Neurofeedback and ADHD

There is strong support in the international community for the treatment of I-ADHD with Neurofeedback (NF). Research supported long-term benefits after the NF was discontinued (Geladé et al., 2018; Gevansleben et al., 2010; & Janssen et al., 2017). Chapter 2 will explore this research in more detail. In addition to the behavioral changes, NF has also demonstrated support for changing the brain itself. International researchers have found evidence that NF changes the connectivity of the brain (Bakhshayesh, Hänsch, Wyschkon, Rezai & Esser, 2011; Lévesque, Beauregard, & Mensour, 2006). Bakhshayesh et al. (2011) focused on the changes in amplitude working to normalize the brain waves and found support for both NF and biofeedback in normalizing brain waves. Similarly, other researchers found that NF impacts brain connectivity (Gevensleben et al., 2009a; Leins et al., 2007; Drechsler et al., 2007). Levesque et al. (2006) completed a functional magnetic resonance imaging (fMRI) study in collaboration with NF. They found that there was significant activation in the brain, and the control group demonstrated no significant changes.

Most significantly, Gani, Birbaumer, and Strehl (2008) found that children learned how to regulate and apply what they used in NF into their homes. Together, these results support longer- 8 term improvements for I-ADHD in changing the brain’s synchrony and normalizing brain waves after NF treatment. However, while there are many clear strengths to NF, there is significant criticism from the research community. Few researchers have successfully used double-blinding, which means that the intervention was hidden to both the participant and the researcher, leading to the argument that the process is useless and a waste of time and money (Loo, 2003; Vollebregt, van Dongen-Boomsma, Buitelaar, & Slaats-Willemse, 2014). In 2012 Lofthouse et al. reviewed 14 NF studies for the treatment of I-ADHD and highlighted the main concern was the difficulty of having a balanced control of removing the possibility of a placebo effect.

However, the researchers highlighted the randomized placement of clients and the reliable use of evidence-based assessments to evaluate outcomes was a strength. Yet, in the United States, there is concern regarding whether NF treats the underlying brain dysfunction, or if results can be attributed merely to the placebo effect (Loo, 200). NF is held to a medical model rather than an ecological model of treatment; opportunities for its success are missed (an ecological model is explained later in this chapter). Impressively, in a recently published article when NF was held to APA guidelines the research supported it as a strong therapeutic option for the treatment of IADHD (Arns et al., 2020). However, like any treatment modality, there are several challenges to NF research, including participant diversity, the type of protocols or computer programs used, size of samples, use of behavioral outcomes, and replication.

Researchers focusing on NF have often evaluated specific protocols that focus on a specific brain wave given the large diversity of protocols, brain waves, and electrode locations (Marzbani et al., 2016). A review by Orndorff-Plunkett, Singh, Aragón, and Pineda (2017) highlighted that a significant problem with NF was measuring its 9 effectiveness behaviorally. The researchers posed the question of whether the goal of NF was to change the connectivity in the brain or to create a behavioral change. Brain wave change would seem pointless if the result was no behavioral change. Researchers highlight the importance of using behavioral outcomes and community functioning measurements (Orndorff-Plunkett et al., 2017), the latter of which refers to the individual’s ability to engage in leisure activities, adapt to change, demonstrate adequate social skills, communicate, and otherwise perform activities necessary for daily life. Altogether, researchers hope to move closer to the goal of creating meaningful behavioral change, using both behavioral outcomes and community functioning measurements to help strengthen the research surrounding NF in I-ADHD treatment.

As noted, the most promising component of NF research has been the finding of maintained results even after the intervention has been removed. A handful of follow-up studies had researchers supporting the long-term effects of NF (Gevensleben et al., 2010; Leins et al., 2007; Strehl et al., 2006). Strehl et al. (2006) found that when asking parents and teachers six months after the NF treatment, they reported that the same decrease in undesirable behaviors. These results were also supported by researchers Leins et al. (2007) and Gevensleben et al. (2010), who found similar long-term stability of behaviors posttreatment. Even more impressively, the researchers reported on a 2-year follow-up, finding that the behavioral gains remained consistent in the children who demonstrated growth initially, whereas the children who did not initially demonstrate growth did not change (Strehl, 2006). Therefore, there may be specific children or even subtypes of I-ADHD who benefit from NF. The American Academy of Pediatrics (AAP, 2001) clinical practice guideline recommends two evidence-based treatments for I-ADHD.

