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?Es efectivo el entrenamiento en Neurofeedback para el tratamiento del TDAH? Resultados a partir de una revision sistematica.

Is Neurofeedback training an efficacious treatment for ADHD? Results from a systematic review

Introduction

The disorder attention deficit hyperactivity disorder (ADHD) is a behavioral disturbance with neurobiological basis, characterized by having difficulties with attention, impulsivity and hyperactivity, affecting globally between 4.1 and 5% of children and teenagers (American Psychological Association APA, 2000; Polanczyk, Lima, Horta, Bierderman & Rhode, 2007; Word Health Organization WHO, 2011). Reported prevalence rates in Colombia ranges from 3.1 % (Torres, Berbesi, Bareno & Montoya, 2010) to 15.86 % in school-age children (Cornejo et al., 2005). Figures show negatively an impact not only in the proper development but also, at the school, family and social performance (Trujillo-Orrego, Ibanez & Pineda, 2012) of this population as well as in adolescent groups.

From the neuropsychological point of view, the most studied disorders of ADHD have been related to executive-level failures, both in tests and scales measuring the effect of executive functions in daily life of patients (Shimoni Engel-Yeger & Tirosh, 2012). However, Willcutt, Doyle, Nigg, Faraone, and Pennington (2008), from a meta-analysis of 83 studies concluded that the heterogeneity of the disorder cannot generalize these executive failures in all ADHD diagnosed patients, for this reason, there have been a number of efforts to conceptualize ADHD from the formulation of different cognitive profiles associated with it.

In this line, Sonuga-Barke, Bitsakou and Thompson (2010) conducted a study to establish empirically the plausibility of an explanatory pattern from two means: one stratal fronto dorsal, which would produce a deregulation in inhibitory processes, and other in which the ventral frontostriatal circuit affect the ability to identify signs of greater latency, what would mean, difficulties to postpone greater rewards in favor of immediate rewards. The results confirm the possibility of these two models and identify a third component associated to failures in the temporal processing, probably related to alterations in the basal ganglia.

Therefore, in the development of new non-pharmacological treatments, neurofeedback (NF) has emerged as an intervention technique that is being investigated as an alternative to the attention of various neuro-psychiatric disorders. Although a great part of the published studies have focused on establishing its efficacy in the treatment of ADHD, many of these studies have used methodologies that make it difficult to extrapolate their results to clinical practice. For that reason, the importance of addressing the conceptual and methodological aspects of the use of NF in the treatment of ADHD, in order to establish possible research areas for clinical use.

As well the NF as the biofeedback, consist in a series of procedures that allow, from the acquired information and a physiological variable of interest, to modify voluntarily values on the participant (Olivares, Mendez & Bermejo, 1998). Also, it is understood as a self-regulation technique in which patients develop a voluntary control what was once thought as involuntary (Frank, Khorshid, Kiffer, Moravec & Mckee, 2010). For this purpose, The NF is supported in equipment designed in order the patient may detect the changes produced in the selected physiological responses and through operant or classical conditioning processes, he can learn to modify the values of the signal (See Figure 1); in the specific case of NF, physiological signal is used as brain waves. From this perspective, it is considered more like training than a therapy, insofar the patients play an active role and practice until developing the control skill (Frank, et al., 2010).

The participant produces a physiological signal and consequently the equipment is in charge of registering, transforming, and enlarging it in a pattern that can be presented to the participant with the aim of receiving direct information of the changes produced in the physiological signal, and thus learning how to modify it through classical conditioning and/or operant processes. (Graphic based on Carrobles & Godoy, 1987).

Among the main objectives to be achieved with the use of NF are: controlling a system of physiological responses through training, keeping controlled these responses in the absence of the feedback and generalizing and maintaining the achieved self-control (Conde & Menendez, 2002).

