Differential EMG biofeedback for children with ADHD: a control method for neurofeedback training with a case illustration

The objective of the present paper was to develop a differential electromyographic biofeedback (EMG-BF) training for children with attention-deficit/hyperactivity disorder (ADHD) matching multiple neurofeedback training protocols in order to serve as a valid control training. This differential EMG-BF training method feeds back activity from arm muscles involved in fine motor skills such as writing and grip force control. Tonic EMG-BF training (activation and deactivation blocks, involving bimanual motor tasks) matches the training of EEG frequency bands, while phasic EMG-BF training (short activation and deactivation trials) was developed as an equivalent to the training of slow cortical potentials. A case description of a child who learned to improve motor regulation in most task conditions and showed a clinically relevant reduction of behavioral ADHD symptoms illustrates the training course and outcome. Differential EMG-BF training is feasible and provides well-matched control conditions for neurofeedback training in ADHD research. Future studies should investigate its value as a specific intervention for children diagnosed with ADHD and comorbid sensorimotor problems.

Comparing tomographic EEG neurofeedback and EMG biofeedback in children with attention-deficit/hyperactivity disorder

Two types of biofeedback (BF), tomographic electroencephalogram (EEG) neurofeedback (NF) and electromyographic biofeedback (EMG-BF), both with phasic and tonic protocols, were compared for treatment effects and specificity in attention-deficit/hyperactivity disorder (ADHD). Thirteen children with ADHD trained their brain activity in the anterior cingulate cortex (ACC), and twelve trained activity of arm muscles involved in fine motor skills. In each training session, resting state 24-channel EEG and training performances were recorded. Both groups showed similar behavioral improvements and artifact reduction in selected conditions, with no significant advantages despite medium effect sizes on primary outcomes for NF. Only the EMG-BF group, however, showed clear improvement in training regulation performance, and specific motor coordination effects. The NF group tended to present individual normalization of trained frequency bands in the ACC during rest across training. The results provide evidence for some specific effects in our small sample, albeit only to a small extent.

[ADHD and conduct disorder: trends in diagnosis and therapy]

Since 2010 trends outlined in diagnosis and therapy in the German speaking countries in the area of externalizing disorders (ADHD, conduct disorder) are presented. In particular, publications of children and adolescent psychiatry and clinical psychology have been examined. It turns out that in the German-speaking countries, the concern with conduct disorder (including psychopathy) increased compared with the discussion of the significance of ADHD. This development reflects the important therapeutic challenge of conduct disorders.

Current status of neurofeedback for attention-deficit/hyperactivity disorder

As conventional treatments offer incomplete benefit for over 33 % of children with attention-deficit/hyperactivity disorder (ADHD) and many refuse to try them, additional treatments are needed. One of the most promising is neurofeedback (NF, EEG biofeedback), which trains the brain with real-time video/audio information about its electrical activity measured from scalp electrodes. Since 2010, data from 8 randomized controlled studies of NF have been published with overall mean effect sizes of: 0.40 (all measures), 0.42 (ADHD measures), 0.56 (inattention), and 0.54 (hyperactivity/ impulsivity). Unfortunately, the benefit reported from randomized studies has not been observed in the few small blinded studies conducted. Main study strengths include randomization, evidence-based diagnostic assessments, multi-domain treatment outcomes, use of some type of blinding, and sham control conditions. Main study limitations include lack of large samples, abnormal EEG participant selection, double-blinding, and testing of blind validity and sham inertness. Most recently, a collaborative NF research group has been planning a definitive double-blind well-controlled trial.

Evidence-based information on the clinical use of neurofeedback for ADHD

Neurofeedback (NF) is a training to enhance self-regulatory capacity over brain activity patterns and consequently over brain mental states. Recent findings suggest that NF is a promising alternative for the treatment of attention-deficit/hyperactivity disorder (ADHD). We comprehensively reviewed literature searching for studies on the effectiveness and specificity of NF for the treatment of ADHD. In addition, clinically informative evidence-based data are discussed. We found 3 systematic review on the use of NF for ADHD and 6 randomized controlled trials that have not been included in these reviews. Most nonrandomized controlled trials found positive results with medium-to-large effect sizes, but the evidence for effectiveness are less robust when only randomized controlled studies are considered. The direct comparison of NF and sham-NF in 3 published studies have found no group differences, nevertheless methodological caveats, such as the quality of the training protocol used, sample size, and sample selection may have contributed to the negative results. Further data on specificity comes from electrophysiological studies reporting that NF effectively changes brain activity patterns. No safety issues have emerged from clinical trials and NF seems to be well tolerated and accepted. Follow-up studies support long-term effects of NF. Currently there is no available data to guide clinicians on the predictors of response to NF and on optimal treatment protocol. In conclusion, NF is a valid option for the treatment for ADHD, but further evidence is required to guide its use.