Several years ago I summarized the scientific support for neurofeedback treatment — see here - and noted that although positive findings had been reported in multiple published studies, limitations of these studies led many researchers to regard neurofeedback as a promising, but unproven treatment.

The American Psychological Association has established a 5-level system for grading the evidence in support of mental health treatments. These grades, and their associated levels of research support, are as follows:

Level 1 Not Empirically Supported 

Supported only through anecdotal evidence or non-peer reviewed case-studies.

Level 2 Possibly Efficacious 

Shown to have a significant impact in at least one study, but the study lacked a randomized assignment between controls.

Level 3 Probably Efficacious 

Shown to produce positive effects in more than one clinical, observational wait list or within-subject or between-subject study.

Level 4 Efficacious 

Shown to be more effective than a no-treatment or placebo control group; the study must contain valid and clearly specified outcome measures, and it must be replicable by at least two independent researchers demonstrating the same degree of efficacy.

Level 5 Efficacious and Specific 

Shown to be statistically superior to credible placebo therapies or to actual treatments, and it must be shown as such in two or more independent studies.

Using the grading system above, and based on studies published through 2005, the conclusion reached by the Professional Advisory Board of CHADD was that evidence supporting neurofeedback treatment for ADHD warranted a Level 2, or ‘Possibly Efficacious’. You can read CHADD’s summary statement at www.help4adhd.org/en/treatment/complementary/WWK6A and I believe you will find this to be of interest.

Based on a research base that includes more recently published studies, however, the conclusions reached by Arn et. al., (2009) were far more positive. These researchers conducted a meta-analysis of 15 studies, 4 of which were reported to be randomized controlled trials. Their conclusion was that “Neurofeedback treatment for ADHD can be considered ‘Efficacious and Specific’ (Level 5) with a large effect size for inattention and impulsivity and a medium effect size for hyperactivity.” This is a very different conclusion from the CHADD review and it is understandable that parents, educators, and professionals would be confused about the strength of the evidence base for neurofeedback treatment.

New Review Provides Some Clarification

The Journal of Attention Disorders recently published an updated review of neurofeedback treatment for ADHD that helps clarify its scientific support [Lofthouse et. al., (2011). A review of neurofeedback treatment for ADHD. Journal of Attention Disorders, published online 16 November 2011. DOI: 10.1177/1087054711427530]. The authors include scientists who have conducted research trials of neurofeedback and also been part of the Multimodal Treatment Study of ADHD (MTA Study), the largest ADHD treatment study ever conducted. They are thus well equipped, in my view, to provide a thorough and objective review of a complicated area.

The research base for their review was 14 studies of neurofeedback treatment for children with ADHD in which participants were randomized to neurofeedback treatment or a control condition. Eleven of these studies were conducted between 2005 and 2010; this speaks to the strong acceleration of neurofeedback research, which is a welcome development.

Their review was limited to those that randomly assigned children to treatment or control conditions which is an essential element of rigorous treatment studies. For each study, the authors provide a detailed critique it’s strengths and limitations. As a detailed review of the individual study critiques is beyond what I can do here, below I summarize the authors’ conclusions on the state of the science.

Results Summary

Treatment effects

When averaged across the studies for which appropriate outcome data was available, the overall mean effect size (ES) was .79 for inattention measures, and .71 for hyperactivity/impulsivity measures. These are in a range that would be considered ‘large’ for inattention and ‘moderate’ for hyperactivity/impulsivity and are below what is typically reported for stimulant medication. Five of the studies showed neurophysiological changes that were specific to neurofeedback treatment. Overall, these results are consistent with beneficial effects of neurofeedback treatment for ADHD.

Summary of study limitations

The authors identified 5 different limitations that undermine the conclusions about neurofeedback treatment efficacy that can be made.

1. Minimal use of Triple Blinding 

The ideal study would be one where children, parents and/or teachers who rate children’s behavior before and after treatment, and clinicians don’t know whether the child received active treatment. This eliminates — or at least strongly reduces — the likelihood that apparent benefits associated with neurofeedback can be explained by expectations that the child would benefit.

Only 4 of the 14 studies utilized triple blind procedures, however, and in 6 of the studies none of these 3 sources was blind.

2. Nature of Control Group 

The strongest neurofeedback treatment study would be one that used ‘sham’ treatment for children randomized to the control group, i.e., participants receive feedback that is not linked to the EEG state that is the focus of actual training. The benefit of this is that — in theory — it keeps children, parents, and clinicians blind to whether real treatment is being provided, thus eliminating potential biases to the outcome ratings they provide.

For the 14 studies review, however, only 4 employed sham treatment. And, of those 4, only 1 used what was felt to be a truly credible ‘sham’. In the absence of a credible ‘sham’ treatment, conducting a ‘triple blind’ study is not possible.

The other studies either used ‘wait list’ controls or compared neurofeedback treatment to a different type of cognitive training. The use of wait list and alternative treatment control groups are prevalent in the treatment literature, but are less able than a true ‘sham’ condition to unequivocally establish that treatment gains associated with neurofeedback are attributable to the feedback children receive on their EEG state.

3. Insufficient identification, measurement, and control of concomitant treatments

Children participating in these studies were frequently receiving other treatments as well, either medication, psychotherapy, or educational interventions. Because the presence and changes in concomitant treatments tended not to be carefully monitored, however, positive change associated with neurofeedback may have been caused, or at least influenced in some way, by unreported changes in these other treatments.

4. General lack of post-treatment follow-up 

Following children beyond the end of neurofeedback treatment is critical for determining long-term efficacy and/or the need for booster sessions. However, only 3 of the studies included a post-treatment follow up of neurofeedback. And, in these studies, the procedures for assessing the sustainability of treatment benefits were judged to be compromised. Thus, the authors conclude that the duration of any gains associated with neurofeedback remains largely unknown.

5. Limited attention to possible adverse side effects

Although neurofeedback is described as safe and without side effects, only 1 study actually monitored and reported adverse events that children and parents related to treatment. Although no such effects were found, some have argued that all truly effective treatments produce some side effects in some percentage of individuals who receive them. Thus, rather than not attending to this possibility in neurofeedback studies because the treatment is assumed to be safe, the authors suggest that this is an area where greater scrutiny is warranted.

Overall Summary

Based on their review of the literature, the authors argue that “…due to the lack of blinding and sham control conditions in randomized studies” neurofeedback treatment for ADHD should not be considered ‘Efficacious and Specific’ as was concluded in the 2009 review by Arn and his colleagues.

Instead, they believe that a grade of 3 on the APA evidence scale, which corresponds to ‘Probably Efficacious’ is warranted. They note that a large multisite triple-blind sham-controlled Randomized Controlled Trial is needed to settle the issue.

Clearly, it is possible to review the same evidence and reach a different conclusion. Some would argue that the authors are overly cautious in the evidence grade they assign and that more is being required of neurofeedback than of other ADHD treatments. For example, although the long-term benefits of neurofeedback treatment may remain relatively unknown, evidence on the long-terms benefits of medication treatment is also limited.

One could also argue that requiring a triple-blind trial with a credible sham condition is unreasonable because this is a higher standard than that employed most psychotherapy outcome research. In studies to establish the efficacy of behavioral treatment for ADHD, for example, a triple blind trial is not possible because clinicians know what treatment they are providing and parents will know what treatment their child is receiving. Despite this, behavior therapy is considered a strong evidence-based treatment for ADHD.

In response to this objection, the authors argue that the highest standard of scientific rigor should be required for any treatment offered to the public for which triple blind studies are possible (they are not possible for behavior therapy), and which are not precluded by strong ethical considerations. They note that this is especially true for neurofeedback, as such a study is possible and the treatment requires substantial time, effort, and expense.

Some Final Thoughts

My view is consistent with the authors. I would very much like to see the type of study they call for and believe the evidence grade they suggest of ‘Probably Efficacious’ is appropriate. Having this conclusion published in a scientific journal that does not focus on neurofeedback research represents significant progress for the field as it was not too long ago that a commonly held view seemed to be that there was little if any credible evidence supporting this treatment.

It is also important to recognize that what remains unclear is not whether children with ADHD who receive carefully administered neurofeedback will generally derive some benefit — the studies reviewed in this article establish that — but, rather, why does benefit occurs. Here is what the authors say:

“…due to the lack of controls, it is unclear as to whether the large ESs for impulsivity and inattention and the medium ES for hyperactivity are due to the active component of EF and/or nonspecific treatment factors.”

