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Wilens TE, Stone M, Lanni S, Berger A, Wilson RLH, Lydston M, Surman CB. Treating Executive Function in Youth With Attention Deficit Hyperactivity Disorder: A Review of Pharmacological and Non-Pharmacological Interventions. J Atten Disord 2024; 28:751-790. [PMID: 38178649 DOI: 10.1177/10870547231218925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Executive function (EF) deficits are common in youth with ADHD and pose significant functional impairments. The extent and effect of interventions addressing EF in youth with ADHD remain unclear. METHODS We conducted a systematic literature review using PRISMA guidelines. Included studies were randomized controlled trials of interventions to treat EF in youth with ADHD. RESULTS Our search returned 136 studies representing 11,443 study participants. We identified six intervention categories: nonstimulant pharmacological (N = 3,576 participants), neurological (N = 1,935), psychological (N = 2,387), digital (N = 2,416), physiological (N = 680), and combination (N = 366). The bulk of the evidence supported pharmacological interventions as most effective in mitigating EF, followed by psychological and digital interventions. CONCLUSION A breadth of treatments exists for EF in youth with ADHD. Pharmacological, psychotherapeutic, and digital interventions had the most favorable, replicable outcomes. A lack of outcome standardization across studies limited treatment comparison. More data on the persistence of intervention effects are necessary.
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Affiliation(s)
- Timothy E Wilens
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mira Stone
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Amy Berger
- Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Craig B Surman
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Smith EG, Grigorian HL. A System for Rapidly Yet Rigorously Evaluating the Quality of Randomized Controlled Trials. J Clin Psychopharmacol 2023; 43:306-312. [PMID: 37378832 DOI: 10.1097/jcp.0000000000001724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
ABSTRACT This tutorial describes a system for rapidly yet rigorously assessing the quality of randomized controlled trials (RCTs). The system has 7 criteria, represented by the acronym "BIS FOES." The BIS FOES system directs readers to assess RCTs based on the following 7 criteria: the RCT's use (or not) of effective (1) Blinding; the RCT's use (or not) of (2) Intent-to-Treat Analysis; the RCT's (3) Size and other information reflecting the effectiveness of randomization; the amount of sample lost during (4) Follow-up; the (5) Outcomes examined by the RCT (specifically, the outcome measures used by the RCT), the (6) Effects reported (ie, the statistical and clinical significance of the RCT's primary, secondary, and safety findings), and any (7) Special Considerations (ie, additional strengths, limitations, or notable features of the RCT). The first 6 criteria are of basic importance to the assessment of every RCT, whereas the Special Considerations criteria allows the system to be expanded to include virtually any other important aspect of the RCT. This tutorial explains the importance of these criteria and how to assess them. This tutorial also describes how many BIS FOES criteria can be initially assessed from the RCT Abstract while also directing readers to specific locations in the RCT article where additional important information can be found. We hope that the BIS FOES system will help healthcare trainees, but also potentially clinicians, researchers, and the general public, rapidly and thoroughly assess RCTs.
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Hasslinger J, Meregalli M, Bölte S. How standardized are “standard protocols”? Variations in protocol and performance evaluation for slow cortical potential neurofeedback: A systematic review. Front Hum Neurosci 2022; 16:887504. [PMID: 36118975 PMCID: PMC9478392 DOI: 10.3389/fnhum.2022.887504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
Neurofeedback (NF) aims to alter neural activity by enhancing self-regulation skills. Over the past decade NF has received considerable attention as a potential intervention option for many somatic and mental conditions and ADHD in particular. However, placebo-controlled trials have demonstrated insufficient superiority of NF compared to treatment as usual and sham conditions. It has been argued that the reason for limited NF effects may be attributable to participants' challenges to self-regulate the targeted neural activity. Still, there is support of NF efficacy when only considering so-called “standard protocols,” such as Slow Cortical Potential NF training (SCP-NF). This PROSPERO registered systematic review following PRISMA criteria searched literature databases for studies applying SCP-NF protocols. Our review focus concerned the operationalization of self-regulatory success, and protocol-details that could influence the evaluation of self-regulation. Such details included; electrode placement, number of trials, length per trial, proportions of training modalities, handling of artifacts and skill-transfer into daily-life. We identified a total of 63 eligible reports published in the year 2000 or later. SCP-NF protocol-details varied considerably on most variables, except for electrode placement. However, due to the increased availability of commercial systems, there was a trend to more uniform protocol-details. Although, token-systems are popular in SCP-NF for ADHD, only half reported a performance-based component. Also, transfer exercises have become a staple part of SCP-NF. Furthermore, multiple operationalizations of regulatory success were identified, limiting comparability between studies, and perhaps usefulness of so-called transfer-exercises, which purpose is to facilitate the transfer of the self-regulatory skills into every-day life. While studies utilizing SCP as Brain-Computer-Interface mainly focused on the acquisition of successful self-regulation, clinically oriented studies often neglected this. Congruently, rates of successful regulators in clinical studies were mostly low (<50%). The relation between SCP self-regulation and behavior, and how symptoms in different disorders are affected, is complex and not fully understood. Future studies need to report self-regulation based on standardized measures, in order to facilitate both comparability and understanding of the effects on symptoms. When applied as treatment, future SCP-NF studies also need to put greater emphasis on the acquisition of self-regulation (before evaluating symptom outcomes).
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Affiliation(s)
- John Hasslinger
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Healthcare Services, Region Stockholm, Stockholm, Sweden
- Child and Adolescent Psychiatry, Stockholm Healthcare Services, Region Stockholm, Stockholm, Sweden
- *Correspondence: John Hasslinger
| | - Micaela Meregalli
- Child and Adolescent Psychiatry, Stockholm Healthcare Services, Region Stockholm, Stockholm, Sweden
| | - Sven Bölte
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Healthcare Services, Region Stockholm, Stockholm, Sweden
- Child and Adolescent Psychiatry, Stockholm Healthcare Services, Region Stockholm, Stockholm, Sweden
- Curtin Autism Research Group, Curtin School of Allied Health, Curtin University, Perth, WA, Australia
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Results of Neurofeedback in Treatment of Children with ADHD: A Systematic Review of Randomized Controlled Trials. Appl Psychophysiol Biofeedback 2022; 47:145-181. [PMID: 35612676 DOI: 10.1007/s10484-022-09547-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/02/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent disorders in children and adolescents. Neurofeedback, a nonpharmaceutical treatment, has shown promising results. To review the evidence of efficacy of neurofeedback as a treatment for children and adolescents with ADHD. A systematic review of the specific scientific studies published in 1995-2021, identifying and analyzing randomized controlled trials (RCT). A total of 1636 articles were identified and 165 met inclusion criteria, of which 67 were RCTs. Neurofeedback training was associated with significant long-term reduction in symptoms of ADHD. Though limitations exist regarding conclusions about the specific effects of neurofeedback, the review documents improvements in school, social, and family environments.
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Behzadifard B, Sabaghypour S, Farkhondeh Tale Navi F, Nazari MA. Training the brain to time: the effect of neurofeedback of SMR-Beta1 rhythm on time perception in healthy adults. Exp Brain Res 2022; 240:2027-2038. [PMID: 35576072 DOI: 10.1007/s00221-022-06380-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 04/25/2022] [Indexed: 11/04/2022]
Abstract
The timing ability plays an important role in everyday activities and is influenced by several factors such as the attention and arousal levels of the individuals. The effects of these factors on time perception have been interpreted through psychological models of time, including Attentional Gate Model (AGM). On the other hand, research has indicated that neurofeedback (NFB) training improves attention and increases arousal levels in the clinical and healthy population. Regarding the link between attentional processing and arousal levels and NFB and their relation to time perception, this study is a pilot demonstration of the influence of SMR-Beta1 (12-18 Hz) NFB training on time production and reproduction performance in healthy adults. To this end, 12 (9 female and 3 males; M = 26.3, SD = 3.8) and 12 participants (7 female and 5 males; M = 26.9, SD = 3.1) were randomly assigned into the experimental (with SMR-Beta1 NFB) and control groups (without any NFB training), respectively. The experimental group underwent intensive 10 sessions (3 days a week) of the 12-18 Hz up-training. Time production and reproduction performance were assessed pre and post NFB training for all participants. Three-way mixed ANOVA was carried out on T-corrected scores of reproduction and production tasks. Correlation analysis was also performed between SMR-Beta1 and time perception. While NFB training significantly influenced time production (P < 0.01), no such effect was observed for the time reproduction task. The results of the study are finally discussed within the frameworks of AGM, dual-process and cognitive aspects of time perception. Overall, our results contribute to disentangling the underlying mechanisms of temporal performance in healthy individuals.
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Affiliation(s)
- Behnoush Behzadifard
- Department of Psychology, Kish International Branch, Islamic Azad University, Kish Island, Iran
| | - Saied Sabaghypour
- Department of Cognitive Neuroscience, University of Tabriz, Tabriz, Iran
| | | | - Mohammad Ali Nazari
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Hemmat Exp.way, Tehran, Iran.
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Louthrenoo O, Boonchooduang N, Likhitweerawong N, Charoenkwan K, Srisurapanont M. The Effects of Neurofeedback on Executive Functioning in Children With ADHD: A Meta-Analysis. J Atten Disord 2022; 26:976-984. [PMID: 34697957 DOI: 10.1177/10870547211045738] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Possible beneficial effects of neurofeedback in improving ADHD functional outcomes have been increasingly reported. This meta-analysis aimed to evaluate the relationship between neurofeedback and executive functioning in children with ADHD. METHODS PubMed, EMBASE, EBSCO, Web of Science, and Cochrane databases were searched to identify studies reporting the effects of neurofeedback on executive functioning, including response inhibition, sustained attention, and working memory, assessed by neuropsychological tests. Only randomized controlled studies of children aged 5 to 18 years were included using a random-effects model. RESULTS Ten studies were included. The effects of neurofeedback were not found on three domains of executive functions. A meta-regression analysis revealed a trend of numbers of neurofeedback sessions positively associated with response inhibition (p = .06). CONCLUSION Results did not show the benefits of neurofeedback on executive functions assessed by neuropsychological tests. Future studies should focus on standard neurofeedback protocols, the intensity of intervention, and neuropsychological outcomes.
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Damanskyy Y, Olsen A, Hollup S. Prior Prognostic Expectations as a Potential Predictor in Neurofeedback Training. JOURNAL OF COGNITIVE ENHANCEMENT 2021. [DOI: 10.1007/s41465-021-00234-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
AbstractThe present study evaluated whether subjects’ expectations and neurofeedback training performance predict neurofeedback efficacy in cognitive training by controlling both factors as statistical variables. Twenty-two psychology students underwent neurofeedback training, employing beta/theta protocol to enhance beta1 power (13–21 Hz) and suppress theta (4–7 Hz) power. Neurofeedback efficacy was evaluated by behavioral components measured on pre-tests and post-tests employing a visual continuous performance task. The results revealed a significant interaction term between change in reaction time from pre-test to post-test and expectancy effect, indicating that participants with high prognostic expectations showed better improvement in reaction time scores. The data did not reveal that actual neurofeedback performance influenced the post-test measurements of the visual continuous performance task. No significant differences were found for reaction time variability, omission, or commission errors. Possible factors contributing to the results are discussed, and directions for future research are suggested.
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Effects of hemoencephalographic biofeedback with virtual reality on selected aspects of attention in children with ADHD. Int J Psychophysiol 2021; 170:59-66. [PMID: 34653532 DOI: 10.1016/j.ijpsycho.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 09/13/2021] [Accepted: 10/04/2021] [Indexed: 11/23/2022]
Abstract
For children with attention deficit/hyperactivity disorder (ADHD), a reduction of inattention by biofeedback has been shown in several studies. As evidenced by previous reports, biofeedback (BFB) with virtual reality (VR) allows for controlling distractors, providing an environment that captures participants' attention. The purpose of this study was to evaluate the effects of hemoencephalographic (HEG) BFB with VR in treating deficits in vigilance (assessed using the short form of the Mackworth Clock Task), visual search (the Visual Search Task), and divided attention (Multitasking Test) among children with ADHD. Data subjected to analysis were collected from 87 participants aged 9-15 years. Children were assigned to one of three groups (standard 2D BFB in the lab, VR BFB with a limited visual scene, VR BFB with a complex visual scene) and were subjected to ten HEG BFB sessions. Children in the VR BFB groups exhibited a bigger regional cerebral blood oxygenation slope during BFB and better performance in cognitive tests following the experiment compared to children in the 2D BFB group. The data obtained suggest that HEG BFB with VR may have a more beneficial effect in treating attention deficits compared to standard 2D HEG BFB. We believe that the strong effects of HEG BFB with VR stem from the increased commitment and motivation in individuals, rather than from manipulation with regard to visual scene complexity.
