effects for visual attention/control. Teachers reported significant decreases in ADHD symptoms.
• Pharmacology improved 11/18 IVA/CPT measures, with large effects on attention, especially auditory. Parents reported decreased inattention on ADDES.
• Behavior therapy improved 11/18 IVA/CPT measures, more in auditory attention/control. All parent and teacher rating scales showed significant large improvements.

Between-treatment ANOVAs on pre-post change scores found pharmacology superior to neurofeedback and behavior therapy on 5 IVA/CPT attention measures.

Neurofeedback and behavior therapy each surpassed pharmacology on 1-2 IVA/CPT measures. There were no significant differences on rating scales, but behavior therapy consistently had the largest effect sizes.

In summary, all treatments improved ADHD symptoms, but pharmacology had greater effects on attention, while neurofeedback and behavior therapy showed more improvement in impulsivity/hyperactivity.

Behavior therapy produced the broadest enhancements across neuropsychological and rating scale measures.

Insight

This study provides valuable insight into the differential impact of neurofeedback, pharmacological, and behavioral treatments for childhood ADHD. While all three treatments were beneficial, they showed distinct patterns of improvement.

Pharmacology, as the mainstream treatment, demonstrated the largest gains in attention on a computerized test.

However, neurofeedback matched or exceeded medication’s effects on measures of impulsivity and hyperactivity, especially when visual stimuli were involved. This suggests neurofeedback training may uniquely strengthen self-control.

Behavior therapy emerged as the most well-rounded treatment, with significant improvements observed by parents, teachers, and the attention test.

The broad efficacy may stem from behavior therapy’s multi-pronged approach of child, parent, and teacher training targeting multiple environments.

Pragmatically, the results imply that treatment choice should consider the specific deficits of each child. Medication may be preferred for severe inattention, neurofeedback for impulsivity, and behavior therapy for global improvement.

Combining treatments may be optimal, with medication augmenting attention while neurofeedback and behavior therapy buttress self-regulation and implement skills across settings.

Future studies should replicate these comparisons in larger samples and examine longer-term outcomes. Best practices may involve tailored treatment plans integrating pharmacological and behavioral interventions to maximize benefits for children with ADHD.

Strengths

The study had many methodological strengths, enhancing the reliability and generalizability of the findings:

• Randomized controlled design enabled rigorous comparison of three leading ADHD treatments
• Inclusion of children who were stimulant-naïve reduced confounding effects of prior medication use
• Multi-modal assessment captured ADHD symptoms via computerized test and reports from children, parents, and teachers
• Significant effects were found on both neuropsychological functioning and “real world” symptom measures
• Analyzing both within-group pre-post changes and between-group differences provided comprehensive view of treatment efficacy
• 20-week treatment duration was suitably long to evaluate impact
• Manualized treatment protocols ensured standardization and replicability
• Control for comorbidities, IQ, medical issues, and prior treatment strengthened internal validity

Limitations

While the study had notable strengths, some limitations should be considered when interpreting the results:

• Small sample size (n=59) divided between three treatments may have limited power to detect effects, especially between-group differences
• Lack of follow-up data precluded evaluation of long-term outcomes and durability of effects
• Sample was predominantly male, limiting generalizability to girls with ADHD
• No evaluation of academic, social, or global functioning measures beyond core ADHD symptoms
• Participants were mainly recruited from one health district in Spain, limiting geographic representativeness
• Some pretreatment group differences in IVA/CPT scores, though not statistically significant, may have influenced outcomes
• No placebo or “treatment as usual” control group to establish effects above and beyond standard care or expectancy
• Medication management was done by community pediatricians rather than study personnel, potentially introducing heterogeneity

Implications

The results of this study have important clinical implications for the treatment of childhood ADHD. By directly comparing three empirically-supported treatments, the findings offer guidance for practitioners in selecting interventions best suited for a child’s symptomatic profile.

Pharmacological treatment with stimulant medication, the most widely used approach, was especially effective in improving attentional capacities. This suggests that for children whose primary difficulties lie in inattention, medication may be the frontline treatment of choice.

However, the study also highlighted the unique strengths of non-pharmacological approaches. Neurofeedback yielded larger gains in impulse control and hyperactivity, particularly when visual stimuli were involved.