In other words, the research establishes that neurofeedback treatment yields benefits for core ADHD symptoms but is not clear on what explains those benefits. Is it the specific feedback on EEG activity and learning to control that activity that produces the gains? Or do nonspecific factors associated with the treatment, e.g., expectancy effects, clinician attention, praise for the effort involved, etc., that actually accounts for the gains?

This is the important scientific question that remains to be answered. In the meantime, however, the research reviewed here indicates that if parents obtain high quality neurofeedback treatment for their child there is a reasonable basis for expecting that benefits will occur. The decision to do so should be made with the knowledge that medication treatment and behavioral therapy would be regarded as having stronger research support at this time.

To dismiss neurofeedback treatment simply as ‘unproven’, however, ignores the considerable research on this approach that has been conducted. Helping families better understand the strengths and limitations of this research can enable them to make a better informed decision about whether to consider this treatment option for their child.

– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity.  His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing.  He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

Previous articles by Dr. Rabiner:

• New Study Supports Neurofeedback Treatment for ADHD
• Neurofeedback/ Quantitative EEG for ADHD diagnosis
• Self-Regulation and Barkley’s Theory of ADHD

As with children and adolescents, medication treatment for adults with ADHD can be quite helpful, especially for reducing core ADHD symptoms of inattention and hyperactivity/impulsivity.  However, as is true for children and adolescents, many adults with ADHD continue to struggle despite benefits provided by medication.  In addition, some derive little if any benefit and even when core ADHD symptoms diminish, difficulties in other important areas often remain. Thus, medication alone is frequently an insufficient treatment treatment guidelines developed in the US and overseas recommend multimodal treatment for ADHD in adults. This would include psychoeducation, pharmacotherapy, and cognitive behavior therapy (CBT).

Cognitive behavior therapy was originally developed for the treatment of depression and anxiety disorders and is focused on identifying problematic ways of thinking, i.e., cognitions, that contribute to problematic behaviors. Once problematic ways of thinking are identified, the client is encouraged to evaluate whether their cognitions are accurate and to consider alternative ways for thinking about their situation. As faulty thinking patterns are altered, more adaptive ways of behaving can begin to take shape.

For example, an adult who struggled throughout their schooling because of undiagnosed ADHD might think of themselves as stupid and unable to learn. One can imagine how these thoughts could lead to poor self-esteem, depressive symptoms, and avoidance of situations that are linked to schooling and education. In CBT, the clinician would work with the client to develop a more realistic explanation for their academic struggles, e.g., you are actually quite capable intellectually but performed poorly because your ADHD was never diagnosed and treated. In conjunction with helping the client embrace this more reasonable way to think about their academic history, the clinician would help the client develop new and more adaptive behavior patterns. For a very nice discussion of CBT for adult ADHD see http://add.about.com/od/treatmentoptions/a/Cognitive-Behavioral-Therapy-And-The-Treatment-Of-Adult-Adhd.htm

There have been a handful of CBT trials for adults with ADHD. In general, these studies indicate that CBT can help with core ADHD symptoms in addition to benefits provided by medication. However, the benefits of CBT on co-occurring difficulties that adults with ADHD often have, e.g., depression, anxiety, relationship problems, etc., have not been clearly demonstrated. This is discouraging and somewhat surprising given that CBT is an effective treatment for depression and anxiety in adults who do not have ADHD.

A study published recently in BioMed Central Psychiatry [Cognitive behaviour therapy in medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. Emillson et al., (2011). BioMed Central Psychiatry, 11:116] presents new findings on CBT delivered in a group format to adults with ADHD. (Note — This is a peer reviewed open access journal and you can review the entire study online at http://www.biomedcentral.com/content/pdf/1471-244X-11–116.pdf). The goal of this study was to test whether a cognitive behavioural group treatment program called Reasoning and Rehabilitation for ADHD Youths and Adults, i.e., R&R2, alleviated core ADHD symptoms and comorbid problems in adults with ADHD who were receiving medication.

The study was conducted in Iceland and involved 54 adults with ADHD (34 women, mean age 34.1), all of whom were receiving ADHD medication. In addition to their ADHD diagnosis, 35 reported depression, 20 reported some form of anxiety disorder, 12 reported a history of drug/alcohol abuse, and 9 reported some other psychiatric problem; only 8 reported no comorbid difficulties.

Participants were randomly assigned to cognitive therapy or to the treatment as usual condition; the latter involved medication only, although participants were free to pursue whatever additional treatments they wished. Adults assigned to CBT remained on medication. Thus, the researchers could learn whether CBT added to any benefits already being provided by medication treatment.

R&R2 ADHD Group Cognitive Behavioural Therapy

The treatment is a 15 session structured CBT intervention that aims to decrease core ADHD symptoms and improve social functioning, problem solving, and organizational skills. It targets the following 5 areas:

1. Neurocognitive functioning — Learning strategies to improve attentional control, memory, impulse control and planning.
2. Problem solving — Developing adaptive problem solving strategies, anticipating consequences, and managing conflict.
3. Emotional Control — Learning to manage feelings of anger and anxiety.
4. Pro-social skills — Learning to recognize the thoughts and feelings of others, negotiation skills, and conflict resolutions skills.
5. Critical reasoning — Learning to evaluate options and develop behavioral skills to pursue goals appropriately.

These areas were covered in twice weekly small group sessions that lasted for 90 minutes. In addition to the group meetings, coaches met individually with participants each week for 30 minutes to review session material and assist with assigned homework. Thus, during the 15-week treatment, participants devoted 3.5 hours weekly to the program, not counting travel time; it was thus a fairly time-intensive treatment.

Measures

The researchers employed a wide range of measures to evaluate core ADHD symptoms and comorbid difficulties. Adults reported on their ADHD symptoms using the Barkley ADHD Current Symptoms Scale. They also reported on depressive and anxiety symptoms using the Beck Depression Inventory and the Beck Anxiety Inventory; both are widely used measures that have been shown to provide reliable and valid information. Finally, participants completed a measure developed specifically for the study that assessed emotional control, antisocial behavior, and social functioning.

An important strength of the study was that in addition to the self-report measures noted above, participants were evaluated by clinicians who did not know whether they had received CBT treatment or were in the control condition. These clinicians provided an independent assessment of adults’ ADHD symptoms and overall level of functioning.

These measures were collected on both groups of participants before treatment began, immediately following the CBT program, and again 3 months later. Although baseline assessments were obtained on nearly all participants, the post-treatment assessment was collected on only 17 adults in each group. At the 3-month follow-up, self-report measures were collected on a similar number but the independent evaluation was only conducted with 8 adults from the CBT group and 13 from the treatment as usual group. This reflected difficulty getting participants back to the study site for the interviews to be collected, a common difficulty in such studies. (Presumably, the self-report measures could be returned via mail.)

Results

Twenty of 27 participants (74%) who began CBT treatment completed it. This was comparable to the treatment as usual condition.

Post-treatment findings

Independent raters — After controlling for baseline ratings of ADHD symptoms, CBT participants received significantly lower symptom ratings from independent evaluators immediately after treatment. The magnitude of the treatment vs. control differences would be considered large. Independent clinicians raters also tended to rate CBT participants as functioning better overall.

Self-reports — Controlling for baseline ratings, CBT participants reported significantly fewer problems with attention and with hyperactivity-impulsivity. The magnitude of the differences were large for attention problems and smaller for hyperactivity-impulsivity. However, no post-treatment differences were evident in participants’ reports of anxiety or depression. There were also no differences found for emotional control or social functioning. CBT participants did report greater reductions in antisocial behavior.

Three-month follow-up

Independent raters — Differences in ratings of ADHD symptoms made by independent raters remained significant and of large magnitude. In addition, ratings of overall adjustment also significantly favored CBT participants at follow-up.

Self-reports — Group differences in self-reported ADHD symptoms remained significant at follow-up. In addition, group differences were also evident in participants’ reports of depression, anxiety, emotional control, antisocial behavior, and social functioning. In all cases, the differences were of a magnitude that would be considered large.

Summary and Implications

The key findings from this study are that group CBT improved core ADHD symptoms at the end of treatment according to blind, independent observers and participants themselves. And, three months after treatment ended, evidence emerged that CBT was associated with significant reductions in a range of comorbid difficulties that many adults with ADHD struggle with. Because all participants were receiving medication, these findings suggest that the CBT program yielded benefits beyond those provided by medication.

A key strength of the study was the use of ‘blind’ clinicians to assess outcomes for core ADHD symptoms. Because these clinicians did not know the treatment of the adults they were evaluating, their ratings would not be influenced by this knowledge. A limitation, however, is that these clinicians only rated core ADHD symptoms and overall functioning, rather than each of the domains covered in participants’ self-reports. Had these clinicians evaluated participants on depression, anxiety, etc., and reached conclusion consistent with the self-report findings, the results from this study would be even stronger.