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Dashbozorgi Z, Ghaffari A, Karamali Esmaili S, Ashoori J, Moradi A, Sarvghadi P. Effect of Neurofeedback Training on Aggression and Impulsivity in Children With Attention-Deficit/Hyperactivity Disorder: A Double-Blinded Randomized Controlled Trial. Basic Clin Neurosci 2021; 12:693-702. [PMID: 35173923 PMCID: PMC8818111 DOI: 10.32598/bcn.2021.2363.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 12/28/2020] [Accepted: 01/06/2021] [Indexed: 01/14/2023] Open
Abstract
Introduction Aggression and impulsivity are some of the behavioral symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). Neurofeedback (NF) training has been suggested as a promising treatment in these children. This study aimed to investigate the effect of NF training on aggression and impulsivity in schoolchildren with ADHD. Methods A total of 40 male elementary school children with ADHD (aged 11.17±0.97 years) were randomized into the NF and sham groups. The NF group received 12 NF training sessions, each taking about 60 minutes for six consecutive weeks (twice a week), based on the Hammond protocol. The subjects' parents were questioned to evaluate the outcomes, including aggression and impulsivity, using the Buss-Perry Aggression Questionnaire (BPAQ) and Barratt Impulsiveness Scale (BIS). Results After the intervention, in the NF group, the BPAQ score changed from 87.60±9.33 to 81±7.23 and the BIS score from 94.7±7.25 to 88.05±5.4, which were significant (P=0.001). The results indicated the large effect size of NF on aggression and impulsivity in ADHD. Conclusion Our findings suggest NF training as a clinically applicable method for decreasing aggression and impulsivity, also support concurrent use of medication and NF training in children with ADHD.
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Affiliation(s)
- Zahra Dashbozorgi
- Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran
| | - Amin Ghaffari
- Department of Occupational Therapy, School of Rehabilitation Science, Iran University of Medical Sciences, Tehran, Iran
| | - Samaneh Karamali Esmaili
- Department of Occupational Therapy, School of Rehabilitation Science, Iran University of Medical Sciences, Tehran, Iran
| | - Jamal Ashoori
- Department of Psychology, Isfahan (Khorasgan) Branch, Islamic Azad University
| | - Ali Moradi
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Pooria Sarvghadi
- Department of Occupational Therapy, School of Rehabilitation Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Double-Blind Placebo-Controlled Randomized Clinical Trial of Neurofeedback for Attention-Deficit/Hyperactivity Disorder With 13-Month Follow-up. J Am Acad Child Adolesc Psychiatry 2021; 60:841-855. [PMID: 32853703 PMCID: PMC7904968 DOI: 10.1016/j.jaac.2020.07.906] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 07/01/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine whether theta/beta-ratio (TBR) electroencephalographic biofeedback (neurofeedback [NF]) has a specific effect on attention-deficit/hyperactivity disorder (ADHD) beyond nonspecific benefit. METHOD In a 2-site double-blind randomized clinical trial, 144 children aged 7 to 10 years with rigorously diagnosed moderate/severe ADHD and theta/beta-ratio (TBR) ≥4.5 were randomized 3:2 to deliberate TBR downtraining versus a control of equal duration, intensity, and appearance. Two early dropouts left 142 children for modified intent-to-treat analysis. The control used prerecorded electroencephalograms with the participant's artifacts superimposed. Treatment was programmed via Internet by an off-site statistician-guided co-investigator. Fidelity was 98.7% by trainers/therapists and 93.2% by NF expert monitor. The primary outcome was parent- and teacher-rated inattention; analysis was mixed-effects regression. Because the expense and effort of NF can be justified only by enduring benefit, follow-ups were integrated. RESULTS Blinding was excellent. Although both groups showed significant improvement (p < .001, d = 1.5) in parent/teacher-rated inattention from baseline to treatment end and 13-month follow-up, NF was not significantly superior to the control condition at either time point on this primary outcome (d = 0.01, p = .965 at treatment end; d = 0.23, p = .412 at 13-month follow-up). Responders (Clinical Global Impression-Improvement [CGI-I] = 1-2) were 61% of NF and 54% of controls (p = .36). Adverse events were distributed proportionally between treatments. The 13-month follow-up found nonsignificant improvement from treatment end for NF (d = 0.1), with mild deterioration for controls (d = -0.07). NF required significantly less medication at follow-up (p = .012). CONCLUSION This study does not support a specific effect of deliberate TBR NF at either treatment end or 13-month follow-up. Participants will be reassessed at 25-month follow-up. CLINICAL TRIAL REGISTRATION INFORMATION Double-Blind 2-Site Randomized Clinical Trial of Neurofeedback for ADHD; https://clinicaltrials.gov/; NCT02251743.
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Wexler BE, Vitulano LA, Moore C, Katsovich L, Smith SD, Rush C, Grantz H, Dong J, Leckman JF. An integrated program of computer-presented and physical cognitive training exercises for children with attention-deficit/hyperactivity disorder. Psychol Med 2021; 51:1524-1535. [PMID: 32090720 DOI: 10.1017/s0033291720000288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND This study integrated an experimental medicine approach and a randomized cross-over clinical trial design following CONSORT recommendations to evaluate a cognitive training (CT) intervention for attention deficit hyperactivity disorder (ADHD). The experimental medicine approach was adopted because of documented pathophysiological heterogeneity within the diagnosis of ADHD. The cross-over design was adopted to provide the intervention for all participants and make maximum use of data. METHODS Children (n = 93, mean age 7.3 +/- 1.1 years) with or sub-threshold for ADHD were randomly assigned to CT exercises over 15 weeks, before or after 15 weeks of treatment-as-usual (TAU). Fifteen dropped out of the CT/TAU group and 12 out of the TAU/CT group, leaving 66 for cross-over analysis. Seven in the CT/TAU group completed CT before dropping out making 73 available for experimental medicine analyses. Attention, response inhibition, and working memory were assessed before and after CT and TAU. RESULTS Children were more likely to improve with CT than TAU (27/66 v. 13/66, McNemar p = 0.02). Consistent with the experimental medicine hypotheses, responders improved on all tests of executive function (p = 0.009-0.01) while non-responders improved on none (p = 0.27-0.81). The degree of clinical improvement was predicted by baseline and change scores in focused attention and working memory (p = 0.008). The response rate was higher in inattentive and combined subtypes than hyperactive-impulsive subtype (p = 0.003). CONCLUSIONS Targeting cognitive dysfunction decreases clinical symptoms in proportion to improvement in cognition. Inattentive and combined subtypes were more likely to respond, consistent with targeted pathology and clinically relevant heterogeneity within ADHD.
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Affiliation(s)
- Bruce E Wexler
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Christina Moore
- Child Study Center, Yale School of Medicine, New Haven, CT, USA
- Department of Psychology, University of Delaware, Newark, DE, USA
| | | | - Stephanie D Smith
- Child Study Center, Yale School of Medicine, New Haven, CT, USA
- Department of Psychology, University of Southern Mississippi, Hattiesburg, MS, USA
| | - Cindy Rush
- Department of Statistics, Columbia University, New York, NY, USA
| | - Heidi Grantz
- Child Study Center, Yale School of Medicine, New Haven, CT, USA
| | | | - James F Leckman
- Child Study Center, Yale School of Medicine, New Haven, CT, USA
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Neurofeedback and Attention-Deficit/Hyperactivity-Disorder (ADHD) in Children: Rating the Evidence and Proposed Guidelines. Appl Psychophysiol Biofeedback 2021; 45:39-48. [PMID: 32206963 PMCID: PMC7250955 DOI: 10.1007/s10484-020-09455-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Stimulant medication and behaviour therapy are the most often applied and accepted treatments for Attention-Deficit/Hyperactivity-Disorder (ADHD). Here we explore where the non-pharmacological clinical intervention known as neurofeedback (NFB), fits on the continuum of empirically supported treatments, using standard protocols. In this quantitative review we utilized an updated and stricter version of the APA guidelines for rating ‘well-established’ treatments and focused on efficacy and effectiveness using effect-sizes (ES) and remission, with a focus on long-term effects. Efficacy and effectiveness are compared to medication and behaviour therapy using benchmark studies. Only recent systematic reviews and meta-analyses as well as multi-centre randomized controlled trials (RCT’s) will be included. Two meta-analyses confirmed significant efficacy of standard neurofeedback protocols for parent and teacher rated symptoms with a medium effect size, and sustained effects after 6–12 months. Four multicenter RCT’s demonstrated significant superiority to semi-active control groups, with medium-large effect sizes end of treatment or follow-up and remission rates of 32–47%. Effectiveness in open-label studies was confirmed, no signs of publication bias were found and no significant neurofeedback-specific side effects have been reported. Standard neurofeedback protocols in the treatment of ADHD can be concluded to be a well-established treatment with medium to large effect sizes and 32–47% remission rates and sustained effects as assessed after 6–12 months.
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Pigott HE, Cannon R, Trullinger M. The Fallacy of Sham-Controlled Neurofeedback Trials: A Reply to Thibault and Colleagues (2018). J Atten Disord 2021; 25:448-457. [PMID: 30078340 PMCID: PMC7783691 DOI: 10.1177/1087054718790802] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background: Sham-controlled neurofeedback (NFB) trials consistently find no separation on ADHD outcome measures leading many to conclude that NFB's beneficial effects are due to placebo. Method: We deconstruct the NFB training methodology and findings of six sham-controlled trials that assessed for evidence of learning. Results: All six studies found no evidence NFB subjects learned to self-modulate the targeted electroencephalogram (EEG). Careful analyses revealed these studies' training methodologies were antithetical to the established science of operant conditioning thereby preventing subjects from learning to self-modulate. These findings are in marked contrast to NFB studies whose methodology mirror the best practices of operant conditioning. Conclusion: The premise that NFB's beneficial effects are due to placebo phenomenon is unproven as these studies compared two forms of false-feedback, not operant conditioning of the EEG. Because these studies are highly cited and considered the gold standard in scientific rigor, a reappraisal of the evidence is urgently needed.
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Affiliation(s)
- H. Edmund Pigott
- NeuroThrive, LLC, Lutherville, MD, USA,Private Practice, Juno Beach, FL, USA,H. Edmund Pigott, Private Practice, 430 N. Lyra Circle, Juno Beach, FL 33408, USA.
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Riesco-Matías P, Yela-Bernabé JR, Crego A, Sánchez-Zaballos E. What Do Meta-Analyses Have to Say About the Efficacy of Neurofeedback Applied to Children With ADHD? Review of Previous Meta-Analyses and a New Meta-Analysis. J Atten Disord 2021; 25:473-485. [PMID: 30646779 DOI: 10.1177/1087054718821731] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: We reviewed previously published meta-analyses of neurofeedback applied to children with ADHD and conducted a new meta-analysis of randomized controlled trials (RCTs) that updates previous results and incorporates methodological modifications. Method: Searches were carried out through PubMed, Sage, PsycINFO, SpringerLink, and Psicodoc. We used Hedges' (adjusted) g and a random-effects model. To assess heterogeneity, Q and I2 were calculated. We performed different analyses depending on the control groups, ADHD symptoms, pre- and/or posttreament data used and symptom evaluator. Results: We reviewed seven meta-analyses, and 17 studies were incorporated into the meta-analysis. RCTs support the efficacy of neurofeedback applied to ADHD when most proximal evaluators assess symptoms. Neurofeedback significantly improves inattention symptoms when possibly blinded evaluators assess symptoms. The preliminary results suggest that stimulant medication is more effective than neurofeedback. Conclusion: New RCTs that establish links between ADHD symptom measurements, subjects' learning after neurofeedback, and neurophysiological measures could improve the quality of the conclusions.
