About Neurofeedback

Numerous studies have shown that EBF, also called neurofeedback, results in measurable and replicable improvements in attention, impulsivity, mood, anxiety, memory, and learning. There are also clinically significant improvements in addictive disorders and epilepsy in children and adults.

For a detailed overview on the field of neurofeedback as a treatment, its potential risks, as well as selecting a legitimate qualified practitioner, please download the D. Corydon Hammond article – in PDF file format.

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Child Adolescent Psychiatric Clinics of North America 14 (Jan. 2005)

Emerging brain-based interventions for children and adolescents: overview and clinical perspective

› This article has been edited/adapted by David Dubin, MD

Laurence M. Hirshberg, PhDa,b,*, Sufen Chiu, MD, PhDc,
Jean A. Frazier, MD The NeuroDevelopment Ctr, Providence, RI
Dept of Psychiatry, Harvard Med. School, Cambridge Hosp, Cambridge, MA

As this issue of Child and Adolescent Psychiatric Clinics of North America makes clear, there is an ample body of research on EEG biofeedback (EBF). Although much fundamental research remains to be conducted, virtually all the EBF research has demonstrated what recent fMRI studies have replicated using a more complex and sophisticated imaging technology.

Neurofeedback, whether using EEG or real-time fMRI, is applicable to functional brain disorders that arise out of various patterns of functional disturbance or dysregulation. The initial application to epilepsy led to using it for related disorders (attention deficit disorder [ADD], traumatic brain injury [TBI], depression, etc.).

Multiple pathways for intervention in psychiatry

Not too long ago, clinical bias toward treating psychiatric disorders was that medication was the only treatment. New research presents new alternatives.

EEG biofeedback should be understood as a form of self- regulation. Given the robust effect size of EBF, which repeatedly has been shown to be equivalent to that of stimulant medication, it is easy to forget that the technique simply involves showing the trainee what his or her brain is doing.

Individuals accustomed to more traditional, linear-based thinking in western medicine and psychology may find it hard to believe that merely showing the brain to itself has the same strength of effect as a carefully controlled psychoactive medication.

Summary of articles on feedback strategies

The bulk of research on EBF has been with ADHD. Five controlled studies have been published, including one randomized, controlled trial (RCT). A double-blind, randomized, sham treatment study has just been completed but is not yet published.

Many open or clinical trials, with hundreds of participants, also have been published. These studies uniformly show significant benefit for 70% to 80% of participants, with an effect size for EBF equivalent to that of stimulants. Although much more follow-up research needs to be conducted, several studies show the maintenance of gains years after the EBF training ended.

Substantial validation research also has been completed on EBF for epilepsy. Several controlled studies have been completed. A recent meta-analysis indicated that 82% of patients demonstrated more than 30% reduction in seizures, with an average more than 50% reduction. This outcome is all the more significant because most of the participants included in these studies were refractory to medical treatment; for many, EBF was the only alternative to surgery.

Multiple small studies on generalized anxiety disorder (GAD), obsessive-compulsive disorder, phobias, and posttraumatic stress disorder (PTSD) have been published, with several controlled trials. Overall results show significant reduction in anxiety with EBF.

With depression, several case studies have been published providing preliminary evidence of efficacy with major depression.

In adults with addiction disorders, multiple controlled and uncontrolled studies have shown EEG changes and improvements on measures of depression, attention, and stress. Several long-term follow-ups showed a significant reduction in the 1-year abstinence/ recidivism rate for the EBF group compared with controls.

Given that EBF is medication free and has been shown to be effective with ADHD, a frequent co-morbid condition, EBF seems to have particular value for these patients (ie, individuals with psychoactive substance use and ADHD), in whom the risk of medication abuse is high.

Reviews of the literature on treatment for traumatic brain injury (TBI) and reading disabilities indicate that few of the commonly used interventions have shown efficacy in formal research and that the effect size of these techniques is usually small. Several open case series and controlled studies have shown significant benefits for EBF with TBI, primarily in adults, with improvements on measures of attention, executive function, cognitive flexibility, problem solving, information processing, verbal fluency, and depression and in the EEG.

The American Academy of Child and Adolescent Psychiatry (AACAP)

Many advances in psychiatry have been caused by changes in the way medications are use in clinical practice rather than based on methods first validated in research. Much discovery occurs through the clinical use of interventions before formal empirical study; and the AACAP guidelines recognize this fact. This process of clinical discovery followed by empirical testing is seen in most other areas of mental health.