A second limitation is that fewer than half the participants were evaluated by the independent clinicians at the 3-month follow-up. The adults who completed the 3-month independent evaluation may have been a more motivated group than those who did not, perhaps because they had attained greater benefits. However, the same argument would apply to those in the control group who returned for the 3-month follow-up. It was also the case that the subset of adults who completed the follow-up evaluation did not differ from other participants at baseline on any of the study measures. These factors serve to mitigate concerns about the validity of the follow-up data. However, the fact remains that only a small number of participants fully completed the follow-up assessment which highlights the need for replicating these findings with a larger sample.

Two other caveats are worth noting. First, the study was conducted in Iceland and whether similar findings would be attained with adults from other countries is unknown. There is no reason to assume that special characteristics of Icelandic adults with ADHD would explain the findings, however. Second, those in the CBT group received substantial amounts of attention and time from clinicians relative to those in the treatment as usual group. Thus, it is possible that it was the extra attention alone and not the specific nature of the CBT program that accounts for the more positive outcomes in the CBT group. It would be difficult to conclusively rule out this possibility in future studies, however, as it would be ethically problematic to involve adults with ADHD in a time consuming intervention that was not intended to produce tangible benefits, but simply to function as a control for the amount of attention that CBT treated participants received.

In summary, results from this study highlight that although medication treatment provides important benefits to many adults with ADHD, the addition of a well-conceived and structured group CBT treatment can yield significant incremental improvements. These gains appear to extend beyond alleviating core ADHD symptoms to include many of the important comorbid problems that adults with ADHD often struggle with. Making such treatment more widely available to adults in the community, in addition to conducting additional research on treatments for adults with ADHD, should thus be an important priority.

(Note - If you are interested in learning more about cognitive behavioral treatment for adults with ADHD, an excellent book you can consult is titled “Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach” by Drs. Russell Ramsay and Anthony Rostain. It is available on Amazon and elsewhere.)

– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity.  His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing.  He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

–> For related arti­cles by Dr. David Rabiner on atten­tion deficits, click Here.

(Pic source: BigStockPhoto)

This shared decision-making approach is especially important for conditions like ADHD where there is not a single treatment that is the most appropriate and preferred option for all patients. However, little research has addressed the extent to which medical care for ADHD conforms to a ‘shared decision making approach, and those studies that have examined this issue suggest it is lacking.

For example, compared to reports of families whose child was treated for asthma — which is also a chronic medical condition — parents of children with ADHD reported feeling less like active partners in their child’s care, and were less likely to feel that clinicians listened to their perspective or provided them with sufficient information to make well informed decisions.

A study recently published online in the Journal of Attention Disorders [Davis et al., (2011). Putting families in the center: Family perspective on decision making and ADHD and implications for ADHD care. Journal of Attention Disorders, published online 10/5/2011,DOI:10.1177/1087054711413077] presents new data on families’ experience with ADHD and it’s treatment. Participants were a racially and socioeconomically diverse group of 28 families from the San Diego area who were interviewed about their experience having a child with ADHD as well as their experience with treatment. The researchers were especially interested in how families felt about:

1. the treatment decision making process;

2. their perspectives on the cause and impact of their child’s symptoms; and,

3. their treatment goals and preferences.

Results

- Families’ perspectives on decision making: The majority of families believed that parents or family members should be responsible for treatment decision making while approximately 20% preferred a shared process that included physicians. Very few families felt that physicians should be solely responsible for treatment decisions.

Families’ perspectives on the causes of their child’s ADHD symptoms

Families’ perspectives were divided into 4 broad domains: factors internal to the child, e.g., a ‘chemical imbalance’, genetics; factors external to the child, e.g., parental conflict or separation, significant stressors; mixed internal and external factors, and developmental factors, e.g., ‘boys are just like this but he’ll grow out of it’.

Each type of explanation was provided by multiple families within the sample. Thus, although ADHD is widely considered to be a biologically based condition with strong genetic component, many families attributed their child’s symptoms to stressful life circumstances and/or transient developmental factors.

For many families, a substantial change in understanding of their child’s symptoms emerged over time. In almost all cases, the change was from a developmental/nonpathological perspective to one that emphasized genetic and other biological vulnerabilities. This was more likely to occur when parents felt that physician valued their input and involved them in a shared decision making approach. Parents who felt their input was not valued were less likely to accept the physician’s biologically based explanation and treatment recommendations.

Families’ perspective regarding the impact of their child’s symptoms

Most families felt that their child’s ADHD caused stress and strain on family relationships. Many families reported adverse health and mental health consequences within the family, martial conflict and sibling conflict.

Some families reported that their child’s symptoms had affected their job performance. Helping their child with homework was a significant time burden in some families. A small number of families felt ostracized by neighbors and others because of their child’s behaviors.

Families perspective on the impact on their child

Most families felt ADHD had the greatest negative impact on their child’s school performance. Many also expressed concern about how ADHD was impacting their child’s social relationships and self-esteem.

Families’ treatment goals and preferences

The majority of families were willing to use medication to treat their child’s symptoms. However, the process of accepting medication was often a gradual one and that emerged after other options were not successful.

Many families expressed strong interest in alternative treatments to address core ADHD symptoms including dietary modifications, bio/neurofeedback, and exercise-based approaches. Many families expressed frustration at what they perceived to be the limited information they received about ADHD treatment options.

Families’ treatment goals

Most families were interested in treatments that addressed issues beyond the management of core ADHD symptoms. A commonly expressed desire was for nonpharmacological interventions that would enhance their child’s overall quality of life. Towards that end, some parents sought out social skills training to help their child with peer relations, others sought counseling to address self-esteem issues, and others looked for additional academic supports. In addition to seeking these supports for their child, many parents emphasized a desire for supportive counseling for themselves. Here is a particularly poignant quote from one of the parents:

“I need therapy. I do; it’s just terrible…you start to build resentment, you get angry, and then he gets me angry, so angry all the time that I say things I shouldn’t say of course.”

Another parent expressed, “I think counseling for children does help, but there should be more counseling available for the parents…because it’s very tough and you always, always feel bad.”

Summary and implications

Results from this study highlight provide important information for understanding what is important to many families seeking treatment for a child with ADHD. Families desire an active role in making decisions about their child’s treatment and are intent on addressing broad quality of life issues in addition to managing core ADHD symptoms. The understandings that families bring to clinicians concerning the basis for their child’s symptoms can vary widely and will influence the types of treatment approaches that will most resonate with them.

Especially important are findings pertaining to the impact of ADHD on parents’ own feelings of stress and well being, the conflicts it can cause within families, and the spillover effects this can have on parents’ work life. Unfortunately, these important issues may not be addressed or even considered in many instances even though it is clear that “…integrating approaches that target the child’s identified needs and address parental stressors, including marital interventions…into treatment programs for families of children with ADHD” is important to pursue.

Another interesting finding from this study is that parents’ understanding of their child’s ADHD, and the types of treatment approaches they are open to, can change over time. Many parents also have strong interest in learning about alternative ADHD treatments that can complement traditional interventions, but feel that the information required to make well-informed decisions about the best overall approach for their child is difficult to obtain.

Making it easier for families to obtain such information, assessing families preferences with regard to their role in decision making about their child’s treatment, and developing evidence-based interventions that address a broad range of impairments beyond core ADHD symptoms all emerge from this study as important avenues to pursue. Also valuable would be continuing the work begun here with a larger and broader representation of families so that the issues identified pertaining to families’ perspectives on ADHD and it’s treatment can be further delineated and better understood. Ultimately, such information can help clinicians better provide family-centered care for ADHD that addresses the wide range of concerns that families seek assistance for.

– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing. He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

–> For related arti­cles by Dr. David Rabiner on atten­tion deficits, click Here.

For example, children with ADHD have poorer academic achievement as adolescents compared to their peers and this trend continues into adulthood. Research pertaining to occupational functioning is limited but available data clearly points to poorer employment histories in adults with ADHD. Predictors of occupational outcomes in individuals with ADHD have not been carefully investigated, however.

A recent study conducted in Norway with a large sample of adults with ADHD begins to address some of the important gaps in our knowledge of these issues [Halmoy et al.(2009). Occupational outcome in adult ADHD: Impact of symptom profile, comorbid psychiatric problems, and treatment. Journal of Attention Disorders, 13, 175–187].