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Thibault RT, Veissière S, Olson JA, Raz A. EEG-Neurofeedback and the Correction of Misleading Information: A Reply to Pigott and Colleagues. J Atten Disord 2021; 25:458-459. [PMID: 30378452 DOI: 10.1177/1087054718808379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - Amir Raz
- Chapman University, Irvine, CA, USA
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Konicar L, Radev S, Prillinger K, Klöbl M, Diehm R, Birbaumer N, Lanzenberger R, Plener PL, Poustka L. Volitional modification of brain activity in adolescents with Autism Spectrum Disorder: A Bayesian analysis of Slow Cortical Potential neurofeedback. Neuroimage Clin 2021; 29:102557. [PMID: 33486138 PMCID: PMC7829342 DOI: 10.1016/j.nicl.2021.102557] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/18/2020] [Accepted: 01/02/2021] [Indexed: 11/29/2022]
Abstract
Autism spectrum disorder is (ASD) characterized by a persisting triad of impairments of social interaction, language as well as inflexible, stereotyped and ritualistic behaviors. Increasingly, scientific evidence suggests a neurobiological basis of these emotional, social and cognitive deficits in individuals with ASD. The aim of this randomized controlled brain self-regulation intervention study was to investigate whether the core symptomatology of ASD could be reduced via an electroencephalography (EEG) based brain self-regulation training of Slow Cortical Potentials (SCP). 41 male adolescents with ASD were recruited and allocated to a) an experimental group undergoing 24 sessions of EEG-based brain training (n1 = 21), or to b) an active control group undergoing conventional treatment (n2 = 20), that is, clinical counseling during a 3-months intervention period. We employed real-time neurofeedback training recorded from a fronto-central electrode intended to enable participants to volitionally regulate their brain activity. Core autistic symptomatology was measured at six time points during the intervention and analyzed with Bayesian multilevel approach to characterize changes in core symptomatology. Additional Bayesian models were formulated to describe the neural dynamics of the training process as indexed by SCP (time-domain) and power density (PSD, frequency-domain) measures. The analysis revealed a substantial improvement in the core symptomatology of ASD in the experimental group (reduction of 21.38 points on the Social Responsiveness Scale, SD = 5.29), which was slightly superior to that observed in the control group (evidence Ratio = 5.79). Changes in SCP manifested themselves as different trajectories depending on the different feedback conditions and tasks. Further, the model of PSD revealed a continuous decrease in delta power, parallel to an increase in alpha power. Most notably, a non-linear (quadratic) model turned out to be better at predicting the data than a linear model across all analyses. Taken together, our analyses suggest that behavioral and neural processes of change related to neurofeedback training are complex and non-linear. Moreover, they have implications for the design of future trials and training protocols.
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Affiliation(s)
- L Konicar
- Department of Child and Adolescence Psychiatry, Medical University of Vienna, Vienna, Austria.
| | - S Radev
- Department of Child and Adolescence Psychiatry, Medical University of Vienna, Vienna, Austria; Institute of Psychology, University of Heidelberg, Germany
| | - K Prillinger
- Department of Child and Adolescence Psychiatry, Medical University of Vienna, Vienna, Austria
| | - M Klöbl
- Neuroimaging Labs, Department of Psychiatry & Psychotherapy, Medical University of Vienna, Austria
| | - R Diehm
- Department of Child and Adolescence Psychiatry, Medical University of Vienna, Vienna, Austria
| | - N Birbaumer
- Wyss Center for Bio and Neuroengineering, Geneva, Switzerland
| | - R Lanzenberger
- Neuroimaging Labs, Department of Psychiatry & Psychotherapy, Medical University of Vienna, Austria
| | - P L Plener
- Department of Child and Adolescence Psychiatry, Medical University of Vienna, Vienna, Austria
| | - L Poustka
- Department of Child and Adolescence Psychiatry, Medical University of Göttingen, Göttingen, Germany
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Skalski S. Impact of placebo-related instruction on HEG biofeedback outcomes in children with ADHD. APPLIED NEUROPSYCHOLOGY-CHILD 2020; 11:383-390. [PMID: 33349043 DOI: 10.1080/21622965.2020.1861546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Studies to date have not revealed any differences between biofeedback (BFB) methods vs. placebo treatment in reducing ADHD symptoms. The purpose of this randomized controlled study was to assess the impact of placebo expectations on gain in hemoencephalographic (HEG) BFB. The final cohort consisted of 33 children with ADHD aged 9-14. Individuals were assigned to one of two groups (with standard active training instruction vs. placebo-related instruction) and were subjected to five HEG BFB sessions. Children with standard instruction exhibited higher growth of regional cerebral blood oxygenation during the HEG BFB session as well as better results in cognitive tests (vigilance and visual search) at the end of the experiment compared to children with placebo-related instruction. The data obtained indicate the difficulty in designing studies assessing BFB efficacy. Placebo expectation may adversely affect HEG BFB outcomes in children with ADHD.
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18
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Gevensleben H, Schmiedeke D, Heinrich H, Rothenberger A. Yes, I can - maybe … Effects of placebo-related instructions on neuroregulation in children with ADHD. J Neural Transm (Vienna) 2020; 127:1093-1096. [PMID: 32390102 PMCID: PMC7293682 DOI: 10.1007/s00702-020-02193-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 04/15/2020] [Indexed: 10/26/2022]
Abstract
Neurofeedback training (NFT) provides strategies for children with ADHD to achieve changes on the neurophysiological and behavioral level to attenuate ADHD symptoms. We assume self-efficacy (an "active attitude"), a core variable in successful NFT. In a randomized, double-blind controlled study, we investigated the impact of a "placebo instruction" on the EEG-regulation performance during two sessions of Theta-Beta-NFT in children with ADHD (age 8-12 years). Children receiving the information "this might be a placebo-training" showed inferior neuroregulation (n = 10) compared to children receiving a standard instruction (n = 12). Results of our pilot study are discussed in view of factors necessary for a valid training (ensuring maximal self-efficacy in the participants) and the fidelity of placebo-controlled trials in NFT-research.
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Affiliation(s)
- Holger Gevensleben
- Clinic for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Str. 5, D37075, Goettingen, Germany.
| | - David Schmiedeke
- Clinic for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Str. 5, D37075, Goettingen, Germany
| | - Hartmut Heinrich
- NeuroCare Group, Munich, Germany.,Research Institute Brainclinics, Nijmegen, The Netherlands.,kbo-Heckscher-Klinikum, Munich, Germany.,Department of Child and Adolescent Mental Health, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Aribert Rothenberger
- Clinic for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, von-Siebold-Str. 5, D37075, Goettingen, Germany
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19
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Van Doren J, Arns M, Heinrich H, Vollebregt MA, Strehl U, K Loo S. Sustained effects of neurofeedback in ADHD: a systematic review and meta-analysis. Eur Child Adolesc Psychiatry 2019; 28:293-305. [PMID: 29445867 PMCID: PMC6404655 DOI: 10.1007/s00787-018-1121-4] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/05/2018] [Indexed: 12/11/2022]
Abstract
Neurofeedback (NF) has gained increasing interest in the treatment of attention-deficit/hyperactivity disorder (ADHD). Given learning principles underlie NF, lasting clinical treatment effects may be expected. This systematic review and meta-analysis addresses the sustainability of neurofeedback and control treatment effects by considering randomized controlled studies that conducted follow-up (FU; 2-12 months) assessments among children with ADHD. PubMed and Scopus databases were searched through November 2017. Within-group and between-group standardized mean differences (SMD) of parent behavior ratings were calculated and analyzed. Ten studies met inclusion criteria (NF: ten studies, N = 256; control: nine studies, N = 250). Within-group NF effects on inattention were of medium effect size (ES) (SMD = 0.64) at post-treatment and increased to a large ES (SMD = 0.80) at FU. Regarding hyperactivity/impulsivity, NF ES were medium at post-treatment (SMD = 0.50) and FU (SMD = 0.61). Non-active control conditions yielded a small significant ES on inattention at post-treatment (SMD = 0.28) but no significant ES at FU. Active treatments (mainly methylphenidate), had large ES for inattention (post: SMD = 1.08; FU: SMD = 1.06) and medium ES for hyperactivity/impulsivity (post: SMD = 0.74; FU: SMD = 0.67). Between-group analyses also revealed an advantage of NF over non-active controls [inattention (post: SMD = 0.38; FU: SMD = 0.57); hyperactivity-impulsivity (post: SMD = 0.25; FU: SMD = 0.39)], and favored active controls for inattention only at pre-post (SMD = - 0.44). Compared to non-active control treatments, NF appears to have more durable treatment effects, for at least 6 months following treatment. More studies are needed for a properly powered comparison of follow-up effects between NF and active treatments and to further control for non-specific effects.
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Affiliation(s)
- Jessica Van Doren
- Department of Child and Adolescent Mental Health, University Hospital Erlangen, Erlangen, Germany
| | - Martijn Arns
- Department of Experimental Psychology, Utrecht University, Utrecht, The Netherlands.
- neuroCare Group, Munich, Germany.
- Research Institute Brainclinics, Bijleveldsingel 34, 6524 AD, Nijmegen, The Netherlands.
| | - Hartmut Heinrich
- Department of Child and Adolescent Mental Health, University Hospital Erlangen, Erlangen, Germany
- kbo-Heckscher-Klinikum, Munich, Germany
| | - Madelon A Vollebregt
- Research Institute Brainclinics, Bijleveldsingel 34, 6524 AD, Nijmegen, The Netherlands
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ute Strehl
- Institute for Medical Psychology, University of Tuebingen, Tuebingen, Germany
| | - Sandra K Loo
- Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine, University of California, Los Angeles, USA
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20
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Abstract
PURPOSE OF REVIEW Current traditional treatments for ADHD present serious limitations in terms of long-term maintenance of symptom remission and side effects. Here, we provide an overview of the rationale and scientific evidence of the efficacy of neurofeedback in regulating the brain functions in ADHD. We also review the institutional and professional regulation of clinical neurofeedback implementations. RECENT FINDINGS Based on meta-analyses and (large multicenter) randomized controlled trials, three standard neurofeedback training protocols, namely theta/beta (TBR), sensori-motor rhythm (SMR), and slow cortical potential (SCP), turn out to be efficacious and specific. However, the practical implementation of neurofeedback as a clinical treatment is currently not regulated. We conclude that neurofeedback based on standard protocols in ADHD should be considered as a viable treatment alternative and suggest that further research is needed to understand how specific neurofeedback protocols work. Eventually, we emphasize the need for standard neurofeedback training for practitioners and binding standards for use in clinical practice.
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Affiliation(s)
- Stefanie Enriquez-Geppert
- Department of Clinical and Developmental Neuropsychology, Faculty of Behavioural and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS, Groningen, The Netherlands.
- Department of Biomedical Sciences of Cells & Systems, Section of Cognitive Neuropsychiatry, University of Groningen, Groningen, The Netherlands.
| | - Diede Smit
- Department of Clinical and Developmental Neuropsychology, Faculty of Behavioural and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS, Groningen, The Netherlands
| | - Miguel Garcia Pimenta
- Department of Clinical and Developmental Neuropsychology, Faculty of Behavioural and Social Sciences, University of Groningen, Grote Kruisstraat 2/1, 9712 TS, Groningen, The Netherlands
| | - Martijn Arns
- Department of Experimental Psychology, Utrecht University, Utrecht, The Netherlands
- neuroCare Group, Munich, Germany
- Research Institute Brainclinics, Nijmegen, The Netherlands
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21
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Bussalb A, Congedo M, Barthélemy Q, Ojeda D, Acquaviva E, Delorme R, Mayaud L. Clinical and Experimental Factors Influencing the Efficacy of Neurofeedback in ADHD: A Meta-Analysis. Front Psychiatry 2019; 10:35. [PMID: 30833909 PMCID: PMC6388544 DOI: 10.3389/fpsyt.2019.00035] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/21/2019] [Indexed: 11/13/2022] Open
Abstract
Meta-analyses have been extensively used to evaluate the efficacy of neurofeedback (NFB) treatment for Attention Deficit/Hyperactivity Disorder (ADHD) in children and adolescents. However, each meta-analysis published in the past decade has contradicted the methods and results from the previous one, thus making it difficult to determine a consensus of opinion on the effectiveness of NFB. This works brings continuity to the field by extending and discussing the last and much controversial meta-analysis by Cortese et al. (1). The extension comprises an update of that work including the latest control trials, which have since been published and, most importantly, offers a novel methodology. Specifically, NFB literature is characterized by a high technical and methodological heterogeneity, which partly explains the current lack of consensus on the efficacy of NFB. This work takes advantage of this by performing a Systematic Analysis of Biases (SAOB) in studies included in the previous meta-analysis. Our extended meta-analysis (k = 16 studies) confirmed the previously obtained results of effect sizes in favor of NFB efficacy as being significant when clinical scales of ADHD are rated by parents (non-blind, p-value = 0.0014), but not when they are rated by teachers (probably blind, p-value = 0.27). The effect size is significant according to both raters for the subset of studies meeting the definition of "standard NFB protocols" (parents' p-value = 0.0054; teachers' p-value = 0.043, k = 4). Following this, the SAOB performed on k = 33 trials identified three main factors that have an impact on NFB efficacy: first, a more intensive treatment, but not treatment duration, is associated with higher efficacy; second, teachers report a lower improvement compared to parents; third, using high-quality EEG equipment improves the effectiveness of the NFB treatment. The identification of biases relating to an appropriate technical implementation of NFB certainly supports the efficacy of NFB as an intervention. The data presented also suggest that the probably blind assessment of teachers may not be considered a good proxy for blind assessments, therefore stressing the need for studies with placebo-controlled intervention as well as carefully reported neuromarker changes in relation to clinical response.