Finally, recent studies suggest that an overly strong emphasis on the need for RCTs to demonstrate efficacy may be mistaken [24–26], because results from nonrandomized observational studies generally have been similar to RCTs.

EBF meets the AACAP criteria for ‘‘Clinical Guidelines’’ for treatment of ADHD, seizure disorders, anxiety (eg, obsessive-compulsive disorder, GAD, posttraumatic stress disorder, phobias), depression, reading disabilities, and addictive disorders. This finding suggests that EBF always should be considered as an intervention for these disorders.

Clearly there is stronger evidence of efficacy—the strongest among the three new approaches being considered in this issue—for the use of EBF for ADHD. EBF also is widely used with children and adolescents with anxiety, depression, and disruptive or explosive behavior.

Specific recommendations based on the body of empirical evidence currently available suggest that EBF be considered by clinicians and parents as a first-line treatment for ADHD when parents or patients prefer not to use medication. EBF should be considered an empirically supported treatment choice for epilepsy, anxiety and depression, addictive disorders, and TBI when patients or parents prefer not to use medication, when medications are not well tolerated or are not fully effective, or when psychotherapeutic approaches are ineffective. EBF also may be used in combination with psychopharmacology or psychoherapy. EBF for reading disabilities may be recommended when more conventional methods fail.

Emerging areas of application of EBF are with migraines, reactive attachment disorder, and autistic spectrum disorder (ASD).

There are consistent and widespread clinical reports of efficacy with migraines and reactive attachment disorder. Based largely on word of mouth communication among parents of children with autistic spectrum disorder, there is rapidly growing clinical experience with EBF.

In one published controlled group study of EBF for autism [33], 24 autistic participants were randomly assigned either to the EBF treatment or to a waitlist control group. Twenty or more sessions (average, 36) of EBF were given. EBF participants showed significant improvements on measures of sociability, communication, health, and sensory awareness compared with controls.

There is a strong consensus among EBF clinicians who work with ASD that EBF offers substantial benefit to a significant percentage of this population. It seems to be helpful to more severe autistic individuals and individuals with high functioning autism and Asperger’s disorder. Approximately 70% to 80% of patients with ASD benefit from the treatment. The degree of benefit ranges from mild to profound.

For example, one 4-year-old boy recently was diagnosed with pervasive developmental disorder-not otherwise specified (NOS). He had severe behavioral and emotional self-regulation problems, with episodes of extreme aggression toward his brother and parents and self-injurious behavior, such as biting and head banging many times daily. He spoke in two- to three-word phrases, primarily echolalic, engaged in considerable repetitive behavior, and showed little social engagement, even with his mother. After 3 months of twice weekly EBF sessions, aggressive behavior and tantrums had largely subsided, language had improved markedly, he began to engage in parallel and some joint pretend play with peers, and his relatedness with his parents and brother had improved markedly.

Generally, improvements are seen in attention and other aspects of executive function, in anxiety and emotional self-regulation, and in the degree to which a child is tuned in to or engaged with the world around him rather than being ‘‘in his own world.’’ It seems to be the case that EBF treatment in ASD requires many more sessions than for other disorders; therefore, home training under the supervision of the clinician is often used.

The rationale for use of neurofeedback for ASD is similar to that for psychopharmacology for this population. Virtually all children with ASD have significant attention deficits and often impulsivity. Although this fact is widely ignored in practice, the Diagnostic and Statistical Manual IV recognizes this when it dictates that ADHD should not be diagnosed in the context of a pervasive developmental disorder. Virtually all children with ASD also suffer from anxiety, obsessive-compulsive symptoms, and mood disturbances. EBF, like psychopharmacology for ASD, is targeted at these specific domains of dysfunction—attention and executive function deficits in general, anxiety and obsessive symptoms, and mood.

There are few risks or contraindications for EBF.

Proper use of EBF has been shown to reduce seizure frequency; there are no documented reports of adverse effects when appropriately used with this disorder or with any other disorder. Temporary negative effects, such as sleep-onset insomnia or increased irritability, anxiety, or emotional lability, can occur. These effects are self-limiting or can be ameliorated by adjusting the training protocol. There are no published reports of permanent negative effects from EBF training.

Comments on Research

Major research support has been lacking, which is unfortunate given the promise shown by EBF. Further research is warranted. In particular, research into the mechanism of effect and the specificity of effect using different training protocols would be useful. Better understanding of the neurophysiologic basis of EBF may facilitate wider acceptance by the general medical community.