Participants were 414 adults (198 women and 216 men) who were diagnosed with ADHD and whose clinician was seeking to treat them with stimulant medication. As recently as 2005 in Norway, physicians looking to prescribe stimulant medication for adults needed to conduct a comprehensive assessment based on national guidelines and have their findings reviewed by an expert committee. The committee needed to support the request to prescribe stimulants before the physician could do so. This was the required procedure even for individuals who were treated with stimulants prior to turning 18. The 414 participants with ADHD were recruited from nearly 2000 adults whose information was sent for committee review between 2004 and 2006. Comparison subjects (n=357) were drawn from a random sample of adults from across the country.

Both groups of adults completed a number of self-report measures to assess their current functioning in multiple areas including their educational attainment, occupational status, and psychiatric symptoms. For the adults with ADHD, information on whether they were treated with stimulant medication as children was also obtained.

- Results -

As expected, a number of important differences were found between adults with and without ADHD. Key among these were the following:

- Only 23% of the ADHD group had attained a university level education compared to 59% of controls.

- 29% of the ADHD group had only a junior high school education vs. only 6% of controls.

- Lifetime rates of significant anxiety or depression was reported by 70% of the ADHD group vs. only 17% of controls.

- Lifetime problems with alcohol were reported by nearly 30% of the ADHD group compared to less than 3% of controls.

Group differences in the occupational realm were also striking. At the time of the assessment, only 24.3% of adults in the ADHD group reported being employed compared to nearly 80% of the comparison adults. More than half of adults with ADHD were either receiving disability or were in vocational rehabilitation compared to only 5% of comparison adults. These differences were consistent across gender.

- Correlates of occupational outcome -

The researchers were interested in testing factors related to the occupational status of participants with ADHD. The factors that they tested included severity of ADHD symptoms, ADHD subtype (inattentive, combined, or hyperactive-impulsive), symptoms of depression and anxiety, alcohol or drug problems, and whether the adult had been treated with stimulant medication in childhood.

After controlling for all variables in the model, only ADHD subtype and medication treatment in childhood was associated with current employment status. Adults with the inattentive or combined subtype were more likely to be out of work than those with the hyperactive-impulsive subtype. Thus, high rates of attention difficulties — either with or without hyperactivity — was a risk factor for being unemployed.

Results pertaining to childhood medication treatment were quite interesting. Adults with ADHD who had not received medication treatment as children (n=329) were over three times as likely to be unemployed than those who had (n=75). This finding remained even when educational attainment was controlled for.

Adults who had not been treated with medication in childhood also reported significantly higher rates of anxiety and depressive symptoms.

- Summary and implications -

Results from this study clearly indicate that adults with ADHD have poorer educational outcomes, report more psychiatric difficulties, and are more likely to be unemployed than other adults. The difference in employment status was especially striking and highlights the significant impairment that frequently accompanies ADHD into adulthood.

An especially intriguing finding was the strong relationship between medication treatment in childhood and employment status in adulthood, as those who had been treated were far more likely to be employed. What makes this finding particularly striking is that individuals treated with medication as children would be likely to have had more severe cases of ADHD to begin with, particularly since medication treatment is less common in Norway than in the US. If this were the case, it would have worked against more positive occupational outcomes in adulthood, thus suggesting an especially important role for medication treatment.

The authors are careful to note that no definitive conclusion can be made about whether childhood medication treatment was responsible for higher employment rates. One important reason for this is that there is no way to determine whether other factors associated with receiving treatment, rather than treatment itself, led to the obtained result. For example, parents who obtained medication treatment for their child may have obtained other treatment services or supports for their child that contributed to greater occupational success. This possibility, however, was not investigated and efforts to rule out this alternative explanation would have strengthened the study.

It is also important to note that the lower employment rates and greater psychiatric difficulties of adults with ADHD in this study is likely to overestimate what is true for the general population of adults with ADHD. Adults with ADHD in this study were struggling sufficiently to have their physician initiate the complex and time consuming procedure required in Norway to obtain permission to prescribe stimulants. Thus, these adults were likely to be more impaired by their ADHD than the general population of adults with ADHD. Had a more representative sample of adults with ADHD been included as participants, I suspect that differences with the comparison subjects would have been attenuated.

It is also the case that results found in one country may not necessarily generalize to other countries, and this should be kept in mind as well.

These limitations not withstanding, the findings reported highlight the important struggles that many adults with ADHD experience and emphasize the need for effective treatment of ADHD during the adult years. It is especially interesting that adults who received medication treatment as children had better occupational outcomes as adults. Although a causal relationship cannot be definitively established from these data, the importance of early identification and treatment of ADHD in promoting more positive long-term outcomes is certainly supported.
– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing. He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

–> For related articles by Dr. David Rabiner on attention deficits, click Here.

Indeed, evidence from several large-scale experimental studies suggests that physical activity training can have a positive influence on children’s cognitive functioning. Systematic research on the impact of physical activity on youth with ADHD is relatively lacking, however, despite the positive anecdotal reports that one frequently hears from parents. A study published recently online in the Journal of Attention Disorders begins to remedy this situation by examining the effects of an extended physical activity training program on children with ADHD.

Participants were 21 children (19 boys) ranging in age from 7 to 12 years. All children were diagnosed with either the combined or hyperactive-impulsive subtype of ADHD. (Children with the inattentive subtype were excluded because the authors anticipated greater benefits of exercise in youth for whom hyperactivity was an important part of their
symptom picture.) Children were assigned to either the physical activity program group or a control group; these assignments were not done randomly, however. Instead, because of recruitment difficulties, participants in the activity group were all from the same school while children in the control group were recruited from different areas. As the authors acknowledge, the absence of random assignment is an important limitation of the study.

Children in the exercise group completed a 45-minute exercise routine 3 times per week during the school day over a 10-week period. All sessions were supervised by a physical education teacher and included a combination of aerobic activity, strength training, and motor skills training. The objective was to maintain moderate to vigorous intensity in
each session; this was monitored using a heart rate monitor.

Measures
A variety of measures were collected on the activity and control group before and after the 10-week exercise program. The different domains measured were:

• Fitness and motor performance — Measures of motor abilities and muscular strength
• Behavioral measures — Children’s behavior was assessed via the Child Behavior Checklist and the Teacher Report Form. These are widely-used, standardized behavior measures that assess children in multiple domains, including behaviors directly related to ADHD.
• Neuropsychological measures — Children’s attention and response inhibition, i.e., the ability to refrain from impulsive responding, were measured using the Test of Everyday Attention for Children.

Results

• Impact on Fitness

Not surprisingly, children in the exercise group showed significant gains relative to controls on measures of motor skills and muscular strength.
Behavior

• Behavioral Ratings

Parent ratings on the Child Behavior Checklist showed significant reductions for children in the exercise group on 3 of the CBCL subscales: Total Problems, Thought Problems, and Attention Problems.
It is important to note, however, that even though the exercise group had lower scores on these scales at the end of the program, after controlling for their baseline scores, average scores remained in a clinically elevated range.
For teacher ratings, a tendency for improvement in the exercise group was reported on all scales. This included statistically significant reductions in problem scores on the Anxiety-Depression scale and the Social Problems scale.

• Neuropsychological Functioning

Some improvements were also evident on neuropsychological functioning as measured by the Test of Everyday
Attention for Children. Results on this measure were consistent with children in the exercise group showing better auditory sustained attention.

Summary and Implications
Results from this study provide initial evidence that a systematic and rigorous physical activity program may be beneficial to youth with ADHD. As discussed above, youth who participated in the exercise group showed
significant improvements relative to controls in a number of areas, based on reports from parents and teachers as well as on a measure of neuropsychological functioning.

Although these findings suggest that exercise may be helpful in addressing some symptoms of ADHD, as well as difficulties that often accompany ADHD, it is important to put these positive findings into an appropriate perspective. First, even though the activity program was associated with improvements in several areas, children continued to show clinically elevated difficulties even in areas where improvements were seen. Thus, there was no evidence that the exercise program reduced children’s difficulties into the normative range.

Second, as the authors note, the absence of random assignment limits the conclusions that can be drawn from this study. The authors also suggest caution because parents and teachers were not blind to children’s status, and expectations of positive results from the exercise program may have biased their ratings.

These issues all need to be addressed in a follow-up study that includes a larger sample, random assignment, and, ideally, ratings from observers who do not know which children received the program and which did not. In
the meantime, a vigorous physical activity program could certainly be valuable for many children with ADHD for a variety of reasons, even if the ultimate impact of exercise on core ADHD symptoms is not yet known.

