The program that had most evidence behind for that specific context is Cogmed Working Memory Training.

~~~

"The most conclusive test of neurofeedback treatment would include random assignment and a control condition that closely matched the neurofeedback condition. For example, children could receive video game coaching from a supportive adult for the same time period. Or, even better, they could do exactly what children getting the neurofeedback were doing but not receive direct feedback on their EEG states." - Dr. Rabiner

~~~

EEG neurofeedback is not a "treatment" in the classical sense. It is a training program that requires tailoring over time by the practitioner and active participation from the patient. It is not possible to simulate this effectively over time for a "blind" study, much less a double blind study.

But the larger answer as to why no one attempts the type of study he proposes is $$$:

"For a very promising treatment targeting such a
serious condition as epilepsy, the number of large-scale clinical trials of neurofeedback
training to date is disappointing. A likely reason for this state of affairs is that
neurofeedback research is a very time- and work-intensive enterprise that has
traditionally not received extensive research funding and has, for obvious reasons, not
been pursued by the pharmaceutical industry."

http://sica.stanford.edu/events/brainwaves/FoundationsofNeurofeedback.pdf

As I mentioned previously, no company owns a patent on EEG neurofeedback - it's a training process, not a drug or specific medical device. It is not economically justifiable for a for-profit company to sponsor the necessary research. There is no ROI. So, it's up to non-profit groups/charities to sponsor this kind of research. While some have sponsored small studies recently (such as FACES at NYU), there hasn't been and isn't anything being done on the scale that appears to be necessary for the skeptics.

I don't mind if you republish the comment.

Play Attention is not a full fledged neurofeedback machine like the ones used in studies. It only processes (IIRC) the alpha wave channel. EEG Neurofeedback machines like Brainmaster's Atlantis system, Zengar Institute's NeuroCare system, etc. manage up to 5 wave channels - alpha, beta, theta, delta and (sometimes) gamma. It also doesn't perform QEEG mappings, so it is not on the same level as a treatment option as EEG neurofeedback as defined in the studies.

You raise many good points. And I am happy that neurofeedback helped your wife. Now, nothing that you have written, in my view, contradicts Dr. Rabiner's conclusion. Furthermore, the fact that neurofeedback has been around for so long, may make one question why no one attempts the type of study he proposes.

In fact, in those same ratings you link to, one can see only one application reaches Levels 5, and it is not ADD/ ADHD. Which is basically what Dr. Rabiner is saying, with other words.

This is not about drugs vs. no drugs. Some non-drug-based approaches, such as cognitive therapy or forms of computer-based working memory training are starting to show efficacy as complement to drugs in well-designed trials. And it is not about biofeedback in general, which has clear research support for specific applications.

You may know that companies like Play Attention sell neurofeedback machines direct to parents, for use with kids who have ADD/ ADHD. Have you seen research supporting an investment of more than $1,000 in such programs? They may work, and parents are free to spend their money as they want- but they deserve to know that it is not proven.

After 3 and a half months of twice weekly sessions, we almost gave up on the neurofeedback. It was burning a hole in our wallet (no insurance covered it) and we were not seeing any results. However, we stuck with it (mostly because my wife refused to poison her liver with anti-epileptic drugs).

After 5 months, it was like someone had turned a switch. She stopped having seizures, was calmer, had better memory and cognitive functioning (thinking clearer). We stopped the neurofeedback sessions and she went 4 years without a single seizure event and likely would still be completely seizure free today we had not started a family (her TC seizure activity returned, but not the absence seizures, and got progressively worse with each pregnancy - but that's a different story).

After our experience, I did as much digging as I could about EEG neurofeedback (see http://www.coping-with-epilepsy.com/forums/f22/eeg-neurofeedback-501/ ) and I'm really outraged that the medical industry continues to "poo-poo" the resounding body of evidence for it.

Snippets from my findings:"Randomized double blind placebo controlled clinical trials (RCT) are the current “gold standard” for demonstrating clinical efficacy of new drugs or therapies. It is very difficult for new therapeutic interventions to gain broad acceptance in the absence of such trials. Recent events have raised serious questions about the conditions under which placebo (sham) controls can be used. The international standards published by the World Medical Association (Declaration of Helsinki) prohibit placebo-controlled studies when known effective treatments exist. Additionally, there is new interest in identifying the mechanisms underlying the placebo response, which may challenge the “placebo” as a legitimate control condition. Both of these events should be of considerable interest to those interested in clinical psychophysiology in general and neurotherapy in particular. "

"Recent New England Journal of Medicine reviews of research design have cast doubt on the need for placebo controlled designs. Their review has shown that when there is a preponderance of case series reports, the concordance between those results and those of the "gold standard" (double blind placebo controlled studies) was very high. Many in the field are now arguing against doing a double blind study due to the lack of proper humane treatment of those in the control group (receiving no treatment), an approach which is also now considered unethical by the World Health Organization when known treatments exist."

"Since the first single-case study, reported over 30 years ago (Sterman & Friar, 1972), a fair number of controlled clinical studies, stemming from many different laboratories, have produced consistent data on the efficacy of SMR training in epileptic patients. It is particularly noteworthy that these results have been achieved in an extremely difficult subgroup of epilepsy patients, those with poorly controlled seizures who had proven unresponsive to pharmacological treatment. We will here provide only a cursory overview of this clinical research literature. For a more detailed treatment the interested reader is referred to Sterman (2000), while other recent summaries have also been provided by Monderer et al. (2002), and Walker and Kozlowski (2005).

...
In reviewing the data accumulated in these studies, Sterman (2000) found that 82% of 174 participating patients who were otherwise not controlled had shown significantly improved seizure control (defined as a minimum of 50% reduction in seizure incidence), with around 5% of these cases reporting a complete lack of seizures for up to 1 year subsequent to training cessation. ..."

Because of the problems with designing a gold standard study, the Association for Applied Psychophysiology and Biofeedback (AAPB) has developed their own rating scale for measuring efficacy of neurofeedback for a given condition:

Rating explanation:
http://www.aapb.org/i4a/pages/index.cfm?pageid=3336

Conditions with ratings:
http://www.aapb.org/i4a/pages/index.cfm?pageid=3327

What really gets my goat is that EEG neurofeedback has been studied now since the 60s - almost 50 years and there have been no reports of iatrogenesis (a harmful effect produced by the healer or the healing process): "Fortunately, adverse reactions to biofeedback training are overall rare, and when they occur they are relatively transient or readily dealt with by competent practitioners (Hammond, 2001; Schwartz & Schwartz, 1995)."

So here we have a treatment option that has been studied for over 50 years, has no negative/side/adverse effects, has tons of evidence supporting it's efficacy, but doesn't have a single commercial entity that "owns" it in the same way that drug companies and medical device companies own their solutions. No company is pushing for FDA approval - or studies - or marketing it, because it's not cost effective for them.

Cyberonics was able to get FDA approval, acceptance by the neurology industry and insurance coverage for their VNS medical device for epilepsy with studies showing more dubious efficacy than EEG neurofeedback and with well established, potentially serious adverse risks. It truly infuriates me to see how the commercial aspect of the medical industry drives options for patient choice in treatments.

In any case, enjoy -I hope- the rest of the blog.

Thanks for your comment.

Now, no matter one's opinion regarding Chadd, Dr. Rabiner has presented a compelling case on why neurofeedback treatment for ADHD is promising, yet unproven, based on his own analysis. What is your reaction to his reasoning?