The NF or Biofeedback encephalographic has as a purpose that the patient, by means of operant conditioning, learns to control the brain's electrical activity, which is an unconscious physiological function, increasing the frequency of desired brainwave and deleting the unwanted one (Friel, 2007). The NF has been studied in depth, for treatments in epilepsy, anxiety , depression, and learning disorders (Fernandez et al., 2007), Asperger (Thompson, Thompson & Reid, 2010) and, there are particularly, a variety of studies related to ADHD (Masterpasqua & Healey, 2003; Heinrich, Gevensleben & Strehl, 2007; Legarda, McMahon, Othmer & Othmer, 2011; Gruzelier & Egner, 2005; Thompson & Thompson, 2005).

The mentioned studies are based on findings of the electroencephalogram (EEG) in children with ADHD, which have identified a higher proportion of waves Theta / Beta, a high level of Theta waves and low level of Betha waves (Loo & Barkley, 2005; Othemer & Kaiser, 2000; Butnik, 2005), This is apparently related to the behavior of motor restlessness and lack of concentration. In addition, the EEG in children with ADHD has shown a positive correlation with the levels of cerebral perfusion associated with hypoperfusion in the frontal lobe that is related to an alteration in the rate of Theta waves (Gunkelman & Johnstone, 2005).

These results have supported the development of NF as a technique that would change the typical EEG patterns of ADHD and also improve its symptoms. While medication has been one of the most evident effective treatment, along the cognitive behavioral therapy, it has been suggested that about 20% of children do not respond adequately or have side effects that hinder their use (Diaz, 2006), that is the reason, this technique has become especially important in recent years (Baydala & Wikman, 2001, Meisel et al, 2011;. Rossiter, 2004), without presenting relevant side effects so far (Gevenselebel, et al. 2009; Henrich et al 2007; Bakhtadaze, Janelidze, & Khachapuridze, 2011).

Preliminary findings indicate that train individuals on controlling their own electrocortical activity, may have beneficial effects on reducing symptoms of ADHD (Masterpasqua & Healey, 2003; Butnik, 2005). To this purpose, it has been developed a variety of protocols, such as the Theta / Betha, which is based on increasing Betha waves while Theta waves are been decreasing. This protocol has yielded positive effects on the concentration and hyperactivity symptoms reduction (Harvard Mental Health Letter, 2010). Another protocol is based on training slow cortical potentials [Slow Cortical Potential Training] (SCP), in order to regulate the phasic cortical activity rather than the tonic.

One aspect of particular interest is the effectiveness in brainwaves modification after 20 training sessions in over 30% of patients with ADHD and the prevalence of its effects, which is estimated from one to ten years, having as a consequence the decreasing of impulsivity and hyperactivity symptoms (Fox, Tharp & Fox, 2005). In addition, several studies report a significant improvement in the levels of attention in the IQ, and the scores on the conduct scales carried out by parents and teachers (Gevensleben, Holl, Albrecht, Vogel, et al, 2009.; Gevensleben, Holl, Albrecht, Schlamp, Kratz, Studer, Wangler, et al, 2009;. Leins et al, 2007; Strehl, et al, 2005).

Although, some of these studies have been controversial due to the lack of scientific rigurosity, and limitations such as lack of control groups, small sample sizes and non-probability sampling (Harvard Mental Health Letter, 2010, Heinrich et al 2007,. Drechsler et al. 2007).

In order to obtain greater effectiveness, it is proposed to join the NF to a multimodal therapy that combines some of the following aspects: psychoeducation, medication, behavioral intervention, parent training and / or academic support, among others (Campbell, 2004; Hoekstra, 2010; Lansbergen, Dongen-Boomsma, & Buitelaar Slaats-Willemse, 2011). School and parents support have proved to be crucial in the treatment, so most studies have attempted to involve them (Pop-Jordanova, Markovska-Simoska & Zorcec, 2005, Roman, 2010).

This study aims to track and analyze the implemented advances in NF technique as an alternative treatment to ADHD, and classify the findings according the efficacy levels proposed by the Association for Applied Psychophysiology and Biofeedback, [Association for Applied Psychophysiology and Biofeedback ] (AAPB) and the Society for Neuronal Regulation in 2001.

Method

The present work is a systematic revision, where articles related to NF and ADHD in children and adolescents from the database PubMed, Ebsco database (Psychology and Behavioral Sciences) and PsyARTICLES were taken as a unit of analysis, during a temporary margin of 11 years, between 2000 and 2011.