Reference: Verret, et.al., A physical activity program improves behavior and cognitive functions in children with ADHD: An exploratory study. (2010). Journal of Attention Disorders. published on September 13, 2010 as doi 10:1177/1087054710379735

Read more posts by Dr. Rabiner on other factors impacting ADHD:

• ‘Western’ Style Diet Increases Risk of ADHD
• A Controlled Trial of Herbal Treatment for ADHD

– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing. He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

Some have argued that research on the relationship between diet and ADHD is more important than ever because the diets of children in Western countries have shown steady increases in the amounts of heavily processed foods rich in saturated fats, salt, and sugars accompanied by decreases in omega-3 fatty acids, fiber, and folate. Is it possible that such ‘Western’ style diets are associated with an increased risk of ADHD, and perhaps a contributing factor to the high prevalence of the disorder?

This important question was examined in a study published recently online in the Journal of Attention Disorders [Howard et. al. (2010). ADHD is associated with a “Western” dietary pattern in adolescents. Journal of Attention Disorders]. Participants were 1172 14 year-old Australian adolescents and their parents who had been recruited into the study and followed since the mothers were between 16 and 20 weeks pregnant. The data collected in this study was part of a large-scale longitudinal investigation focused on a variety of issues related to understanding healthy and maladaptive development.

When youth were 14, parents were asked whether their child had ever been diagnosed with ADHD by a qualified health professional. One hundred and fifteen — nearly 10% — had been diagnosed, including 91 boys and 24 girls. These diagnoses were confirmed by reviewing children’s medical records. Primary caregivers also completed the Food Frequency Questionnaire (FFQ) in which they rated the typical intake by their child of over 200 different foods from nearly 40 different food groups.

Based on responses to the FFQ, 2 major dietary patterns were identified.

• The ‘Western’ pattern was positively associated with higher intakes of total fat, saturated fat, refined sugars, and sodium. Specific food types prominent in the Western diet included ‘takeaway’ foods (I believe this refers to ‘fast’ food’) red meat, processed meats, soft drinks, full fat dairy products, soft drinks, sugary foods, and fried foods.
• The ‘Healthy’ pattern (these labels were assigned by the investigators) was positively associated with omega-3 fatty acids, fiber, and folate. Prominent foods in the healthy diet included all types of vegetables, fresh fruit, whole grains, legumes, and fish.

Adolescents received scores on both diet patterns based on parents’ responses about their typical food intake. Those above the mean were classified as ‘high’ for that pattern and those below the mean were classified as ‘low’. Thus, each adolescent was placed in a high or low group for both the Westerns style and Healthy diets. By classifying participants in this way, the researchers could examine whether being high vs. low for a Western diet and a Healthy diet was associated with an increased likelihood of being diagnosed with ADHD.

Because many factors besides diet may increase risk of ADHD, the researchers measured a number of other variables that could potentially confound the results. These included maternal age at conception, maternal education, maternal smoking during pregnancy, presence of biological father in the home during pregnancy, family income during pregnancy, and the number of stressful life events experienced by the mother during pregnancy. In addition, data was collected on adolescents’ typical weekly level of physical activity and the number of hours they spent each day watching television, playing video games, or using the computer.

- Results -
After controlling for all the other variables noted above, adolescents in the ‘high’ group for the Western dietary pattern were more than twice as likely as those in the ‘low’ group to have been diagnosed with ADHD.
These results were consistent for boys and girls. A high score for the Healthy dietary pattern, however, was not associated with reduced risk of having a diagnosis.

When the authors looked at specific food groups, high consumption of fast food, red meat, processed meats, and high-fat dairy products, potato chips, and soft drinks were all associated with increased risk of an ADHD diagnosis.

Increased likelihood of an ADHD diagnosis was also related to mothers having experienced multiple stressful events during pregnancy. The only variable associated with lower odds of diagnosis was physical activity, as youth who exercised at least 2 hours per week outside of school were less likely than others to be diagnosed.

- Summary and Implications -
Results from this study based on a large community sample of youth clearly indicate that a Western-style dietary pattern is associated with greater odds of having ADHD. This was true for both boys and girls. The Western-style diet identified in this study was one that was high in total fat, saturated fats, refined sugars, and sodium.

One possible interpretation of these findings is that diets high in these food elements play a direct causal role in the development of ADHD. However, there was no evidence that adhering to a healthy diet, i.e., one high in vegetables, fresh fruit, whole grains, and fish, reduced the odds of being diagnosed. Thus, while Western style diets may increase risk for ADHD, the findings do not support the notion that adhering to a healthier diet reduces such risk. This does not mean that the healthy dietary pattern may not have had other benefits, but only that it did not alter the risk for ADHD beyond what could be explained by being high vs. low for the Western-style pattern.

While it is tempting to conclude that the Western dietary pattern directly contributed to the development of ADHD in some youth, the authors are careful to note that the design of their study does not allow causal conclusions to be made. For example, although the consumption of a more ‘Western’ style diet may have “…promoted the expression of attention deficits” it is also possible that “…diagnosed attention deficits led to poorer food choices and a more ‘Western’ style diet.” For example, the authors suggest that their results “…could be explained by the tendency for adolescents experiencing emotional distress to crave fat-rich snack foods as a self-soothing strategy.” It is also worth
noting that this study did not examine whether dietary changes can reduce ADHD symptoms and that the findings should not be interpreted in that way.

While no single study can fully answer complicated questions pertaining to the role of diet and nutritional factors in the etiology of ADHD, this research clearly highlights that a Western-style dietary pattern is associated with increased odds of having an ADHD diagnosis. This suggests, but does not prove, that dietary patterns may be implicated in the development of ADHD, and highlights the need for additional study so that a more definitive understanding of this important issue can be obtained.

These findings also provide an reminder that although risk for ADHD has been strongly linked to genetic factors, it is important to continue the exploration of other factors that may increase risk. Such exploration should ultimately lead to a richer understanding of the disorder and how it develops, and hopefully to the development of more effective treatments.

– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing. He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

One alternative approach to treating ADHD has relied on the use of Compound Herbal Preparations (CHP) derived from traditional Chinese medicine. Practitioners of this approach believe that such preparations have important cognitive enhancing properties because they supply essential nutrients, fatty acids, phospholipids, amino acids, B vitamins, minerals, and other micronutrients that are important for optimal brain growth and development. As a treatment for ADHD, the idea is that many individuals with ADHD have deficiencies in essential nutrients that compromise healthy brain development and result in ADHD symptoms. Providing these nutrients via an appropriately prepared herbal compound thus has the potential to be therapeutic and reduce these symptoms.

This idea was tested recently in a randomized-controlled trial of a specific CHP for children with ADHD [Katz, Kol-Degani, & Kav-Venaki (2010). A compound herbal preparation (CHP) in the treatment of ADHD: A randomized controlled trial. Journal of Attention Disorders. Published online on March 12, 2010.] Participants were 120 6–12 year-old children newly diagnosed with ADHD based on a comprehensive diagnostic evaluation. These children were all evaluated at the Sheba Medical Center, one of the largest university-affiliated tertiary care centers in Israel.

(Editor´s note: Dr. David Rabiner, author of this article, previously reviewed a 2005 meta-analysis whose findings need to be kept in mind to contextualize this new study. In the article Dietary Intervention for ADHD: A Meta-Analysis, Dr. Rabiner concluded that “Results from this meta-analysis provide strong evidence that the behavior of children with ADHD can be made worse by dietary factors, and that eliminating AFCs from their diets will, on average, result in behavioral improvements. This result is consistent with with accumulating evidence that neurobehavioral toxicity may result from a wide variety of distributed chemicals.”)

Children were randomly assigned to receive either the CHP (n=80) or a placebo (n=40) that was specially prepared to taste, smell, and look similar to the herbal formula. Randomization was done in a 2:1 ratio because the treatment was to last 4 months, and investigators wished to minimize the number of children who would receive placebo treatment for which no benefit was anticipated.

Active ingredients in the CHP — brand name Nurture & Clarity — included Paeoniae Alba, Withania Somnifera, Centella Asiatica, Spirulina Platensis, Bacopa Monieri, and Mellissa Officinalis. All raw herbs used in the preparing the compound were approved by the Israeli Ministry of Health as safe, food-grade herbs.

Neither parents, children, research assistants who tested the children or staff members who distributed the appropriate formula to participants knew who received the CHP and who was given the placebo. To confirm that the placebo preparation could not be distinguished from the CHP, 20 Israeli medical students were provided with both preparations and asked which was which; these students were unable to reliably tell them apart. Based on the information provided, therefore, this appears to have been a carefully conducted trial with strong randomization and blinding procedures.

