Neurofeedback of Slow Cortical Potentials in Children with Attention-Deficit/Hyperactivity Disorder: A Multicenter Randomized Trial Controlling for Unspecific Effects

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Abstract

Background: Neurofeedback (NF) in children with attention-deficit/hyperactivity disorder (ADHD) has been investigated in a series of studies over the last years. Previous studies did not unanimously support NF as a treatment in ADHD. Most studies did not control for unspecific treatment effects and did not demonstrate that self-regulation took place. The present study examined the efficacy of NF in comparison to electromyographic (EMG) feedback to control for unspecific effects of the treatment, and assessed self-regulation of slow cortical potentials (SCPs).

Methods: A total of 150 children aged 7–9 years diagnosed with ADHD (82% male; 43% medicated) were randomized to 25 sessions of feedback of SCPs (NF) or feedback of coordination of the supraspinatus muscles (EMG). The primary endpoint was the change in parents’ ratings of ADHD core symptoms 4 weeks after the end of treatment compared to pre-tests.

Results: Children in both groups showed reduced ADHD-core symptoms (NF 0.3, 95% CI -0.42 to -0.18; EMG 0.13, 95% CI -0.26 to -0.01). NF showed a significant superiority over EMG (treatment difference 0.17, 95% CI 0.02–0.3, p = 0.02). This yielded an effect size (ES) of d = 0.57 without and 0.40 with baseline observation carried forward (BOCF). The sensitivity analysis confirmed the primary result. Successful self-regulation of brain activity was observed only in NF. As a secondary result teachers reported no superior improvement from NF compared to EMG, but within-group analysis revealed effects of NF on the global ADHD score, inattention, and impulsivity. In contrast, EMG feedback did not result in changes despite more pronounced self-regulation learning.

Conclusions: Based on the primary parent-rated outcome NF proved to be superior to a semi-active EMG feedback treatment. The study supports the feasibility and efficacy of NF in a large sample of children with ADHD, based on both specific and unspecific effects.

Trial Register: Current controlled trials ISRCTN76187185, registered 5 February 2009.

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Most cited references 41

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Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments.

Edmund Sonuga‐Barke, Daniel Brandeis, Samuele Cortese … (2013)

Nonpharmacological treatments are available for attention deficit hyperactivity disorder (ADHD), although their efficacy remains uncertain. The authors undertook meta-analyses of the efficacy of dietary (restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation) and psychological (cognitive training, neurofeedback, and behavioral interventions) ADHD treatments. Using a common systematic search and a rigorous coding and data extraction strategy across domains, the authors searched electronic databases to identify published randomized controlled trials that involved individuals who were diagnosed with ADHD (or who met a validated cutoff on a recognized rating scale) and that included an ADHD outcome. Fifty-four of the 2,904 nonduplicate screened records were included in the analyses. Two different analyses were performed. When the outcome measure was based on ADHD assessments by raters closest to the therapeutic setting, all dietary (standardized mean differences=0.21-0.48) and psychological (standardized mean differences=0.40-0.64) treatments produced statistically significant effects. However, when the best probably blinded assessment was employed, effects remained significant for free fatty acid supplementation (standardized mean difference=0.16) and artificial food color exclusion (standardized mean difference=0.42) but were substantially attenuated to nonsignificant levels for other treatments. Free fatty acid supplementation produced small but significant reductions in ADHD symptoms even with probably blinded assessments, although the clinical significance of these effects remains to be determined. Artificial food color exclusion produced larger effects but often in individuals selected for food sensitivities. Better evidence for efficacy from blinded assessments is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms.

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Normative data and scale properties of the German parent SDQ.

Wolfgang Woerner, Andreas Becker, Aribert Rothenberger (2004)

The Strengths and Difficulties Questionnaire (SDQ) is a short assessment instrument which addresses positive and negative behavioural attributes of children and adolescents and generates scores for clinically relevant aspects. Although this brief questionnaire has been widely used in Germany to gather information from parents, teachers, and older children themselves, normative results obtained with the German version have not yet been reported to the international scientific community. To allow comparisons with SDQ findings in other countries, normative data for the German parent-rated form as well as a community-based evaluation of scale properties are summarised and complemented by results obtained in a number of clinical samples. Parent ratings were collected for a community-based sample of 930 children and adolescents aged between 6 and 16 years, in which both genders and all age levels were equally represented. Statistical evaluation of psychometric properties included a factor analysis verifying the proposed scale structure, assessment of scale homogeneities, and determination of age, gender and social class effects. Based on the distributions of SDQ scores observed in this normative sample, recommended bandings identifying normal, borderline, and clinical ranges were defined for each scale. Exact replication of the original scale structure, satisfactory internal reliabilities, and observation of the expected associations with age and gender confirmed the equivalence of the German SDQ parent questionnaire with the English original. Differences between community-based results and clinical groups provided descriptive evidence of a dramatic impact of clinically defined psychiatric status on SDQ scores. After evaluating parent ratings obtained in a community-based sample, the German SDQ was shown to possess favourable psychometric properties. Thus, the German translation of this popular and versatile instrument seems to be a similarly reliable and useful assessment tool as the original English questionnaire.