Firstly, the search was conducted using the terms: Neurofeedback and Attention Deficit Hyperactivity Disorder (ADHD), and a total of 88 items were found. 44 articles related to children and adolescent diagnosed with ADHD were taken, and consequently they were intervened with NF as the main technique. Finally, articles of theoretical type were discarded, having a final selection of 11 items. Thus, the inclusion criteria were:

--Empirical articles which sample made up by children and / or adolescents.

--Items selected with a sample who presented as a primary disorder ADHD, intervened with NF technique.

The information is organized into the following categories for the analysis: title, authors, country and year, sample protocol used, design, control group, results and conclusion. Finally, it was assigned to the evidence found a level of effectiveness in accordance with the established parameters by the AAPB and the Society for Neuronal Regulation, which identify five levels (Moss & Gunkelman, 2002), in order to classify the carried out studies on the issue that might lead to future research (Yucha & Gilbert, 2004). See Table 1.

Results

Regarding knowledge production between 2000 and 2011 about the NF and ADHD in children and adolescents, a reduced volume of articles was recorded in the databases. Lack of studies in Latin America is evident and most of the articles from this region are review articles.

Eight of the research articles are studies carried out in Germany (Gevensleben, Holl, Albretch, Vogel, et al., 2009; Leins et al., 2007; Gevensleben et al., 2010; Gevensleben, Holl, Albretch, Schlamp, et al., 2009; Strehl et al., 2005; Wangler, et al., 2011; Bakhshayesh, Hansch, Wyschkon, Rezai & Esser, 2011; Fuchs, Birbaumer, Lutzenberger, Gruzelier & Kaiser, 2003), it corresponds to a 73% of the total analyzed volume that fulfills with the inclusion criteria. The other 27% was divided among Switzerland (Drechsler et al., 2007), Macedonia (Pop-Jordanova et al., 2005) and the Netherlands (Lansbergen et al., 2011) with an article each one.

The studies of Gevensleben et al. (2010); Wangler et al. (2011) y Gevensleben, Holl, Albretch, Schlamp, Kratz, Studer, Wangler, et al. (2009), took final samples from a group of 102 children from Gevensleben, Holl, Albretch, Vogel, et al. (2009) work. Sharing the demography characteristics of this sample, in a way that children and adolescents with comorbid emotional disorders, tics or dyslexia were excluded. On the other hand, Leins et al. (2007) did not exclude participants with psychiatric or neurologic disorders different from Lansbergen, et al. (2011) who did excluded from their study any type of comorbid disorder. On the contrary, Drechsler et al. (2007), had samples without any comorbid disorder or any known neurological damage. While Strehl et al. (2005), similarly than Bakhshayesh et al. (2011), involved participants in this etereo group, with no additional neurological disorders. Finally, the studies of Fuchs et al. (2003) and Pop-Jordanova et al. (2005) did not specify if the comorbid neurological or psychiatric disorders are part of the inclusion criteria.

Secondly, the IQ was part of the initial evaluation, and in several studies those participants who presented a IQ higher than 80 were considered as inclusion criteria (Bakhshayesh et al., 2011; Drechsler et al., 2007; Fuchs et al., 2003; Lansbergen et al., 2011; Leins et al., 2007; Strehl et al., 2005).

Similarly, there were some differences with regard to the inclusion or not of children and adolescents with medication or alternative treatment. In the studies of Gevensleben, Holl, Albrecht, Vogel, et al. (2009); Gevensleben, et al. (2010); Wangler et al. (2011) and Gevensleben, Holl, Albrecht, Schlamp, Kratz, Studer, Wangler, et al. (2009), participants should not be under medication or attending psychotherapy for at least six weeks prior to the study. Meanwhile, in the study of Fuchs et al. (2003) the sample should not be linked to any treatment before or during the study. In contrast, the studies of Lansbergen et al. (2011), Drechsler et al. (2007) and Bakhshayesh et al. (2011) did not exclude children and adolescents who were under medication at the time of the study, provided the dose was controlled without any variation along the study. The mentioned above, is based on the concept that the NF should be part of a multimodal therapy. Finally, Pop-Jordanova et al. (2005) did not specify this criterion.