Prior to beginning treatment with the CHP or placebo, children were administered the Test of Variables of Attention (TOVA), a widely used computerized test of attention and impulsivity. In the TOVA, children sit in front of a computer and are instructed to respond using a particular key whenever a designated stimulus appears. When any other stimulus flashes they are not supposed to respond. The test lasts for over 20 minutes and good performance requires the child to sustain attention to an uninteresting task for a reasonably long period of time.

Failing respond when a response is required — errors of omission — are believed to reflect problems with sustaining attention. Responding when the wrong stimulus appears — errors of commission — reflect impulsive responding. Other measures from the TOVA include response reaction time and reaction time variability. Children receive a score on each scale that compares their performance to age-matched peers from a large normative sample. They are also assigned an overall score, again based on age appropriate norms.

Following baseline administration of the TOVA, children were treated with the CHP or placebo preparation over a 4-month period. At the end of 4 months the TOVA was administered a second time. This enabled the researchers to determine whether children receiving the CHP demonstrated significant improvement on the test compared to those who received placebo.

- Results -

At the follow-up assessment, data was obtained on 73 of 80 children who received the CHP compared to only 19 of 40 who received placebo. The significantly greater drop-out rate among placebo-treated children reflected the greater number of parents who were not satisfied with their child’s response and who withdrew to pursue other options.

Results from the TOVA were analyzed in 2 primary ways. First, within each group, researchers tested whether there was significant improvement from pre-test to post-test. Then, they directly compared CHP vs. placebo differences controlling for age and sex. Because preliminary analyses indicated that results were consistent across different ADHD subtypes, i.e., inattentive, hyperactive-impulsive, and combined, children with each subtype were combined in all analyses.

For the within group analyses, children in the CHP group showed statistically significant improvement on all indices of the TOVA. In fact, their average fell well within the normal range on all TOVA variables. In contrast, those in the placebo group showed small declines on each TOVA variable and continued to perform in the below average range.

A direct comparison of the two groups yielded equally strong results, as CHP– treated children made significantly greater improvement than placebo-treated children on every TOVA scale. The magnitude of these group differences would be considered large.

The authors conducted a final analysis in which they assumed that all control children who withdrew would have improved as much as the average child in the CHP group had they continued and that all CHP children who withdrew would not have improved at all. Even when these conservative assumptions were made, children in the CHP group were still performing significantly better on average.

It should also be noted that careful assessments were conducted during the 4-month trial on the safety and tolerability of the CHP. No serious adverse effects were reported and the rate of even mild adverse events among CHP-treated children was actually lower than for children who received placebo.

- Summary and Implications -

Results from this randomized-controlled trial of a compound herbal treatment for ADHD clearly indicate significant improvement on an objective measure of sustained attention and impulsive responding, i.e., the TOVA. Given how carefully the trial was conducted, and the magnitude of the effects that were found, this is an encouraging and impressive result. Beyond the TOVA results, the fact that over 90% of parents kept their child on the herbal compound over 4 months — compared to under 50% of children receiving placebo — suggests that they were observing real-world benefits in their child and were not receiving pressure from teachers to ‘do something’. Clearly, these findings underscore the potential benefits of this herbal compound in the treatment of ADHD.

Despite these impressive results, however, there remain several important reasons for caution regarding the potential benefits of this treatment. First, this is only a single study and replication with another sample would be important for increasing confidence in the findings. The need for replicating treatment effects is important for any treatment approach and hopefully such work is already underway.

Second, and I believe this is especially important, the outcome measures used to evaluate treatment impact were unfortunately limited. While the TOVA certainly offers objective evidence of improved attention and reduced impulsive responding, the measurement battery would have ideally included behavior ratings made by parents and teachers. Such ratings would provide a clearer indication than the TOVA results of whether treatment yielded reductions in ADHD symptoms that were observed at home and at school, which are the outcomes that really matter. Although the fact that most parents kept their child on the herbal compound for the 4 months suggests that ‘real-world’ reductions in ADHD symptoms were evident, collecting the standardized behavior ratings is necessary to confirm this.

Finally, the study provides no real information on how long any benefits of this treatment would be sustained. Is this compound something children need to take indefinitely — as is often true for medication — or do the benefits persist even after the compound is no longer administered? This would be important information to collect in subsequent work.

These limitations not withstanding, this is an interesting and important study that highlights the need for additional research on this promising intervention approach for children with ADHD.

– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing. He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

Related articles:

• Dietary Intervention for ADHD: A Meta-Analysis
• Nutri­tion and sup­ple­ments (DHEA, Ginkgo Biloba, Omega-3): sep­a­rat­ing myth from fact

Neurofeedback supporters believe that learning this during training generalizes to real world situations and results in improved attention and reduced hyperactive/impulsive behavior. Although a number of neurofeedback studies have yielded promising results it remains somewhat controversial with some researchers arguing that limitations of these studies preclude firm conclusions about the effectiveness of neurofeedback from being drawn.

Last year I reviewed a particularly well-conducted study of neurofeedback treatment for ADHD — see my review here. The study was conducted in Germany and began with 94 children aged 8 to 12. All had been carefully diagnosed with ADHD and over 90% had never received medication treatment. About 80% were boys.

Children were randomly assigned to receive either 36 sessions of neurofeedback training or 36 sessions of computerized attention training. The computerized attention training task was intended to serve as the control intervention and provided equal amounts of time working on a demanding cognitive task under the supervision of an adult; the inclusion of this control condition is a real strength of the study.

The main findings were as follows:

1. Parents of children treated with neurofeedback reported significantly greater reductions in inattentive and hyperactive-impulsive symptoms than parents of control children, i.e,. those who received computerized attention training. The size of the group difference was in a range that would be considered moderate, i.e., about .5 standard deviations. 2. Teachers of children treated with neurofeedback reported significantly greater reductions in inattentive and hyperactive-impulsive symptoms than teachers of control children. The size of the group difference was similar to that found for parents, about .5 standard deviations.

The authors also examined the percentage of children in each group that were judged to derive a ‘significant’ benefit, defined as at least a 25% reduction in core ADHD symptoms. Fifty-one percent of children in the neurofeedback group met this threshold compared to only 26% of children in the attention training control group. This difference was statistically significant.

- New study presents 6-month follow-up results -

Recently, the authors of this study published 6-month follow-up data so that the duration of neurofeedback treatment effects could be examined. This is an important issue to study as one of the purported benefits of neurofeedback treatment is that the effects can endure well beyond when treatment has been completed.

Follow-up data was available on 61 of the original participants including 38 from the neurofeedback group and 23 from the control group. Follow-up data was based on parents ratings only as teacher ratings were not obtained at this time point.

Of the 32 ‘drop outs’, parents of 15 did not return the follow-up rating scales while the remaining 17 had started on medication. Children who began medication were not included because it was not possible to determine the extent to which their current functioning reflected their initial treatment or their current medication. However, it is reasonable to assume that parents would only start medication if they were not satisfied with how their child was doing.

- Results -

Key findings were as follows.

1. Parents’ ratings of core ADHD symptoms indicated that children treated with neurofeedback were still doing significantly better than children who received the ‘control treatment’. The magnitude of the difference was moderate to large, i.e., about .7 standard deviations. Reductions in symptoms scores from the initial baseline ratings were in the range of 25–30% for the neurofeedback group compared to only 10–15% for the control group.

2.Children in the neurofeedback tended to receive lower ratings for delinquent and physically aggressive behavior, but these differences did not quite reach statistical significance.

3. Parents’ reports of homework difficulties showed a greater decline over time for the neurofeedback treated children than for control children.

4. Group differences in a range of problematic situations that occur at home were not significant.

In addition to these analyses, the researchers also computed the percentage of children in each group who were considered to show a good treatment response, defined as at least a 25% reduction in parents’ ratings of core ADHD symptoms compared to baseline. This was true for 50% of children in the NF group compared to 30% of those in the control group. These differences were in the expected direction but did not quite reach statistical significance given the relative small sample size at follow-up, i.e., a total of only 61 children.

- Summary and Implications -

Results indicate that the benefits of neurofeedback treatment were maintained 6 months after treatment had ended. Thus, compared to children who received computerized attention training, which served as the control treatment, neurofeedback treated children continued to receive significantly lower parent ratings of core ADHD symptoms and also showed a greater decline in homework difficulties over time. These are encouraging findings and highlight that neurofeedback can be a beneficial treatment for some children with ADHD.