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Affiliation(s)
- Aurore Bussalb
- Mensia Technologies SA, Paris, France.,Child and Adolescent Psychiatry Department, Robert Debré Hospital, Paris, France
| | - Marco Congedo
- GIPSA-Lab, Université Grenoble Alpes, CNRS, Grenoble-INP, Grenoble, France
| | | | | | - Eric Acquaviva
- Child and Adolescent Psychiatry Department, Robert Debré Hospital, Paris, France
| | - Richard Delorme
- Child and Adolescent Psychiatry Department, Robert Debré Hospital, Paris, France
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22
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Dhindsa K, Gauder KD, Marszalek KA, Terpou B, Becker S. Progressive Thresholding: Shaping and Specificity in Automated Neurofeedback Training. IEEE Trans Neural Syst Rehabil Eng 2018; 26:2297-2305. [DOI: 10.1109/tnsre.2018.2878328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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23
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Thibault RT, Veissière S, Olson JA, Raz A. Treating ADHD With Suggestion: Neurofeedback and Placebo Therapeutics. J Atten Disord 2018; 22:707-711. [PMID: 29717910 DOI: 10.1177/1087054718770012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We propose that clinicians can use suggestion to help treat conditions such as ADHD. METHODS We use EEG neurofeedback as a case study, alongside evidence from a recent pilot experiment utilizing a sham MRI scanner to highlight the therapeutic potential of suggestion-based treatments. RESULTS The medical literature demonstrates that many practitioners already prescribe treatments that hardly outperform placebo comparators. Moreover, the sham MRI experiment showed that, even with full disclosure of the procedure, suggestion alone can reduce the symptomatology of ADHD. CONCLUSION Non-deceptive suggestion-based treatments, especially those drawing on accessories from neuroscience, may offer a safe complement and potential alternative to current standard of care for individuals with ADHD.
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Affiliation(s)
- Robert T Thibault
- 1 McGill University, Montreal, Québec, Canada.,2 Chapman University, Irvine, CA, USA
| | | | - Jay A Olson
- 1 McGill University, Montreal, Québec, Canada
| | - Amir Raz
- 1 McGill University, Montreal, Québec, Canada.,2 Chapman University, Irvine, CA, USA
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24
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Schönenberg M, Wiedemann E, Schneidt A, Scheeff J, Logemann A, Keune PM, Hautzinger M. Confusion regarding operant conditioning of the EEG - Authors' reply. Lancet Psychiatry 2017; 4:897-898. [PMID: 29179925 DOI: 10.1016/s2215-0366(17)30437-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Michael Schönenberg
- University of Tübingen, Department of Clinical Psychology and Psychotherapy, Tübingen, 72076, Germany.
| | - Eva Wiedemann
- University of Tübingen, Department of Clinical Psychology and Psychotherapy, Tübingen, 72076, Germany
| | - Alexander Schneidt
- University of Tübingen, Department of Clinical Psychology and Psychotherapy, Tübingen, 72076, Germany
| | - Jonathan Scheeff
- University of Tübingen, Department of Clinical Psychology and Psychotherapy, Tübingen, 72076, Germany
| | | | - Philipp M Keune
- University of Bamberg, Department of Physiological Psychology, Bamberg, Germany; Klinikum Bayreuth, Department of Neurology, Bayreuth, Germany
| | - Martin Hautzinger
- University of Tübingen, Department of Clinical Psychology and Psychotherapy, Tübingen, 72076, Germany
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25
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Schönenberg M, Wiedemann E, Schneidt A, Scheeff J, Logemann A, Keune PM, Hautzinger M. Neurofeedback, sham neurofeedback, and cognitive-behavioural group therapy in adults with attention-deficit hyperactivity disorder: a triple-blind, randomised, controlled trial. Lancet Psychiatry 2017; 4:673-684. [PMID: 28803030 DOI: 10.1016/s2215-0366(17)30291-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/23/2017] [Accepted: 06/26/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many studies suggest that electroencephalographic (EEG) neurofeedback might be beneficial in the treatment of attention-deficit hyperactivity disorder (ADHD). However, numbers of well controlled studies are low and neurofeedback techniques are regarded as highly controversial. The present trial examined the efficacy (compared with sham neurofeedback) and efficiency (compared with meta-cognitive therapy) of a standard EEG neurofeedback protocol in adults with ADHD. METHODS We did a concurrent, triple-blind, randomised, controlled trial using authorised deception in adults with ADHD from one centre (University of Tübingen) in Tübingen, Germany. Participants were eligible if they fulfilled the DSM-IV-TR criteria for ADHD, were aged between 18 years and 60 years, and had no or stable use of medication for at least 2 months with no intention to change. We excluded participants who had comorbid schizophrenia or schizoaffective disorder, bipolar disorder, borderline personality disorder, epilepsy, or traumatic brain injury; substance abuse or dependence; or current or planned other psychological treatment. Those eligible were randomly assigned to three groups: a neurofeedback group which received 30 verum θ-to-β neurofeedback sessions over 15 weeks, a sham neurofeedback group which received 15 sham followed by 15 verum θ-to-β neurofeedback sessions over 15 weeks, or a meta-cognitive group therapy group which received 12 sessions over 12 weeks. Participants were assigned equally to one of the three interventions through a computerised minimisation randomisation procedure stratified by sex, age, and baseline symptom severity of ADHD. Participants were masked as to whether they were receiving neurofeedback or sham neurofeedback, but those receiving meta-cognitive therapy were aware of their treatment. Clinical assessors (ie, those assessing outcomes) and research staff who did the neurofeedback training were masked to participants' randomisation status only for neurofeedback and sham neurofeedback. The primary outcome was symptom score on the Conners' adult ADHD rating scale, assessed before treatment, at midtreatment (after 8 weeks), after treatment (after 16 weeks), and 6 months later. All individuals with at least one observation after randomisation were included in the analyses. This trial is registered with ClinicalTrials.gov, number NCT01883765. FINDINGS Between Feb 1, 2013, and Dec 1, 2015, 761 people were assessed for eligibility. 656 (86%) were excluded and 118 (15%) were eligible for participation in this study. Eligible participants were randomly assigned to neurofeedback (38 [32%]), sham neurofeedback (39 [33%]), or meta-cognitive therapy (41 [35%]). 37 (97%) individuals for neurofeedback, 38 (97%) for sham neurofeedback, and 38 (93%) for meta-cognitive therapy were included in analyses. Self-reported ADHD symptoms decreased substantially for all treatment groups (B=-2·58 [95% CI -3·48 to -1·68]; p<0·0001) between pretreatment and the end of 6 month follow-up, independent of treatment condition (neurofeedback vs sham neurofeedback B=-0·89 [95% CI -2·14 to 0·37], p=0·168; neurofeedback vs meta-cognitive therapy -0·30 [-1·55 to 0·95], p=0·639). No treatment-related or trial-related serious adverse events were reported. INTERPRETATION Our findings suggest that neurofeedback training is not superior to a sham condition or group psychotherapy. All three treatments were equivalently effective in reducing ADHD symptoms. This first randomised, sham-controlled trial did not show any specific effects of neurofeedback on ADHD symptoms in adults. FUNDING German Research Foundation.
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Affiliation(s)
- Michael Schönenberg
- Department of Clinical Psychology and Psychotherapy, University of Tübingen, Tübingen, Germany.
| | - Eva Wiedemann
- Department of Clinical Psychology and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Alexander Schneidt
- Department of Clinical Psychology and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Jonathan Scheeff
- Department of Clinical Psychology and Psychotherapy, University of Tübingen, Tübingen, Germany
| | | | - Philipp M Keune
- Department of Physiological Psychology, University of Bamberg, Bamberg, Germany; Department of Neurology, Klinikum Bayreuth, Bayreuth, Germany
| | - Martin Hautzinger
- Department of Clinical Psychology and Psychotherapy, University of Tübingen, Tübingen, Germany
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26
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Arns M. A NExT Step for neurofeedback in France. Encephale 2017; 43:97-98. [DOI: 10.1016/j.encep.2017.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 10/10/2016] [Indexed: 11/27/2022]
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27
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Schabus M, Griessenberger H, Gnjezda MT, Heib DPJ, Wislowska M, Hoedlmoser K. Better than sham? A double-blind placebo-controlled neurofeedback study in primary insomnia. Brain 2017; 140:1041-1052. [PMID: 28335000 PMCID: PMC5382955 DOI: 10.1093/brain/awx011] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 12/01/2016] [Accepted: 12/06/2016] [Indexed: 12/16/2022] Open
Abstract
See Thibault et al. (doi:10.1093/awx033) for a scientific commentary on this article.Neurofeedback training builds upon the simple concept of instrumental conditioning, i.e. behaviour that is rewarded is more likely to reoccur, an effect Thorndike referred to as the 'law of effect'. In the case of neurofeedback, information about specific electroencephalographic activity is fed back to the participant who is rewarded whenever the desired electroencephalography pattern is generated. If some kind of hyperarousal needs to be addressed, the neurofeedback community considers sensorimotor rhythm neurofeedback as the gold standard. Earlier treatment approaches using sensorimotor-rhythm neurofeedback indicated that training to increase 12-15 Hz sensorimotor rhythm over the sensorimotor cortex during wakefulness could reduce attention-deficit/hyperactivity disorder and epilepsy symptoms and even improve sleep quality by enhancing sleep spindle activity (lying in the same frequency range). In the present study we sought to critically test whether earlier findings on the positive effect of sensorimotor rhythm neurofeedback on sleep quality and memory could also be replicated in a double-blind placebo-controlled study on 25 patients with insomnia. Patients spent nine polysomnography nights and 12 sessions of neurofeedback and 12 sessions of placebo-feedback training (sham) in our laboratory. Crucially, we found both neurofeedback and placebo feedback to be equally effective as reflected in subjective measures of sleep complaints suggesting that the observed improvements were due to unspecific factors such as experiencing trust and receiving care and empathy from experimenters. In addition, these improvements were not reflected in objective electroencephalographic-derived measures of sleep quality. Furthermore, objective electroencephalographic measures that potentially reflected mechanisms underlying the efficacy of neurofeedback such as spectral electroencephalographic measures and sleep spindle parameters remained unchanged following 12 training sessions. A stratification into 'true' insomnia patients and 'insomnia misperceivers' (subjective, but no objective sleep problems) did not alter the results. Based on this comprehensive and well-controlled study, we conclude that for the treatment of primary insomnia, neurofeedback does not have a specific efficacy beyond unspecific placebo effects. Importantly, we do not find an advantage of neurofeedback over placebo feedback, therefore it cannot be recommended as an alternative to cognitive behavioural therapy for insomnia, the current (non-pharmacological) standard-of-care treatment. In addition, our study may foster a critical discussion that generally questions the effectiveness of neurofeedback, and emphasizes the importance of demonstrating neurofeedback efficacy in other study samples and disorders using truly placebo and double-blind controlled trials.