Protocols of NF used

The protocols of NF used in the studies were Training Theta / Beta and training called Slow Cortical Potential Training (SCP), being used in 73% of the studies analyzed. Some studies have only worked with SCP (Drechsler et al, 2007; Strehl et al, 2005) and a study with the Theta / Beta training (Bakhshayesh et al, 2011). However, some studies have used both protocols either using them in separate blocks to a single group (Wangler et al, 2011; Gevensleben et al, 2010; Gevensleben, Holl, Albrecht, Schlamp et al, 2009; Gevensleben, Holl, Albrecht, Vogel, et al., 2009) or selecting one for each experimental group (Leins et al., 2007). Another protocol widely used is the Rhythm Sensory Motor, which was practiced in 27% [Sensorimotor Rhythm (SMR)] (Fuchs et al, 2003; Lansbergen et al, 2011; Pop-Jordanova et al., 2005). On the other hand, Lansbergen et al. (2011) propose another training way on NF, in which NF individual protocols were used, based on visual inspection and comparison who researchers conducted between the initial EEG of children evaluated and the quantitative electroencephalogram (QEEG) of the NeuroGuide database that contains records of 625 healthy children with electrophysiological heterogeneity.

Control group

All studies, except those by Leins, et al. (2007), Pop-Jordanova et al. (2005) and Strehl et al. (2005), used this methodological strategy, in order to compare the effectiveness of NF with other interventions. These interventions included training on attention skills, electromyography biofeedback training or cognitive behavioral therapy, among others.

Reported main findings

In relation to NF training, regardless of the protocol used, it was found that ADHD symptoms were reduced in all studies, especially in those related to inattention (Bakhshayesh et al., 2011) and self-regulation (Drechsler et al., 2007; Leins et al, 2007). Considering the baselines of psychometric tests and neuropsychological, an improvement in reaction time on the tests was found, as well as in parent and teachers' ratings, and in some cases IQ increasing was presented (Pop-Jordanova et al. 2005; Gevensleben, Holl, Albrecht, Vogel, et al, 2009;. Gevensleben, Holl, Albrecht, Schlamp, et al, 2009; Leins et al, 2007; Strehl et al., 2005).

Referring to Theta / Betha training, a positive impact can be observed, so through this the Theta / Beta tax was reduced (Bakhshayesh et al., 2011) or the presence of theta waves are decreased and Betha waves are increased (Gevensleben, Holl, Albrecht, Vogel, et al, 2009; Gevensleben, Holl, Albrecht, Schlamp, et al, 2009,.. Leins et al, 2007), which was associated with significant reductions in reported symptoms of ADHD.

With respect to the training results with SCP, positive results were found in several studies. An increase in the central midline of the alpha activity was correlated with an improvement in the level of ADHD (Gevensleben, et al., 2010), as well as an increase in the specific CNV (Contingent Negative Variation) to the SCP was associated with a reduction of ADHD symptoms (Wangler et al., 2011) and a learning response in the negative regulation of SCP (Strehl et al., 2005). However, Drechsler et al. (2007) found that less than a half of the participants who received SCP training were able to differentiate their cortical activation in transfer trials Drechsler et al. (2007), so that the effects could not be fully attributed to the electrophysiology training.

Additionally, training with SMR protocol, succeeded in reducing ADHD symptoms in all studies in which it was used (Pop-Jordanova et al, 2005; Lansbergen et al, 2011; Fuchs et al, 2003.). See Table 2.

In table 3 are included the main criteria considered by AAPB and the Neuronal Regulation Society, to defined the efficacy levels in studies with NF.

Discussion and Conclusions

According to the review of the factors that determine the efficacy level of the NF as an alternative for the ADHD treatment, it is determined that the selected studies present efficacy levels between II and IV (see Table 3), which suggests that the NF would be an effective technique for controlling some of the symptoms of ADHD.