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Author and article information

Contributors

Ute Strehl: URI : http://loop.frontiersin.org/people/115512/overview

Pascal Aggensteiner: URI : http://loop.frontiersin.org/people/374857/overview

Daniel Wachtlin: URI : http://loop.frontiersin.org/people/387330/overview

Daniel Brandeis: URI : http://loop.frontiersin.org/people/177985/overview

Björn Albrecht: URI : http://loop.frontiersin.org/people/14195/overview

Tobias Banaschewski: URI : http://loop.frontiersin.org/people/14709/overview

Thorsten Bogen: URI : http://loop.frontiersin.org/people/375131/overview

Christine M. Freitag: URI : http://loop.frontiersin.org/people/64282/overview

Yvonne Fuchsenberger: URI : http://loop.frontiersin.org/people/189535/overview

Anna-Maria Marx: URI : http://loop.frontiersin.org/people/38899/overview

Sabina Millenet: URI : http://loop.frontiersin.org/people/378065/overview

Aribert Rothenberger: URI : http://loop.frontiersin.org/people/115368/overview

Journal

Journal ID (nlm-ta): Front Hum Neurosci

Journal ID (iso-abbrev): Front Hum Neurosci

Journal ID (publisher-id): Front. Hum. Neurosci.

Title: Frontiers in Human Neuroscience

Publisher: Frontiers Media S.A.

ISSN (Electronic): 1662-5161

Publication date (Electronic): 31 March 2017

Publication date Collection: 2017

Volume: 11

Electronic Location Identifier: 135

Affiliations

[1] ¹Institute for Medical Psychology and Behavioral Neurobiology, University of Tübingen Tübingen, Germany

[2] ²Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg Mannheim, Germany

[3] ³Interdisciplinary Center for Clinical Trials at the University Medical Center of the Johannes Gutenberg University of Mainz Mainz, Germany

[4] ⁴Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric Hospital, University of Zurich Zurich, Switzerland

[5] ⁵Center for Integrative Human Physiology, University of Zurich Zurich, Switzerland

[6] ⁶Neuroscience Center Zurich, University of Zurich and ETH Zurich Zurich, Switzerland

[7] ⁷Child and Adolescent Psychiatry, University Medical Center Göttingen Göttingen, Germany

[8] ⁸Department of Psychosomatic Medicine and Psychotherapy, University Hospital Leipzig Leipzig, Germany

[9] ⁹Landschaftsverband Westfalen-Lippe (LWL) University Hospital Hamm for Child and Adolescent Psychiatry, Ruhr-University Bochum Hamm, Germany

[10] ¹⁰Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany

Author notes

Edited by: Lutz Jäncke, University of Zurich, Switzerland

Reviewed by: Yury (Juri) Kropotov, The Institute of the Human Brain of Russian Academy of Sciences, Russia; John H. Gruzelier, Goldsmiths, University of London, UK; Jaime A. Pineda, University of California, San Diego, USA

*Correspondence: Ute Strehl, ute.strehl@ 123456uni-tuebingen.de

^† These authors have contributed equally to this work.

Article

DOI: 10.3389/fnhum.2017.00135

PMC ID: 5374218

PubMed ID: 28408873

SO-VID: 6e702166-55df-452a-b0e6-af8a54195bb0

Copyright © Copyright © 2017 Strehl, Aggensteiner, Wachtlin, Brandeis, Albrecht, Arana, Bach, Banaschewski, Bogen, Flaig-Röhr, Freitag, Fuchsenberger, Gest, Gevensleben, Herde, Hohmann, Legenbauer, Marx, Millenet, Pniewski, Rothenberger, Ruckes, Wörz and Holtmann.

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This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

History

Date received : 31 August 2016

Date accepted : 08 March 2017

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Figures: 6, Tables: 7, Equations: 0, References: 50, Pages: 15, Words: 0

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Neurofeedback of Slow Cortical Potentials in Children with Attention-Deficit/Hyperactivity Disorder: A Multicenter Randomized Trial Controlling for Unspecific Effects

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Most cited references 41

Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments.

Neurobiological mechanisms of the placebo effect.

Normative data and scale properties of the German parent SDQ.

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