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Affiliation(s)
- Manuel Schabus
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, University of Salzburg, Austria
- Centre for Cognitive Neuroscience Salzburg (CCNS), University of Salzburg, Austria
| | - Hermann Griessenberger
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, University of Salzburg, Austria
| | - Maria-Teresa Gnjezda
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, University of Salzburg, Austria
| | - Dominik P. J. Heib
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, University of Salzburg, Austria
- Centre for Cognitive Neuroscience Salzburg (CCNS), University of Salzburg, Austria
| | - Malgorzata Wislowska
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, University of Salzburg, Austria
- Centre for Cognitive Neuroscience Salzburg (CCNS), University of Salzburg, Austria
| | - Kerstin Hoedlmoser
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, University of Salzburg, Austria
- Centre for Cognitive Neuroscience Salzburg (CCNS), University of Salzburg, Austria
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28
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Hollis C, Falconer CJ, Martin JL, Whittington C, Stockton S, Glazebrook C, Davies EB. Annual Research Review: Digital health interventions for children and young people with mental health problems - a systematic and meta-review. J Child Psychol Psychiatry 2017; 58:474-503. [PMID: 27943285 DOI: 10.1111/jcpp.12663] [Citation(s) in RCA: 380] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Digital health interventions (DHIs), including computer-assisted therapy, smartphone apps and wearable technologies, are heralded as having enormous potential to improve uptake and accessibility, efficiency, clinical effectiveness and personalisation of mental health interventions. It is generally assumed that DHIs will be preferred by children and young people (CYP) given their ubiquitous digital activity. However, it remains uncertain whether: DHIs for CYP are clinically and cost-effective, CYP prefer DHIs to traditional services, DHIs widen access and how they should be evaluated and adopted by mental health services. This review evaluates the evidence-base for DHIs and considers the key research questions and approaches to evaluation and implementation. METHODS We conducted a meta-review of scoping, narrative, systematic or meta-analytical reviews investigating the effectiveness of DHIs for mental health problems in CYP. We also updated a systematic review of randomised controlled trials (RCTs) of DHIs for CYP published in the last 3 years. RESULTS Twenty-one reviews were included in the meta-review. The findings provide some support for the clinical benefit of DHIs, particularly computerised cognitive behavioural therapy (cCBT), for depression and anxiety in adolescents and young adults. The systematic review identified 30 new RCTs evaluating DHIs for attention deficit/hyperactivity disorder (ADHD), autism, anxiety, depression, psychosis, eating disorders and PTSD. The benefits of DHIs in managing ADHD, autism, psychosis and eating disorders are uncertain, and evidence is lacking regarding the cost-effectiveness of DHIs. CONCLUSIONS Key methodological limitations make it difficult to draw definitive conclusions from existing clinical trials of DHIs. Issues include variable uptake and engagement with DHIs, lack of an agreed typology/taxonomy for DHIs, small sample sizes, lack of blinded outcome assessment, combining different comparators, short-term follow-up and poor specification of the level of human support. Research and practice recommendations are presented that address the key research questions and methodological issues for the evaluation and clinical implementation of DHIs for CYP.
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Affiliation(s)
- Chris Hollis
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR MindTech Healthcare Technology Co-operative, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Caroline J Falconer
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR MindTech Healthcare Technology Co-operative, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Jennifer L Martin
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR MindTech Healthcare Technology Co-operative, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | | | - Sarah Stockton
- Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Cris Glazebrook
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR MindTech Healthcare Technology Co-operative, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - E Bethan Davies
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR MindTech Healthcare Technology Co-operative, Institute of Mental Health, University of Nottingham, Nottingham, UK
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Strehl U, Aggensteiner P, Wachtlin D, Brandeis D, Albrecht B, Arana M, Bach C, Banaschewski T, Bogen T, Flaig-Röhr A, Freitag CM, Fuchsenberger Y, Gest S, Gevensleben H, Herde L, Hohmann S, Legenbauer T, Marx AM, Millenet S, Pniewski B, Rothenberger A, Ruckes C, Wörz S, Holtmann M. Neurofeedback of Slow Cortical Potentials in Children with Attention-Deficit/Hyperactivity Disorder: A Multicenter Randomized Trial Controlling for Unspecific Effects. Front Hum Neurosci 2017; 11:135. [PMID: 28408873 PMCID: PMC5374218 DOI: 10.3389/fnhum.2017.00135] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 03/08/2017] [Indexed: 11/13/2022] Open
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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Affiliation(s)
- Ute Strehl
- Institute for Medical Psychology and Behavioral Neurobiology, University of TübingenTübingen, Germany
| | - Pascal Aggensteiner
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of HeidelbergMannheim, Germany
| | - Daniel Wachtlin
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of HeidelbergMannheim, Germany.,Interdisciplinary Center for Clinical Trials at the University Medical Center of the Johannes Gutenberg University of MainzMainz, Germany
| | - Daniel Brandeis
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of HeidelbergMannheim, Germany.,Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric Hospital, University of ZurichZurich, Switzerland.,Center for Integrative Human Physiology, University of ZurichZurich, Switzerland.,Neuroscience Center Zurich, University of Zurich and ETH ZurichZurich, Switzerland
| | - Björn Albrecht
- Child and Adolescent Psychiatry, University Medical Center GöttingenGöttingen, Germany
| | - Maria Arana
- Institute for Medical Psychology and Behavioral Neurobiology, University of TübingenTübingen, Germany
| | - Christiane Bach
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of HeidelbergMannheim, Germany.,Department of Psychosomatic Medicine and Psychotherapy, University Hospital LeipzigLeipzig, Germany
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of HeidelbergMannheim, Germany
| | - Thorsten Bogen
- Landschaftsverband Westfalen-Lippe (LWL) University Hospital Hamm for Child and Adolescent Psychiatry, Ruhr-University BochumHamm, Germany
| | - Andrea Flaig-Röhr
- Child and Adolescent Psychiatry, University Medical Center GöttingenGöttingen, Germany
| | - Christine M Freitag
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Goethe UniversityFrankfurt am Main, Germany
| | - Yvonne Fuchsenberger
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Goethe UniversityFrankfurt am Main, Germany
| | - Stephanie Gest
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Goethe UniversityFrankfurt am Main, Germany
| | - Holger Gevensleben
- Child and Adolescent Psychiatry, University Medical Center GöttingenGöttingen, Germany
| | - Laura Herde
- Institute for Medical Psychology and Behavioral Neurobiology, University of TübingenTübingen, Germany
| | - Sarah Hohmann
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of HeidelbergMannheim, Germany
| | - Tanja Legenbauer
- Landschaftsverband Westfalen-Lippe (LWL) University Hospital Hamm for Child and Adolescent Psychiatry, Ruhr-University BochumHamm, Germany
| | - Anna-Maria Marx
- Institute for Medical Psychology and Behavioral Neurobiology, University of TübingenTübingen, Germany
| | - Sabina Millenet
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of HeidelbergMannheim, Germany
| | - Benjamin Pniewski
- Landschaftsverband Westfalen-Lippe (LWL) University Hospital Hamm for Child and Adolescent Psychiatry, Ruhr-University BochumHamm, Germany
| | - Aribert Rothenberger
- Child and Adolescent Psychiatry, University Medical Center GöttingenGöttingen, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Trials at the University Medical Center of the Johannes Gutenberg University of MainzMainz, Germany
| | - Sonja Wörz
- Institute for Medical Psychology and Behavioral Neurobiology, University of TübingenTübingen, Germany
| | - Martin Holtmann
- Landschaftsverband Westfalen-Lippe (LWL) University Hospital Hamm for Child and Adolescent Psychiatry, Ruhr-University BochumHamm, Germany
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Zilverstand A, Sorger B, Slaats-Willemse D, Kan CC, Goebel R, Buitelaar JK. fMRI Neurofeedback Training for Increasing Anterior Cingulate Cortex Activation in Adult Attention Deficit Hyperactivity Disorder. An Exploratory Randomized, Single-Blinded Study. PLoS One 2017; 12:e0170795. [PMID: 28125735 PMCID: PMC5270326 DOI: 10.1371/journal.pone.0170795] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 01/10/2017] [Indexed: 11/19/2022] Open
Abstract
Attention Deficit Hyperactivity Disorder (ADHD) is characterized by poor cognitive control/attention and hypofunctioning of the dorsal anterior cingulate cortex (dACC). In the current study, we investigated for the first time whether real-time fMRI neurofeedback (rt-fMRI) training targeted at increasing activation levels within dACC in adults with ADHD leads to a reduction of clinical symptoms and improved cognitive functioning. An exploratory randomized controlled treatment study with blinding of the participants was conducted. Participants with ADHD (n = 7 in the neurofeedback group, and n = 6 in the control group) attended four weekly MRI training sessions (60-min training time/session), during which they performed a mental calculation task at varying levels of difficulty, in order to learn how to up-regulate dACC activation. Only neurofeedback participants received continuous feedback information on actual brain activation levels within dACC. Before and after the training, ADHD symptoms and relevant cognitive functioning was assessed. Results showed that both groups achieved a significant increase in dACC activation levels over sessions. While there was no significant difference between the neurofeedback and control group in clinical outcome, neurofeedback participants showed stronger improvement on cognitive functioning. The current study demonstrates the general feasibility of the suggested rt-fMRI neurofeedback training approach as a potential novel treatment option for ADHD patients. Due to the study’s small sample size, potential clinical benefits need to be further investigated in future studies. Trial Registration: ISRCTN12390961
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Affiliation(s)
- Anna Zilverstand
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- * E-mail:
| | - Bettina Sorger
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Dorine Slaats-Willemse
- Karakter University Centre for Child and Adolescent Psychiatry, Nijmegen, The Netherlands
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Cornelis C. Kan
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rainer Goebel
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neuroimaging and Neuromodeling, Netherlands Institute for Neuroscience, Amsterdam, The Netherlands
| | - Jan K. Buitelaar
- Karakter University Centre for Child and Adolescent Psychiatry, Nijmegen, The Netherlands
- Department of Psychiatry, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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31
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Janssen TWP, Bink M, Weeda WD, Geladé K, van Mourik R, Maras A, Oosterlaan J. Learning curves of theta/beta neurofeedback in children with ADHD. Eur Child Adolesc Psychiatry 2017; 26:573-582. [PMID: 27866283 PMCID: PMC5394134 DOI: 10.1007/s00787-016-0920-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 11/15/2016] [Indexed: 11/30/2022]
Abstract
UNLABELLED Neurofeedback is widely applied as non-pharmacological intervention aimed at reducing symptoms of ADHD, even though efficacy has not been unequivocally established. Neuronal changes during the neurofeedback intervention that resemble learning can provide crucial evidence for the feasibility and specificity of this intervention. A total of 38 children (aged between 7 and 13 years) with a DSM-IV-TR diagnosis of ADHD, completed on average 29 sessions of theta (4-8 Hz)/beta (13-20 Hz) neurofeedback training. Dependent variables included training-related measures as well as theta and beta power during baseline and training runs for each session. Learning effects were analyzed both within and between sessions. To further specify findings, individual learning curves were explored and correlated with behavioral changes in ADHD symptoms. Over the course of the training, there was a linear increase in participants' mean training level, highest obtained training level and the number of earned credits (range b = 0.059, -0.750, p < 0.001). Theta remained unchanged over the course of the training, while beta activity increased linearly within training sessions (b = 0.004, 95% CI = [0.0013-0.0067], p = 0.005) and over the course of the intervention (b = 0.0052, 95% CI = [0.0039-0.0065], p < 0.001). In contrast to the group analyses, significant individual learning curves were found for both theta and beta over the course of the intervention in 39 and 53%, respectively. Individual learning curves were not significantly correlated with behavioral changes. This study shows that children with ADHD can gain control over EEG states during neurofeedback, although a lack of behavioral correlates may indicate insufficient transfer to daily functioning, or to confounding reinforcement of electromyographic activity. CLINICAL TRIALS REGISTRATION This trial is registered at the US National Institutes of Health (ClinicalTrials.gov, ref. no: NCT01363544); https://clinicaltrials.gov/show/NCT01363544 .