Despite these positive findings, however, it is important to emphasize that only 50% of children treated with neurofeedback showed at least a 25% decline in core ADHD symptoms at 6 months, meaning that the other 50% failed to show this level of clinical response. And, if one assumes that many of the children who began medication were also likely to have been non-responders (presumably parents would not have started medication otherwise), this figure becomes even higher. In addition, no follow-up data from teachers was available so it is not possible to know the extent to which any beneficial effects were maintained at school.

In recognition of these treatment limitations, the authors conclude that “…the low responder rate and the portion of children starting a medication in our study argue against NF as a stand-alone intervention for ADHD. The results indicate that not every child with ADHD may improve after NF treatment. In our opinion, NF should rather be seen as a treatment module for children with ADHD which can be embedded in a multimodal treatment program tailored to the individual needs of the child.”

The authors also noted, however, that because they followed a standardized treatment protocol for research purposes, rather than carefully tailoring neurofeedback treatment to each child, that their results may underestimate what is obtained in actual clinical situations.

In conclusion, results from this follow-up study provide evidence that neurofeedback can yield enduring benefits for some children with ADHD. As suggested by the authors, it may be an important component of a multimodal treatment program but its consistent use as a stand alone treatment does not seem to be supported by the findings reported here.

– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing. He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

Related articles by Dr. Rabiner:

• New Study Supports Neurofeedback Treatment for ADHD
• Neurofeedback/ Quan­ti­ta­tive EEG for ADHD diagnosis
• Promis­ing Cog­ni­tive Train­ing Stud­ies for ADHD
• Mind­ful­ness Med­i­ta­tion for Adults & Teens with ADHD
• How Strong is the Research Sup­port for Neu­ro­feed­back in Atten­tion Deficits?
• Self-Regulation and Barkley’s The­ory of ADHD

A simple example illustrates the importance of WM for particular academic tasks. Try adding 3 and 9 in your head. That was probably easy for you. Now trying adding 33 and 99. That was probably more difficult. Finally, try adding 333 and 999. This is quite challenging for most adults even though each calculation required is trivially easy. The challenge occurred because you need to store information — the sum of 3+9 in the one’s column and then ten’s column — as you process the remaining part of the problem, i.e., 3+9 in the hundred’s column, and this taxed your WM. If your WM capacity was exceeded, you could not complete the problem successfully.

This simple problem also illustrates the difference between short-term memory (STM) and WM. Short-term memory simply involves retaining information in mind for short periods of time, e.g., remembering that the problem you need to solve is 333+999. Working memory, in contrast, involves mentally manipulating — or ‘working’ with — retained information and comes into play in a wide range of learning activities. For example, to answer questions about a science chapter, a child not only has to correctly retain factual information but must mentally work with that information to answer questions about it. Thus, when a child’s WM capacity is low relative to peers, academic performance is likely to be compromised in multiple areas.

Because WM deficits play an important role in the struggles experienced by many individuals with ADHD, it is important to consider how different interventions address this aspect of the disorder. In this study, the authors were interested in comparing the impact of Working Memory Training and stimulant medication treatment on the WM performance of children diagnosed with ADHD.

Participants were 25 8–11 year-old children with ADHD (21 boy and 4 girls) who were being treated with stimulant medication. Children’s memory performance was assessed on 4 occasions using the Automated Working Memory Assessment (AWMA), a computerized test that measures verbal short-term memory, verbal working memory, visuo-spatial short-term memory, and visuo-spatial working memory.

At time 1, the assessment was conducted when children had been off medication for at least 24 hours. The second assessment occurred an average of 5 months later and when children were on medication. The third assessment occurred after children had completed 5 weeks of Cogmed Working Memory Training using the standard training protocol (see below). The final assessment occurred approximately 6 months after training had ended. This design enabled the researchers to make the following comparisons:

- WM performance on medication vs. off medication (T1 vs T2)
– WM performance on medication vs. after training (T2 vs. T3)
– WM performance immediately after training ended vs. 6 months following training (T3 vs. T4)

This final comparison provided information on whether any benefits provided by the training had endured.

In addition to measuring STM and WM at each time point, measures of IQ were collected at times 1, 2, and 3.

- Working Memory Training -

WM training was conducted using the standard Cogmed training protocol with each child completing 20–25 training sessions within a 25 day period. The training requires the storage and manipulation of sequences of verbal, e.g., repeating back a sequence of digits in reverse order, and/or visuo-spatial information, e.g., recalling the location of objects on different portions of the computer screen.

Difficulty level is calibrated on a trial by trial basis so the child is always working at a level that closely matches their performance. For example, if a child successfully recalled three digits in reverse order, on the next trial he had to recall four. When a trial was failed, the next trial was made easier by reducing the number of items to be recalled. This method of ‘adaptive training’ is thought to be a key element because it requires the child to ‘stretch’ their WM capacity to move through the program.

- Results -

- Impact of Short-Term Memory and Working Memory -

Medication vs. no medication — When tested on medication, children showed better visuo-spatial WM relative to when they were tested off medication. However, no improvement was found for verbal STM, verbal WM, or visuo-spatial STM.

Performance on medication vs. performance after WM training — Cogmed WM Training led to significant gains in all four memory scores. Thus, there was evidence that WM training led to greater gains in WM that medication treatment alone. On all areas of memory assessed, the average score of participants had moved from below average to within the average range.

Performance 6 months after training ended — Training gains in 3 of the 4 memory components — all but visuo-spatial STM — remained significant 6 months after training had ended and there was little indication of any decline in children’s performance. Thus, the benefits evident immediately following training had largely persisted.

- Impact on IQ -

IQ results on and off medication were equivalent. Likewise, there was no indication that WM training was associated with any increase in children’s IQ results. Thus, the benefits of training were restricted to children’s performance on the memory tasks.

- Summary and Implications -

Results from this study indicate that WM training yields greater benefits in WM for children with ADHD than are provided by stimulant medication treatment. Furthermore, memory gains following training persist for a significant period. Because adequate WM functioning is critically important for children’s academic success, these are encouraging findings as they suggest that intensive training can ameliorate deficits in this important executive function. The absence of training benefits on IQ suggests that the benefits of training may be limited to WM specifically, although it should be noted that other WM training studies have reported benefits on particular aspects of intelligence. Thus, the impact of WM training on IQ requires further study.

However, it is important not to over interpret the results from this study. While it is tempting to regard this as a comparison of medication treatment and WM training for ADHD, and to view the results as indicating the superiority of the latter, this would be an erroneous interpretation. The constellation of difficulties that comprise ADHD for many children extend significantly beyond WM deficits, and this study did not examine a number of other important outcomes.

For example, it provides no information on the relative benefits of medication and WM training on children’s attention, hyperactivity, other behavior problems, and academic performance. Even though other studies of WM training have found benefits in several of these areas, adding assessments of these critical outcomes to the current study would have strengthened it. This criticism is not intended to discount the important results obtained, but to instead provide an appropriate context for evaluating these interesting findings and it would not be surprising if medication treatment were to have greater impact in other important areas.

It is also the case that the study was limited by restricting the assessment of WM to computerized measures of this capacity, even though validated parent and teacher rating scale measures of WM are available. Incorporating such measures into the study would have provided a more comprehensive of children’s memory functioning at each assessment point.

Although these represent important study limitations, the results provide additional evidence that intensive WM training can yield enduring benefits in this key executive function. Because the benefits providing by training enhance those provided by medication, it also suggests that WM training may be a useful complement to existing evidence-based interventions for ADHD, particularly for children whose WM functioning is limited to begin with.

– Dr. David Rabiner is a child clinical psychologist and Director of Undergraduate Studies in the Department of Psychology and Neuroscience at Duke University. His research focuses on various issues related to ADHD, the impact of attention problems on academic achievement, and attention training. He also publishes Attention Research Update, a complimentary online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD.

Related articles by Dr. Rabiner

- Neurofeedback/ Quantitative EEG for ADHD diagnosis

- Promising Cognitive Training Studies for ADHD

- Mindfulness Meditation for Adults & Teens with ADHD

- Self-Regulation and Barkley’s Theory of ADHD

Neurofeedback treatment for ADHD has been controversial in the field for many years and remains so today. Although a number of published studies have reported positive results many prominent ADHD researchers believe that problems with the design of these studies preclude concluding that neurofeedback is an effective treatment. These limitations have included the absence of random assignment, the lack of appropriate control groups, raters who are not ‘blind’ to children’s treatment status, and small samples. For additional background, you can find a recent review I wrote on existing research support for neurofeedback treatment of ADHD — along with links to extensive reviews of several recently published studies -: How Strong is the Research Support for Neurofeedback in Attention Deficits?