This implies that neurofeedback may be indicated for children who struggle with behavioral self-regulation and impulsivity.

Behavior therapy, incorporating parent, teacher, and child training, showed the broadest impact, with improvements across neuropsychological and rating scale measures.

The pervasive benefits suggest that behavior therapy may be optimal when a more comprehensive treatment targeting multiple domains of functioning is desired.

Importantly, all three treatments were effective to some degree, implying that each has a role in ADHD management.

A multifaceted treatment plan integrating medication to target attention with neurofeedback and/or behavior therapy to enhance self-control and implement skills across settings may be a promising approach.

Clinicians should consider a child’s specific deficits, family preferences, and response to interventions in crafting an individualized treatment plan to optimize outcomes.

Further research is needed to replicate these findings, elucidate mechanisms of action, and evaluate long-term effects. Additionally, studies should examine factors influencing treatment response and develop algorithms for optimally combining and sequencing interventions.

As the present study suggests, leveraging the relative strengths of different modalities may lead to the most powerful, synergistic benefits for children with ADHD.

References

Primary reference

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

Other references

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

Coates, J., Taylor, J. A., & Sayal, K. (2015). Parenting interventions for ADHD: A systematic literature review and meta-analysis. Journal of attention disorders, 19(10), 831-843. https://doi.org/10.1177/1087054714535952

Eiraldi, R. B., Mautone, J. A., & Power, T. J. (2012). Strategies for implementing evidence-based psychosocial interventions for children with attention-deficit/hyperactivity disorder. Child and Adolescent Psychiatric Clinics, 21(1), 145-159. https://doi.org/10.1016/j.chc.2011.08.012

Bitsakou, P., Psychogiou, L., Thompson, M., & Sonuga-Barke, E. J. (2009). Delay aversion in attention deficit/hyperactivity disorder: an empirical investigation of the broader phenotype. Neuropsychologia, 47(2), 446-456. https://doi.org/10.1016/j.neuropsychologia.2008.09.015

Loo, S. K., & Makeig, S. (2012). Clinical utility of EEG in attention-deficit/hyperactivity disorder: a research update. Neurotherapeutics, 9(3), 569-587. https://doi.org/10.1007/s13311-012-0131-z

Murray, D. W., Arnold, L. E., Swanson, J., Wells, K., Burns, K., Jensen, P., Hechtman, L., Paykina, N., Legato, L., & Strauss, T. (2008). A clinical review of outcomes of the multimodal treatment study of children with attention-deficit/hyperactivity disorder (MTA). Current psychiatry reports, 10(5), 424-431. https://doi.org/10.1007/s11920-008-0068-4

Peterson, K., McDonagh, M. S., & Fu, R. (2008). Comparative benefits and harms of competing medications for adults with attention-deficit hyperactivity disorder: a systematic review and indirect comparison meta-analysis. Psychopharmacology, 197, 1-11. https://doi.org/10.1007/s00213-007-0996-4

Pigott, H. E., & Cannon, R. (2014). Neurofeedback is the best available first-line treatment for ADHD: What is the evidence for this claim?. NeuroRegulation, 1(1), 4-4.

Keep Learning

Here are some reflective questions related to this study that could prompt further discussion:

1. Based on the different response patterns to neurofeedback, medication, and behavior therapy, what might this suggest about the underlying mechanisms of each treatment? How might they be targeting different aspects of ADHD pathophysiology?
2. The study found some differences between the effects of treatments on auditory vs. visual outcomes. What are potential explanations for this? How might the modality of stimulus presentation interact with the attentional and impulse control deficits in ADHD?
3. Behavior therapy showed the broadest improvements across neuropsychological functioning and symptom ratings. What components of behavior therapy (e.g. parent training, child skills groups, teacher consultation) might be driving these widespread effects? How could these components complement medication and/or neurofeedback?
4. The results suggest that combined treatment with medication targeting attention deficits and neurofeedback/behavior therapy addressing self-regulation may be most effective. How would you design a study to test this hypothesis? What outcome measures would be most important to include?
5. The study was limited by its small sample size, lack of follow-up, and restricted demographics. How might these factors impact the generalizability and clinical utility of the findings? What additional research is needed to establish the relative efficacy of ADHD treatments in larger, more diverse populations over time?