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Affiliation(s)
- Tieme W P Janssen
- Clinical Neuropsychology Section, Vrije Universiteit, Van Der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands.
| | - Marleen Bink
- Clinical Neuropsychology Section, Vrije Universiteit, Van Der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
| | - Wouter D Weeda
- Department of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands
| | - Katleen Geladé
- Clinical Neuropsychology Section, Vrije Universiteit, Van Der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
| | - Rosa van Mourik
- Royal Dutch Kentalis, Vlampijpstraat 78, 3534 AR, Utrecht, The Netherlands
| | - Athanasios Maras
- Yulius Academy, Dennenhout 1, 2994 GC, Barendracht, The Netherlands
| | - Jaap Oosterlaan
- Clinical Neuropsychology Section, Vrije Universiteit, Van Der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
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Sitaram R, Ros T, Stoeckel L, Haller S, Scharnowski F, Lewis-Peacock J, Weiskopf N, Blefari ML, Rana M, Oblak E, Birbaumer N, Sulzer J. Closed-loop brain training: the science of neurofeedback. Nat Rev Neurosci 2016; 18:86-100. [PMID: 28003656 DOI: 10.1038/nrn.2016.164] [Citation(s) in RCA: 519] [Impact Index Per Article: 64.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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34
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Neurofeedback ineffective in paediatric brain tumour survivors: Results of a double-blind randomised placebo-controlled trial. Eur J Cancer 2016; 64:62-73. [DOI: 10.1016/j.ejca.2016.04.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 03/23/2016] [Accepted: 04/24/2016] [Indexed: 11/20/2022]
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Cortese S, Ferrin M, Brandeis D, Holtmann M, Aggensteiner P, Daley D, Santosh P, Simonoff E, Stevenson J, Stringaris A, Sonuga-Barke EJS, Banaschewski T, Brandeis D, Buitelaar J, Coghill D, Cortese S, Daley D, Danckaerts M, Dittmann RW, Döpfner M, Ferrin M, Hollis C, Holtmann M, Konofal E, Lecendreux M, Rothenberger A, Santosh P, Sergeant JA, Simonoff E, Sonuga-Barke EJ, Soutullo C, Steinhausen H, Stevenson J, Stringaris A, Taylor E, van der Oord S, Wong I, Zuddas A. Neurofeedback for Attention-Deficit/Hyperactivity Disorder: Meta-Analysis of Clinical and Neuropsychological Outcomes From Randomized Controlled Trials. J Am Acad Child Adolesc Psychiatry 2016; 55:444-55. [PMID: 27238063 DOI: 10.1016/j.jaac.2016.03.007] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/24/2016] [Accepted: 03/28/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We performed meta-analyses of randomized controlled trials to examine the effects of neurofeedback on attention-deficit/hyperactivity disorder (ADHD) symptoms and neuropsychological deficits in children and adolescents with ADHD. METHOD We searched PubMed, Ovid, Web of Science, ERIC, and CINAHAL through August 30, 2015. Random-effects models were employed. Studies were evaluated with the Cochrane Risk of Bias tool. RESULTS We included 13 trials (520 participants with ADHD). Significant effects were found on ADHD symptoms rated by assessors most proximal to the treatment setting, that is, the least blinded outcome measure (standardized mean difference [SMD]: ADHD total symptoms = 0.35, 95% CI = 0.11-0.59; inattention = 0.36, 95% CI = 0.09-0.63; hyperactivity/impulsivity = 0.26, 95% CI = 0.08-0.43). Effects were not significant when probably blinded ratings were the outcome or in trials with active/sham controls. Results were similar when only frequency band training trials, the most common neurofeedback approach, were analyzed separately. Effects on laboratory measures of inhibition (SMD = 0.30, 95% CI = -0.10 to 0.70) and attention (SMD = 0.13, 95% CI = -0.09 to 0.36) were not significant. Only 4 studies directly assessed whether learning occurred after neurofeedback training. The risk of bias was unclear for many Cochrane Risk of Bias domains in most studies. CONCLUSION Evidence from well-controlled trials with probably blinded outcomes currently fails to support neurofeedback as an effective treatment for ADHD. Future efforts should focus on implementing standard neurofeedback protocols, ensuring learning, and optimizing clinically relevant transfer.
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Affiliation(s)
- Samuele Cortese
- Academic Unit of Psychology, Developmental Brain-Behaviour Laboratory, University of Southampton, Southampton, UK; New York University Child Study Center, New York, and Solent NHS Trust, UK
| | - Maite Ferrin
- Academic Unit of Psychology, Developmental Brain-Behaviour Laboratory, University of Southampton, Southampton, UK; Huntercombe Hospital Maidenhead, Maidenhead, UK
| | - Daniel Brandeis
- Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Psychiatric Hospital, University of Zurich, the Integrative Human Physiology and the Neuroscience Center Zurich, University of Zurich, Switzerland, and ETH Zurich
| | - Martin Holtmann
- LWL-University Hospital for Child and Adolescent Psychiatry, Ruhr University Bochum, Germany
| | - Pascal Aggensteiner
- Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - David Daley
- School of Medicine and MindTech Institute of Mental Health, University of Nottingham, UK
| | - Paramala Santosh
- Institute of Psychiatry, Psychology and Neurosciences, King's College London, and the Maudsley Hospital, London, UK
| | - Emily Simonoff
- Institute of Psychiatry, Psychology and Neurosciences, King's College London, and the Maudsley Hospital, London, UK
| | - Jim Stevenson
- Academic Unit of Psychology, Developmental Brain-Behaviour Laboratory, University of Southampton, Southampton, UK
| | - Argyris Stringaris
- Institute of Psychiatry, Psychology and Neurosciences, King's College London, and the Maudsley Hospital, London, UK
| | - Edmund J S Sonuga-Barke
- Academic Unit of Psychology, Developmental Brain-Behaviour Laboratory, University of Southampton, Southampton, UK; Ghent University, Ghent, Belgium and Aarhus University, Aarhus, Denmark.
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Janssen TWP, Bink M, Geladé K, van Mourik R, Maras A, Oosterlaan J. A Randomized Controlled Trial Investigating the Effects of Neurofeedback, Methylphenidate, and Physical Activity on Event-Related Potentials in Children with Attention-Deficit/Hyperactivity Disorder. J Child Adolesc Psychopharmacol 2016; 26:344-53. [PMID: 26771913 DOI: 10.1089/cap.2015.0144] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Electroencephalographic (EEG) neurofeedback (NF) is considered a nonpharmacological alternative for medication in attention-deficit/hyperactivity disorder (ADHD). Comparisons of the behavioral efficacy of NF and medication have produced inconsistent results. EEG measures can provide insight into treatment mechanisms, but have received little consideration. In this randomized controlled trial (RCT), effects of NF were compared with methylphenidate (MPH), and physical activity (PA) in children with ADHD on event-related potential (ERP) indices of response inhibition, which are involved in ADHD psychopathology. METHODS Using a multicenter three way parallel group RCT design, 112 children with a Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) (American Psychiatric Association 1994 ) diagnosis of ADHD, between 7 and 13 years of age, were initially included. NF training consisted of 30 sessions of theta/beta training at Cz over a 10 week period. PA training was a semiactive control group, matched in frequency and duration. MPH was titrated using a double-blind placebo controlled procedure in 6 weeks, followed by a stable dose for 4 weeks. ERP measures of response inhibition, N2 and P3, were available for 81 children at pre- and postintervention (n = 32 NF, n = 25 MPH, n = 24 PA). RESULTS Only the medication group showed a specific increase in P3 amplitude compared with NF (partial eta-squared [ηp(2) ] = 0.121) and PA (ηp(2) = 0.283), which was related to improved response inhibition. Source localization of medication effects on P3 amplitude indicated increased activation primarily in thalamic and striatal nuclei. CONCLUSIONS This is the first study that simultaneously compared NF with stimulant treatment and a semiactive control group. Only stimulant treatment demonstrated specific improvements in brain function related to response inhibition. These results are in line with recent doubts on the efficacy and specificity of NF as treatment for ADHD. CLINICAL TRIALS REGISTRATION Train Your Brain? Exercise and Neurofeedback Intervention for ADHD, https://clinicaltrials.gov/show/NCT01363544 , Ref. No. NCT01363544.
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Affiliation(s)
| | - Marleen Bink
- 1 Department of Clinical Neuropsychology, VU University Amsterdam , Amsterdam, the Netherlands
| | | | | | | | - Jaap Oosterlaan
- 1 Department of Clinical Neuropsychology, VU University Amsterdam , Amsterdam, the Netherlands
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Shin MS, Jeon H, Kim M, Hwang T, Oh SJ, Hwangbo M, Kim KJ. Effects of Smart-Tablet-Based Neurofeedback Training on Cognitive Function in Children with Attention Problems. J Child Neurol 2016; 31:750-60. [PMID: 26681772 DOI: 10.1177/0883073815620677] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 11/10/2015] [Indexed: 11/16/2022]
Abstract
We sought to determine whether smart-tablet-based neurofeedback could improve executive function-including attention, working memory, and self-regulation-in children with attention problems. Forty children (10-12 years old) with attention problems, as determined by ratings on the Conners Parent Rating Scale, were assigned to either a neurofeedback group that received 16 sessions or a control group. A comprehensive test battery that assessed general intelligence, visual and auditory attention, attentional shifting, response inhibition and behavior rating scales were administered to both groups before neurofeedback training. Several neuropsychological tests were conducted at posttraining and follow-up assessment. Scores on several neuropsychological tests and parent behavior rating scales showed significant improvement in the training group but not in the controls. The improvements remained through the follow-up assessment. This study suggests that the smart-tablet-based neurofeedback training program might improve cognitive function in children with attention problems.
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Affiliation(s)
- Min-Sup Shin
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Hyejin Jeon
- Department of Child and Adolescent Psychiatry, Seoul National University Children's Hospital, Seoul, Korea
| | - Miyoung Kim
- DMC R&D Center, Samsung Electronics, Suwon, Korea
| | - Taeho Hwang
- DMC R&D Center, Samsung Electronics, Suwon, Korea
| | - Seo Jin Oh
- Department of Psychiatry, Seoul National University Hospital, Seoul, Korea
| | | | - Ki Joong Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Bink M, Bongers IL, Popma A, Janssen TWP, van Nieuwenhuizen C. 1-year follow-up of neurofeedback treatment in adolescents with attention-deficit hyperactivity disorder: randomised controlled trial. BJPsych Open 2016; 2:107-115. [PMID: 27703763 PMCID: PMC4995578 DOI: 10.1192/bjpo.bp.115.000166] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 10/31/2015] [Accepted: 01/11/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Estimates of the effectiveness of neurofeedback as a treatment for attention-deficit hyperactivity disorder (ADHD) are mixed. AIMS To investigate the long-term additional effects of neurofeedback (NFB) compared with treatment as usual (TAU) for adolescents with ADHD. METHOD Using a multicentre parallel-randomised controlled trial design, 60 adolescents with a DSM-IV-TR diagnosis of ADHD receiving NFB+TAU (n=41) or TAU (n=19) were followed up. Neurofeedback treatment consisted of approximately 37 sessions of theta/sensorimotor rhythm (SMR)-training on the vertex (Cz). Outcome measures included behavioural self-reports and neurocognitive measures. Allocation to the conditions was unmasked. RESULTS At 1-year follow-up, inattention as reported by adolescents was decreased (range ηp2=0.23-0.36, P<0.01) and performance on neurocognitive tasks was faster (range ηp2=0.20-0.67, P<0.005) irrespective of treatment group. CONCLUSIONS Overall, NFB+TAU was as effective as TAU. Given the absence of robust additional effects of neurofeedback in the current study, results do not support the use of theta/SMR neurofeedback as a treatment for adolescents with ADHD and comorbid disorders in clinical practice. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Marleen Bink
- , PhD, Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam; Scientific Center for Care & Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands
| | - Ilja L Bongers
- , PhD, GGzECenter for Child and Adolescent Psychiatry, Eindhoven; Scientific Center for Care & Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands
| | - Arne Popma
- , MD, PhD, Academic Department of Child & Adolescent Psychiatry, VUmc/De Bascule, Duivendrecht, The Netherlands
| | - Tieme W P Janssen
- , MSc, Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Chijs van Nieuwenhuizen
- , PhD, Scientific Center for Care & Welfare (Tranzo), Tilburg University, Tilburg; GGzECenter for Child and Adolescent Psychiatry, Eindhoven, The Netherlands
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39
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Thibault RT, Lifshitz M, Raz A. The self-regulating brain and neurofeedback: Experimental science and clinical promise. Cortex 2016; 74:247-61. [PMID: 26706052 DOI: 10.1016/j.cortex.2015.10.024] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/22/2015] [Accepted: 10/29/2015] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - Amir Raz
- McGill University, Montreal, QC, Canada; The Lady Davis Institute for Medical Research, Montreal, QC, Canada.
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40
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Vollebregt MA, van Dongen-Boomsma M, Slaats-Willemse D, Buitelaar JK, Oostenveld R. How the Individual Alpha Peak Frequency Helps Unravel the Neurophysiologic Underpinnings of Behavioral Functioning in Children With Attention-Deficit/Hyperactivity Disorder. Clin EEG Neurosci 2015; 46:285-91. [PMID: 25392007 DOI: 10.1177/1550059414537257] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 04/30/2014] [Indexed: 11/16/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) has been associated with an elevated resting-state theta/beta power ratio and elevated theta power. However, the potential confounding effect of a low individual alpha peak frequency (IAPF) on the theta-power estimate has often been disregarded when studying the relationship between ADHD and the theta/beta power ratio or theta power alone. The aim of the present study was to assess whether the theta/beta power ratio and relative theta power are correlated with behavioral functioning in children with ADHD, as expected from previous studies. Subsequently, the influence of IAPF and the amount of supposed overlap between the individually determined alpha-band and the fixed theta-band were studied. For 38 children (aged 8-15 years), electroencephalographic (EEG) and investigator-scored ADHD Rating Scale IV data were available. Additional neurocognitive data were available for 32 children. As expected, the theta/beta power ratio and theta were positively related to the ADHD core symptoms. This relationship strengthened when controlling for IAPF, although correlations did not significantly differ from one another. Eight of 38 children (21%) showed a supposed overlap between their individually determined alpha band and the theta band. Neurocognitive performance did not show any relationship with the theta/beta power ratio or theta. The results of this study confirm that the theta/beta power ratio and theta power are indeed correlated with behavioral symptoms in children with ADHD and underscore the relevance of taking the IAPF into account.