- Results from a New Study of Neurofeedback -

Recently, a study of neurofeedback treatment for ADHD was published that addresses several limitations that have undermined prior research [Gevensleben, et al., (2009). Is neurofeedback an efficacious treatment for ADHD? A randomized controlled clinical trial. Journal of Child Psychology and Psychiatry.]

The study was conducted in Germany and began with 102 children aged 8 to 12. All had been carefully diagnosed with ADHD and approximately over 90% had never received medication treatment. About 80% were boys. Children were randomly assigned to one of two treatment conditions: 36 sessions of neurofeedback training or 36 sessions of computerized attention training. The computerized attention training task was intended to serve as the control intervention. Training was conducted in two 50-minute blocks per sessions, with a short break in-between; children in both groups participated in two to three such training sessions per week.

- Description of Training -

Neurofeedback Training — As noted above, neurofeedback entails providing children with real-time feedback on their EEG state so that they become able to learn how to create and maintain a state that is consistent with focused attention. This is done by linking their ability to control what appears on the computer screen to their ability to produce and maintain the EEG state being trained. Technical details of the training protocols are not summarized here but were based on research findings suggesting the specific EEG differences between children with and without ADHD that training should address. For example, one part of training focused on teaching children to elevate their production of higher frequency beta waves and supress the production of lower frequency theta waves. This is based on prior findings that individuals with ADHD tend to have an elevated ratio of theta to beta activity relative (see Neurofeedback/ Quantitative EEG for ADHD diagnosis).

Computerized Attention Training — This treatment was based on a program called ‘Skillies’, described as award-winning German learning software that provides systematic exercises in visual and auditory perception, vigilance, sustained attention, and reactivity. It was considered the ‘control’ condition to which the results of neurofeedback training was compared.

Performing well on the program requires children to sustain their attention to a variety of game-like tasks that become increasingly challenging and that provide children with frequent feedback about their performance. Children thus receive extended practice in ‘paying attention’ for increasing periods to tasks that become increasingly demanding and need to learn to sustain their attention in order to do well. Unlike neurofeedback treatment,however, no direct feedback on EEG state is provided.

- Experimental Controls -

As noted above, children were randomly assigned to treatment condition, which is essential when comparing different interventions. Efforts were also made to make the intervention experience as similar as possible, except for the critical difference as to whether children received direct training in managing their EEG state. Thus, treatment for both groups entailed computer-game like tasks that demanded attention. In both conditions, children were encouraged to develop strategies to focus attention and to practice these strategies at home and school. They also received similar amounts of attention and praise for doing so.

By equalizing as many aspects of the training experience as possible, the researchers could attribute any outcome differences that emerged to critical differences in the programs themselves, i.e., whether feedback on EEG state was provided, as opposed to some extraneous factor such as attention from the experimenters, time spent on a demanding computer task, etc.

In addition to these important controls, efforts were made to keep parents and teachers ‘blind’ to the type of training children received. Thus, parents were only told that their child would receive either of two promising computer-based treatments for ADHD. They also did not accompany their child into the treatment room to observe. Children’s teachers were also not informed about the child’s treatment. Although a number of parents became aware of which treatment their child received, and perhaps some teachers did as well, it is not possible to keep everyone truly ‘blind’ in a study like this.

- Measuring Treatment Outcomes -

The main outcome measure used were parent and teacher ratings of children’s ADHD symptoms. In addition to ratings of core inattentive and hyperactive-impulsive symptoms, ratings were collected on a variety of other behaviors, e.g., oppositional behavior, conduct problems, emotional problems, and social problems. These rating scales were obtained before and after treatment.

To rule out placebo effects as an explanation for any treatment differences found, the researchers also asked parents about their attitudes towards treatment, how motivated they thought their children were, and how satisfied they were with their child’s treatment.

- Results -

Preliminary analysis revealed no group differences in parents’ attitudes towards, or satisfaction with, their child’s treatment or in how motivated they felt their child was. These factors thus should not have influenced parents’ ratings of core symptoms.

Results of the parent and teacher behavior ratings indicated the following:

1. Parents of children treated with neurofeedback reported significantly greater reductions in inattentive and hyperactive-impulsive symptoms than parents of control children, i.e,. those who received computerized attention training. The size of the group difference was in a range that would be considered moderate, i.e., about .5 standard deviations.

2. Teachers of children treated with neurofeedback reported significantly greater reductions in inattentive and hyperactive-impulsive symptoms than teachers of control children. The size of the group difference was similar in magnitude to that found for parents, about .5 standard deviations.

3. Apart from these differences in core ADHD symptoms, few group differences were found. However, neurofeedback was associated with greater reductions in parents’ ratings of oppositional and aggressive behavior. Teacher ratings for the two groups did not differ on any of the remaining behavioral measures.

The results summarized above reflect average differences between the groups. The authors also examined the percentage of children in each group that were judged to derive significant benefit where this was defined as at least a 25% reduction in core ADHD symptoms. Fifty-one percent of children in the neurofeedback group met this threshold compared to only 26% of children in the attention training control group. This difference was statistically significant as well.

- Summary and Implications -

This was a well-designed study of neurofeedback treatment for ADHD that used random assignment, blind raters, and included an appropriate control group. Results indicate that neurofeedback treatment yielded significantly greater reductions in parent and teacher ratings of core ADHD symptoms than the comparison treatment. Furthermore, the magnitude of the reductions appear large enough to be clinically meaningful. Although the impact of neurofeedback treatment on other aspects of children’s functioning was less pronounced, significant reductions in parents’ ratings of oppositional behavior were also found.

Overall, these findings add to the research support for neurofeedback as a treatment for ADHD. However, despite the many strengths of this study, there are concerns to note and reasons why some researchers will find a basis for criticizing it. The main concerns — and my own take on them — include the following:

1. Without getting too technical, some researchers will argue that the statistical tests used in this study were not ideal and may have overestimated the advantages of neurofeedback treatment. My sense from examining the data is that the primary findings would hold up even if more conservative statistical tests were employed. However, it would be really nice to see that done.

2. Neurofeedback is supposed to work by teaching children to transform their EEG state to one that is characteristic of children without ADHD. However, there were no EEG measures taken in this study. Thus, there is no way to know whether neurofeedback actually resulted in these hypothesized changes in EEG. While this is certainly true, this has more to do with documenting the mechanism by which neurofeedback led to reductions in ADHD symptoms and has nothing to do with whether those reductions actually occurred.

I believe that some neurofeedback practitioners would argue that this may have also diminished the benefits provided by neurofeedback treatment. The reason for this is that training was not matched to the specific EEG parameters that needed to be altered for each individual and that additional benefits would have accrued had this been done. Whether this is actually the case, however, would require additional research to determine.

3. No measures of children’s academic functioning were collected. Because improving academic performance is a critical treatment target for most children with ADHD, the absence of this data is an important study limitation. There is no arguing with this and it is unfortunate that measures of academic performance in the classroom were not collected.

4. No long-term follow up was conducted. There is thus no basis for knowing whether neurofeedback treatment resulted in any enduring benefits. While this is certainly a limitation, it should be noted that neither medication treatment nor behavioral treatment have been shown to have enduring benefits after treatment ends. However, one of the reputed advantages of neurofeedback is that it may result in enduring gains. Thus, adding a long-term follow up to this study would have been an important addition.

5. It is important to remember that when improvement was defined as at least a 25% reduction in core ADHD symptoms, about 50% of children treated with neurofeedback did not meet this threshold. Thus, many children did not derive significant benefit from this treatment even though the benefits averaged across all children were statistically significant.

This is not surprising as no treatment — including medication — will help everyone. However, the rate of non-responders is less than what is typically found in controlled studies of medication treatment and this is important to remain aware of.

Despite these limitations and concerns, my take on this study is that it represents an important addition to the research literature on neurofeedback treatment for ADHD. In the context of other positive findings that have been reported for neurofeedback, it provides additional basis for regarding this as an extremely promising treatment approach for some children with ADHD.

– Dr. David Rabiner is a child clinical psychologist and Director of Undergraduate Studies in the Department of Psychology and Neuroscience at Duke University. His research focuses on various issues related to ADHD, the impact of attention problems on academic achievement, and attention training. He also publishes Attention Research Update, a complimentary online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD.

Related articles by Dr. Rabiner

- Neurofeedback/ Quantitative EEG for ADHD diagnosis

- Promising Cognitive Training Studies for ADHD

- Mindfulness Meditation for Adults & Teens with ADHD

- How Strong is the Research Support for Neurofeedback in Attention Deficits?

- Self-Regulation and Barkley’s Theory of ADHD