The AAP recommends that the treatment of preschool children (4 to 5 years old) focus on behavioral therapy interventions. 10 Behavioral therapy interventions focus on teaching and rewarding positive or pro-social behaviors in to reduce negative behaviors. In extreme situations, if behavioral therapy does not positively impact the child, stimulant medication might be an appropriate treatment option. For children 6 years old and older, the AAP recommends a combination approach, using both medication and behavioral therapy. The AAP identified NF as a Level 1 or Best Practices intervention for the treatment of ADHD (AAP, 2001). Medication, however, treats the symptoms rather than working to address the underlying neurological dysfunction. At the same time, behavioral therapy can lead to positive lasting changes in the brain.

Although medication is the most popular intervention, many parents have concerns about putting their child on a stimulant due to the potential side effects (Concannon & Tang, 2005). Many children experience adverse side effects due to medication (Efron, Jarman, & Barker, 1998). According to the Child Mind Institute, a leading resource for parents and behavioral health professionals, taking a stimulant medication can lead to sleep problems, decreased appetite, headaches, stomachaches, irritability, moodiness, and, in some cases, permanent development of tics (Boorady, 2018). Together, these side effects and the stress of deciding whether to put a child on regular medication is a challenging decision for parents weighing the potential outcomes. The National Institute of Mental Health created a team to investigate the largest study to date featuring I-ADHD (Jensen et al., 2001).

The study included 579 participants with ADHD and assigned them to medication, behavioral treatment, and a combination over a 14-month period. Researchers found a significant impact for individuals within the medication and combined treatment group. Combining treatments is in line with the work of previous researchers who advocated a strength-based ecological model for serving children (D’Amato, CrepeauHobson, Huang, & Giel, 2005; Rhodes, D’Amato, & Rothlisberg, 2009). For too long, we have 11 focused on the medical model of treatment of I-ADHD instead of using a strength-based ecological model. The medical model often focuses on treating solely the symptoms that manifest within the individual (D’Amato et al., 2005). The ecological model instead places the child’s problem behaviors into the broader context of the child’s academic setting and home environment. Assessment and intervention should focus on a child’s areas of strength, including educational, personal, and within the home (D’Amato et al., 2005). From this perspective, individuals who have a neurological or psychological deficit should be viewed in ways that support their abilities, thereby encouraging a more holistic approach to interventions.

Again, the rationale for the proposed research was to examine NF with a neurodiverse individual. Research related to NF was often heavily focused on male participants and typically only used pure ADHD diagnoses with additional diagnoses often excluded from research studies (Arns et al., 2020). This makes sense for the initial broad support of NF, but the field continues to need more detailed case studies to support populations with more unique neuropsychological features. In the current study, the researcher examined NF with a female child, Jane, who had a primary diagnosis of ADHD, SLD with an impairment in reading and mathematics, visuospatial deficit, and fine motor control deficit. The researcher used a detailed archival neuropsychological assessment to examine any psychological change in the data before and after her intervention. The intervention or NF collected data related to High Hold scores at each session, which is the longest continuous number of seconds that Jane maintained her desired brain wave zone during a session.

At the time of this research, no other studies have been published focusing on exploring individuals with multiple diagnoses, nor examining continuous data through High Hold scores. This research focused on three locations of the electrode placement using an SMR protocol as the desired brain wave zone. This research had two main questions. First, does the NF output of 12 High Hold scores or seconds maintaining the desired range, increase over the course of the treatment highlighting a learning pattern? Second, are there changes in the neuropsychological data from preassessment to postassessment? NF is the future of treatment in the international community. As the world continues to learn about the brain and its underlying functions, clinicians are better able to utilize advancing technology to treat and normalize brain activity, thus impacting clinical neuropsychology and children receiving treatment.

As the United States becomes more established in NF research, it too will become a leader in NF as an intervention in a clinical setting. The implications of this research would be significant for the mental health community, as it supports a more diverse application of NF than previously explored. The current research builds on previous behavioral research in NF, hopefully adding a complexity factor of evaluating an individual with a unique neuropsychological profile. If we can positively impact children who are struggling with ADHD-related symptoms and underlying deficits of complex attention and sustained attention, we can reduce the academic and behavioral stress from I-ADHD̵-related symptoms, then clinicians can build a healthier and happier community. Increased understanding of the brain is our future, and neuropsychological research is an essential component. Researchers and clinicians can build a better tomorrow by learning how the brain impacts the child and creating neuropsychologically based health services, such as synchronizing brain waves through NF