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Affiliation(s)
- Madelon A Vollebregt
- Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, Netherlands Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Cognitive Neuroscience, Nijmegen, Netherlands Donders Institute for Brain, Cognition and Behaviour, Centre for Cognitive Neuroimaging, Nijmegen, Netherlands
| | - Martine van Dongen-Boomsma
- Radboud University Medical Centre, Department of Psychiatry, Nijmegen, Netherlands Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, Netherlands Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Cognitive Neuroscience, Nijmegen, Netherlands
| | - Dorine Slaats-Willemse
- Radboud University Medical Centre, Department of Psychiatry, Nijmegen, Netherlands Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, Netherlands Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Cognitive Neuroscience, Nijmegen, Netherlands
| | - Jan K Buitelaar
- Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, Netherlands Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Cognitive Neuroscience, Nijmegen, Netherlands Donders Institute for Brain, Cognition and Behaviour, Centre for Cognitive Neuroimaging, Nijmegen, Netherlands
| | - Robert Oostenveld
- Donders Institute for Brain, Cognition and Behaviour, Centre for Cognitive Neuroimaging, Nijmegen, Netherlands
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41
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Bink M, van Nieuwenhuizen C, Popma A, Bongers IL, van Boxtel GJM. Behavioral effects of neurofeedback in adolescents with ADHD: a randomized controlled trial. Eur Child Adolesc Psychiatry 2015; 24:1035-48. [PMID: 25477074 DOI: 10.1007/s00787-014-0655-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 11/22/2014] [Indexed: 11/28/2022]
Abstract
Neurofeedback has been proposed as a potentially effective intervention for reducing Attention Deficit Hyperactivity Disorder (ADHD) symptoms. However, it remains unclear whether neurofeedback is of additional value to treatment as usual (TAU) for adolescents with clinical ADHD symptoms. Using a multicenter parallel-randomized controlled trial design, adolescents with ADHD symptoms were randomized to receive either a combination of TAU and neurofeedback (NFB + TAU, n = 45) or TAU-only (n = 26). Randomization was computer generated and stratified for age group (ages 12 through 16, 16 through 20, 20 through 24). Neurofeedback treatment consisted of approximately 37 sessions of theta/sensorimotor rhythm (SMR)-training on the vertex (Cz). Primary behavioral outcome measures included the ADHD-rating scale, Youth Self Report, and Child Behavior Checklist all assessed pre- and post-intervention. Behavioral problems decreased equally for both groups with medium to large effect sizes, range of partial η2 = 0.08-0.31, p < 0.05. Hence, the combination of NFB + TAU was not more effective than TAU-only on the behavioral outcome measures. In addition, reported adverse effects were similar for both groups. On behavioral outcome measures, the combination of neurofeedback and TAU was as effective as TAU-only for adolescents with ADHD symptoms. Considering the absence of additional behavioral effects in the current study, in combination with the limited knowledge of specific treatment effects, it is questionable whether theta/SMR neurofeedback for adolescents with ADHD and comorbid disorders in clinical practice should be used. Further research is warranted to investigate possible working mechanisms and (long-term) specific treatment effects of neurofeedback.
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Affiliation(s)
- Marleen Bink
- Scientific Center for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands,
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42
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Quaedflieg CWEM, Smulders FTY, Meyer T, Peeters F, Merckelbach H, Smeets T. The validity of individual frontal alpha asymmetry EEG neurofeedback. Soc Cogn Affect Neurosci 2015; 11:33-43. [PMID: 26163671 DOI: 10.1093/scan/nsv090] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 07/07/2015] [Indexed: 12/31/2022] Open
Abstract
Frontal asymmetry in alpha oscillations is assumed to be associated with psychopathology and individual differences in emotional responding. Brain-activity-based feedback is a promising tool for the modulation of cortical activity. Here, we validated a neurofeedback protocol designed to change relative frontal asymmetry based on individual alpha peak frequencies, including real-time average referencing and eye-correction. Participants (N = 60) were randomly assigned to a right, left or placebo neurofeedback group. Results show a difference in trainability between groups, with a linear change in frontal alpha asymmetry over time for the right neurofeedback group during rest. Moreover, the asymmetry changes in the right group were frequency and location specific, even though trainability did not persist at 1 week and 1 month follow-ups. On the behavioral level, subjective stress on the second test day was reduced in the left and placebo neurofeedback groups, but not in the right neurofeedback group. We found individual differences in trainability that were dependent on training group, with participants in the right neurofeedback group being more likely to change their frontal asymmetry in the desired direction. Individual differences in trainability were also reflected in the ability to change frontal asymmetry during the feedback.
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Affiliation(s)
- C W E M Quaedflieg
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands,
| | - F T Y Smulders
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - T Meyer
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands, Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands, and
| | - F Peeters
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - H Merckelbach
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - T Smeets
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
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43
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Zuberer A, Brandeis D, Drechsler R. Are treatment effects of neurofeedback training in children with ADHD related to the successful regulation of brain activity? A review on the learning of regulation of brain activity and a contribution to the discussion on specificity. Front Hum Neurosci 2015; 9:135. [PMID: 25870550 PMCID: PMC4376076 DOI: 10.3389/fnhum.2015.00135] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 02/27/2015] [Indexed: 11/17/2022] Open
Abstract
While issues of efficacy and specificity are crucial for the future of neurofeedback training, there may be alternative designs and control analyses to circumvent the methodological and ethical problems associated with double-blind placebo studies. Surprisingly, most NF studies do not report the most immediate result of their NF training, i.e., whether or not children with ADHD gain control over their brain activity during the training sessions. For the investigation of specificity, however, it seems essential to analyze the learning and adaptation processes that take place in the course of the training and to relate improvements in self-regulated brain activity across training sessions to behavioral, neuropsychological and electrophysiological outcomes. To this aim, a review of studies on neurofeedback training with ADHD patients which include the analysis of learning across training sessions or relate training performance to outcome is presented. Methods on how to evaluate and quantify learning of EEG regulation over time are discussed. “Non-learning” has been reported in a small number of ADHD-studies, but has not been a focus of general methodological discussion so far. For this reason, selected results from the brain-computer interface (BCI) research on the so-called “brain-computer illiteracy”, the inability to gain control over one’s brain activity, are also included. It is concluded that in the discussion on specificity, more attention should be devoted to the analysis of EEG regulation performance in the course of the training and its impact on clinical outcome. It is necessary to improve the knowledge on characteristic cross-session and within-session learning trajectories in ADHD and to provide the best conditions for learning.
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Affiliation(s)
- Agnieszka Zuberer
- Department of Child and Adolescent Psychiatry, University of Zurich Zurich, Switzerland
| | - Daniel Brandeis
- Department of Child and Adolescent Psychiatry, University of Zurich Zurich, Switzerland ; Neuroscience Center Zurich, University of Zurich and ETH Zurich Zurich, Switzerland ; Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/ Heidelberg University Mannheim, Germany ; Center for Integrative Human Physiology, University of Zurich Zurich, Switzerland
| | - Renate Drechsler
- Department of Child and Adolescent Psychiatry, University of Zurich Zurich, Switzerland
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Okazaki YO, Horschig JM, Luther L, Oostenveld R, Murakami I, Jensen O. Real-time MEG neurofeedback training of posterior alpha activity modulates subsequent visual detection performance. Neuroimage 2014; 107:323-332. [PMID: 25514519 DOI: 10.1016/j.neuroimage.2014.12.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 11/04/2014] [Accepted: 12/05/2014] [Indexed: 11/15/2022] Open
Abstract
It has been demonstrated that alpha activity is lateralized when attention is directed to the left or right visual hemifield. We investigated whether real-time neurofeedback training of the alpha lateralization enhances participants' ability to modulate posterior alpha lateralization and causes subsequent short-term changes in visual detection performance. The experiment consisted of three phases: (i) pre-training assessment, (ii) neurofeedback phase and (iii) post-training assessment. In the pre- and post-training phases we measured the threshold to covertly detect a cued faint Gabor stimulus presented in the left or right hemifield. During magnetoencephalography (MEG) neurofeedback, two face stimuli superimposed with noise were presented bilaterally. Participants were cued to attend to one of the hemifields. The transparency of the superimposed noise and thus the visibility of the stimuli were varied according to the momentary degree of hemispheric alpha lateralization. In a double-blind procedure half of the participants were provided with sham feedback. We found that hemispheric alpha lateralization increased with the neurofeedback training; this was mainly driven by an ipsilateral alpha increase. Surprisingly, comparing pre- to post-training, detection performance decreased for a Gabor stimulus presented in the hemifield that was un-attended during neurofeedback. This effect was not observed in the sham group. Thus, neurofeedback training alters alpha lateralization, which in turn decreases performances in the untrained hemifield. Our findings suggest that alpha oscillations play a causal role for the allocation of attention. Furthermore, our neurofeedback protocol serves to reduce the detection of unattended visual information and could therefore be of potential use for training to reduce distractibility in attention deficit patients, but also highlights that neurofeedback paradigms can have negative impact on behavioral performance and should be applied with caution.
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Affiliation(s)
- Yuka O Okazaki
- Department of Life Sciences, University of Tokyo, Tokyo 153-8902, Japan; Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6500HB Nijmegen, the Netherlands.
| | - Jörn M Horschig
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6500HB Nijmegen, the Netherlands.
| | - Lisa Luther
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6500HB Nijmegen, the Netherlands; Behavioural Science Institute, Radboud University, 6525HR Nijmegen, the Netherlands
| | - Robert Oostenveld
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6500HB Nijmegen, the Netherlands
| | - Ikuya Murakami
- Department of Life Sciences, University of Tokyo, Tokyo 153-8902, Japan; Department of Psychology, University of Tokyo, Tokyo 113-0033, Japan.
| | - Ole Jensen
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6500HB Nijmegen, the Netherlands.
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Gevensleben H, Albrecht B, Lütcke H, Auer T, Dewiputri WI, Schweizer R, Moll G, Heinrich H, Rothenberger A. Neurofeedback of slow cortical potentials: neural mechanisms and feasibility of a placebo-controlled design in healthy adults. Front Hum Neurosci 2014; 8:990. [PMID: 25566020 PMCID: PMC4263073 DOI: 10.3389/fnhum.2014.00990] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 11/20/2014] [Indexed: 11/13/2022] Open
Abstract
To elucidate basic mechanisms underlying neurofeedback we investigated neural mechanisms of training of slow cortical potentials (SCPs) by considering EEG- and fMRI. Additionally, we analyzed the feasibility of a double-blind, placebo-controlled design in NF research based on regulation performance during treatment sessions and self-assessment of the participants. Twenty healthy adults participated in 16 sessions of SCPs training: 9 participants received regular SCP training, 11 participants received sham feedback. At three time points (pre, intermediate, post) fMRI and EEG/ERP-measurements were conducted during a continuous performance test (CPT). Performance-data during the sessions (regulation performance) in the treatment group and the placebo group were analyzed. Analysis of EEG-activity revealed in the SCP group a strong enhancement of the CNV (electrode Cz) at the intermediate assessment, followed by a decrease back to baseline at the post-treatment assessment. In contrast, in the placebo group a continuous but smaller increase of the CNV could be obtained from pre to post assessment. The increase of the CNV in the SCP group at intermediate testing was superior to the enhancement in the placebo group. The changes of the CNV were accompanied by a continuous improvement in the test performance of the CPT from pre to intermediate to post assessment comparable in both groups. The change of the CNV in the SCP group is interpreted as an indicator of neural plasticity and efficiency while an increase of the CNV in the placebo group might reflect learning and improved timing due to the frequent task repetition. In the fMRI analysis evidence was obtained for neuronal plasticity. After regular SCP neurofeedback activation in the posterior parietal cortex decreased from the pre- to the intermediate measurement and increased again in the post measurement, inversely following the U-shaped increase and decrease of the tCNV EEG amplitude in the SCP-trained group. Furthermore, we found a localized increase of activity in the anterior cingulate cortex (ACC). Analyses of the estimation of treatment assignment by the participants indicate feasibility of blinding. Participants could not assess treatment assignment confidently. Participants of the SCP-group improved regulation capability during treatment sessions (in contrast to the participants of the placebo-group), although regulation capability appeared to be instable, presumably due to diminished confidence in the training (SCP- or sham-training). Our results indicate that SCP training in healthy adults might lead to functional changes in neuronal circuits serving cognitive preparation even after a limited number of sessions.
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Affiliation(s)
- Holger Gevensleben
- Child and Adolescent Psychiatry, University Medical Center (UMG) Göttingen, Germany
| | - Björn Albrecht
- Child and Adolescent Psychiatry, University Medical Center (UMG) Göttingen, Germany
| | - Henry Lütcke
- Biomedizinische NMR Forschungs GmbH, MPI for Biophysical Chemistry Göttingen, Germany ; Scientific IT Services, ETH Zürich Zürich, Switzerland
| | - Tibor Auer
- Biomedizinische NMR Forschungs GmbH, MPI for Biophysical Chemistry Göttingen, Germany ; 3MRC Cognition and Brain Sciences Unit, University Cambridge Cambridge, UK
| | - Wan Ilma Dewiputri
- Biomedizinische NMR Forschungs GmbH, MPI for Biophysical Chemistry Göttingen, Germany ; Department of Neuroscience, School of Medical Sciences, Universiti Sains Malaysia Pulau Pinang, Malaysia
| | - Renate Schweizer
- Biomedizinische NMR Forschungs GmbH, MPI for Biophysical Chemistry Göttingen, Germany
| | - Gunther Moll
- Department of Child and Adolescent Mental Health, University Hospital of Erlangen Erlangen, Germany
| | - Hartmut Heinrich
- Department of Child and Adolescent Mental Health, University Hospital of Erlangen Erlangen, Germany ; kbo-Heckscher-Klinikum Munich, Germany
| | - Aribert Rothenberger
- Child and Adolescent Psychiatry, University Medical Center (UMG) Göttingen, Germany
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Micoulaud-Franchi JA, Geoffroy PA, Fond G, Lopez R, Bioulac S, Philip P. EEG neurofeedback treatments in children with ADHD: an updated meta-analysis of randomized controlled trials. Front Hum Neurosci 2014; 8:906. [PMID: 25431555 PMCID: PMC4230047 DOI: 10.3389/fnhum.2014.00906] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 10/23/2014] [Indexed: 11/21/2022] Open
Abstract
Objective: We undertook a meta-analysis of published Randomized Controlled Trials (RCT) with semi-active control and sham-NF groups to determine whether Electroencephalogram-neurofeedback (EEG-NF) significantly improves the overall symptoms, inattention and hyperactivity/impulsivity dimensions for probably unblinded assessment (parent assessment) and probably blinded assessment (teacher assessment) in children with Attention Deficit Hyperactivity Disorder (ADHD). Data sources: A systematic review identified independent studies that were eligible for inclusion in a random effects meta-analysis. Data extraction: Effect sizes for ADHD symptoms were expressed as standardized mean differences (SMD) with 95% confidence intervals. Results: Five identified studies met eligibility criteria, 263 patients with ADHD were included, 146 patients were trained with EEG-NF. On parent assessment (probably unblinded assessment), the overall ADHD score (SMD = −0.49 [−0.74, −0.24]), the inattention score (SMD = −0.46 [−0.76, −0.15]) and the hyperactivity/impulsivity score (SMD = −0.34 [−0.59, −0.09]) were significantly improved in patients receiving EEG-NF compared to controls. On teacher assessment (probably blinded assessment), only the inattention score was significantly improved in patients receiving EEG-NF compared to controls (SMD = −0.30 [−0.58, −0.03]). Conclusions: This meta-analysis of EEG-NF in children with ADHD highlights improvement in the inattention dimension of ADHD symptoms. Future investigations should pay greater attention to adequately blinded studies and EEG-NF protocols that carefully control the implementation and embedding of training.
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Affiliation(s)
- Jean-Arthur Micoulaud-Franchi
- Solaris, Unité de Neurophysiologie, Pôle de Psychiatrie Universitaire, Hôpital Sainte-Marguerite Marseille, France ; Institut de Neurosciences Cognitives de la Méditerranée, INCM-CNRS UMR 6193 Marseille, France
| | - Pierre Alexis Geoffroy
- Inserm, UMR-S 1144 Paris, France ; AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences Paris, France ; UMR-S 1144, Université Paris Descartes and Université Paris Diderot Paris, France ; Fondation FondaMental Créteil, France
| | - Guillaume Fond
- Fondation FondaMental Créteil, France ; Université Paris Est-Créteil, Pôle de Psychiatrie du Groupe des Hôpitaux Universitaires de Mondor, DHU Pe-psy, INSERM U955, Eq Psychiatrie Génétique, Réseau des Centres Experts Schizophrénie de France Créteil, France
| | - Régis Lopez
- Centre de Référence National Narcolepsie-hypersomnie Idiopathique, Unité des Troubles du Sommeil, CHU Gui de Chauliac Montpellier, France ; NSERM U1061 Montpellier, France
| | - Stéphanie Bioulac
- Centre Hospitalier Charles Perrens, Pôle Universitaire de Psychiatrie de l'Enfant et de l'Adolescent Bordeaux, France ; USR CNRS 3413 SANPSY, Clinique du Sommeil, CHU Pellegrin, Université de Bordeaux Bordeaux, France
| | - Pierre Philip
- USR CNRS 3413 SANPSY, Clinique du Sommeil, CHU Pellegrin, Université de Bordeaux Bordeaux, France
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Modulation of Posterior Alpha Activity by Spatial Attention Allows for Controlling A Continuous Brain-Computer Interface. Brain Topogr 2014; 28:852-64. [PMID: 25388661 DOI: 10.1007/s10548-014-0401-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
Here we report that the modulation of alpha activity by covert attention can be used as a control signal in an online brain-computer interface, that it is reliable, and that it is robust. Subjects were instructed to orient covert visual attention to the left or right hemifield. We decoded the direction of attention from the magnetoencephalogram by a template matching classifier and provided the classification outcome to the subject in real-time using a novel graphical user interface. Training data for the templates were obtained from a Posner-cueing task conducted just before the BCI task. Eleven subjects participated in four sessions each. Eight of the subjects achieved classification rates significantly above chance level. Subjects were able to significantly increase their performance from the first to the second session. Individual patterns of posterior alpha power remained stable throughout the four sessions and did not change with increased performance. We conclude that posterior alpha power can successfully be used as a control signal in brain-computer interfaces. We also discuss several ideas for further improving the setup and propose future research based on solid hypotheses about behavioral consequences of modulating neuronal oscillations by brain computer interfacing.
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48
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Gevensleben H, Moll GH, Rothenberger A, Heinrich H. Neurofeedback in attention-deficit/hyperactivity disorder - different models, different ways of application. Front Hum Neurosci 2014; 8:846. [PMID: 25374528 PMCID: PMC4204462 DOI: 10.3389/fnhum.2014.00846] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 10/02/2014] [Indexed: 11/22/2022] Open
Abstract
In children with attention-deficit/hyperactivity disorder (ADHD), different neurofeedback (NF) protocols have been applied, with the most prominent differentiation between EEG frequency-band (e.g., theta/beta) training and training of slow cortical potentials (SCPs). However, beyond distinctions between such basic NF variables, there are also competing assumptions about mechanisms of action (e.g., acquisition of regulation capability, generalization to daily life behavior). In the present article, we provide a framework for NF models and suppose two hypothetical models, which we call “conditioning-and-repairing model” and “skill-acquisition model,” reflecting extreme poles within this framework. We argue that the underlying model has an impact not only on how NF is applied but also on the selection of evaluation strategies and suggest using evaluation strategies beyond beaten paths of pharmacological research. Reflecting available studies, we address to what extent different views are supported by empirical data. We hypothesize that different models may hold true depending on the processes and behaviors to be addressed by a certain NF protocol. For example, the skill-acquisition model is supported by recent findings as an adequate explanatory framework for the mechanisms of action of SCP training in ADHD. In conclusion, evaluation and interpretation of NF trials in ADHD should be based on the underlying model and the way training is applied, which, in turn, should be stated explicitly in study reports.
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Affiliation(s)
- Holger Gevensleben
- Child and Adolescent Psychiatry, University Medical Center Göttingen Göttingen, Germany
| | - Gunther H Moll
- Department of Child and Adolescent Mental Health, University Hospital of Erlangen Erlangen, Germany
| | - Aribert Rothenberger
- Child and Adolescent Psychiatry, University Medical Center Göttingen Göttingen, Germany
| | - Hartmut Heinrich
- Department of Child and Adolescent Mental Health, University Hospital of Erlangen Erlangen, Germany ; Heckscher-Klinikum München, Germany
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49
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Holtmann M, Sonuga-Barke E, Cortese S, Brandeis D. Neurofeedback for ADHD: a review of current evidence. Child Adolesc Psychiatr Clin N Am 2014; 23:789-806. [PMID: 25220087 DOI: 10.1016/j.chc.2014.05.006] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Considerable scientific effort has been directed at developing effective treatments for attention-deficit/hyperactivity disorder (ADHD). Among alternative treatment approaches, neurofeedback has gained some promising empirical support in recent years from controlled studies as a treatment of core ADHD symptoms. However, a recent stringent meta-analysis of 8 randomized controlled trials published in 2013 found that the effects were stronger for unblinded measures and 3 recent subsequently published well-controlled trials found no effects for the most blinded ADHD outcome. Firmer conclusions must await upcoming evidence from larger controlled studies and future meta-analyses contrasting different forms of neurofeedback and different outcome measures.
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Affiliation(s)
- Martin Holtmann
- LWL-University Hospital for Child and Adolescent Psychiatry, Ruhr University Bochum, Heithofer Allee 64, D 59071 Hamm, Germany.
| | - Edmund Sonuga-Barke
- Developmental Brain-Behaviour Laboratory, Psychology, Institute for Disorders of Impulse & Attention, University of Southampton, University Road SO17 1BJ, Southampton, UK; Department of Experimental Clinical & Health Psychology, Ghent University, Henri Dunantlaan 2. B-9000, Ghent, Belgium
| | - Samuele Cortese
- Department of Child Psychiatry, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge PE29 2BQ, UK; Division of Psychiatry, Institute of Mental Health, University of Nottingham, Triumph Road, NG7 2TU Nottingham, UK
| | - Daniel Brandeis
- Department of Child and Adolescent Psychiatry, University of Zürich, Neumünsterallee 9/Fach, CH-8032 Zürich, Switzerland; Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, J5, D-68159 Mannheim, Germany
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50
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Simkin DR, Thatcher RW, Lubar J. Quantitative EEG and neurofeedback in children and adolescents: anxiety disorders, depressive disorders, comorbid addiction and attention-deficit/hyperactivity disorder, and brain injury. Child Adolesc Psychiatr Clin N Am 2014; 23:427-64. [PMID: 24975621 DOI: 10.1016/j.chc.2014.03.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article explores the science surrounding neurofeedback. Both surface neurofeedback (using 2-4 electrodes) and newer interventions, such as real-time z-score neurofeedback (electroencephalogram [EEG] biofeedback) and low-resolution electromagnetic tomography neurofeedback, are reviewed. The limited literature on neurofeedback research in children and adolescents is discussed regarding treatment of anxiety, mood, addiction (with comorbid attention-deficit/hyperactivity disorder), and traumatic brain injury. Future potential applications, the use of quantitative EEG for determining which patients will be responsive to medications, the role of randomized controlled studies in neurofeedback research, and sensible clinical guidelines are considered.
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Affiliation(s)
- Deborah R Simkin
- Committee on Integrative Medicine, American Academy of Child and Adolescent Psychiatry, Attention, Memory and Cognition Center, 4641 Gulfstarr Drive, Suite 106, Destin, FL 32541, USA; Department of Psychiatry, Emory University Medical School, Atlanta, Georgia.
| | - Robert W Thatcher
- Neuroimaging Laboratory, Applied Neuroscience Research Institute, 7985 113th Street, Suite 210, Seminole, FL 33772, USA
| | - Joel Lubar
- University of Tennessee, Knoxville, TN, USA; Southeastern Neurofeedback Institute, Inc, 111 North Pompano Beach Boulevard, Suite 1214, Pompano Beach, FL 33062, USA; International Society for Neurofeedback and Research
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