In the same table it can be seen that there are three studies classified in level IV, which suggests that it is a really effective technique. However, according to the proposed classification by the AAPB and the Society for Neuronal Regulation, in order to consider the highest level of efficacy, it is necessary that such studies are conducted by independent groups, but this is not the case, so the three classified studies as level IV, were performed in the same research center. Additionally, there are several factors that deserve to be into consideration.

Furthermore, other mediating variables such as parental and school support have proved to be decisive (Pop-Jordanova et al., 2005). The sample size and the timing and type of measurement are still a limitation in many studies. Hence, the importance of having a baseline of register of EEG and a post NF, in order to know and control fluctuations waves (Vernon, 2005; Dempster & Vernon, 2009).

Based on levels of efficacy, three studies of this type of classification were found. Monastra et al., (2005) assigned to the EEG biofeedback a level of "probable efficacy" as a treatment for ADHD and explained, that in spite of 75% of patients from published studies reported significant clinical improvement, further studies would be necessary with random and controlled groups to provide a better estimate percentage of real patients.

Arns, M. de Ridder, S. Strehl, U. Breteler, M. & Coenen, A. (2009) exposed in a meta-analysis, that the ADHD treatment using the NF technique, improves behavior in open trials with medium sizes of compared samples with active or passive controlled groups. It was concluded that treatment with NF can be ranked in level 5 of efficacy: Effective and specific.

However, a study based on the random presentation of electroencephalographic changes published in 2013, in which a placebo training protocol was used, indicates that there were not statistically significant differences obtained with the group under training with NF (Vollebregt Dongen-Boomsma, Buitelaar Slaats-Willemse, 2013).

Secondly, it is important to differentiate between effectiveness and efficacy. Rossiter (2004) explains that effectiveness studies place a greater emphasis to external validity, while efficacy studies are focused on the internal validity.

In this line, Pine (2009) argues that until the effects are not replicated convincingly, and there are no more results to compare the efficacy of different trials, the NF should not be recommended as an alternate treatment for ADHD. Although, the carried out researches presented some findings in favor the use of NF techniques in ADHD treatment, it cannot be recommended yet, as a unique treatment option. In spite of the multiple factors involved in the disorder and heterogeneity of neuropsychological patterns reported, it is suggested their use as a suitable complement, when it is focused on effective parenting patterns oriented in developing skills that allow dealing with children and adolescents and providing support at the school. Interventions that promote the recognition of the impairment and provide strategies of environmental type are generally favorable and could be an ideal complement to the work with the NF techniques. Its use does not appear to be incompatible with the pharmacological support, though it is not established yet, whether the combination of these two strategies could be better than the particular use of the drug.

Finally, in order to do for further studies, it is important to consider the control level of the variables and select broader samples, as well as to provide a proper diagnosis and establish groups of participants according to neuropsychological performance patterns. In that way, some patients might obtain greater benefit from the use of NF, due to the circuits that could have been affected rather than the technique itself.

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Wangler, S., Gevensleben, H., Albrecht, B., Studer, P., Rothenberger, A., Moll, G. & Heinrich, H. (2011). Neurofeedback in children with ADHD: Specific event-related potential findings of a randomized controlled trial. Clinical Neurophysiology, 122, 942-950.

Willcutt, E.G., Doyle, A.E., Nigg, J.T., Faraone, S.V. & Pennington, B.F. (2008). Validity of the Executive Function Theory of Attention- Deficit/Hyperactivity Disorder: A Meta-Analytic Review. BiolologyPsychiatric. 57, 1336-1346. DOI:10.1016/j.biopsych.2005.02.006.

World Health Organization (2011). World Health Statistics. Recuperado de: http://www.who.int/gho/publications/world_health statistics/EN WHS2011_Full.pdf

Yucha, C. & Gilbert, C. (2004). Practice in Biofeedback and Neurofeedback. Applied phychophysiology & Biofeedback, an international society for mind-body research, health care and education. Recuperado de: http://www.aapb.org/files/public/Yucha-Gilbert EvidenceBased2004.pdf

Received: February 3-2014 Revised: April 4-2014 Accepted: April 30-2014

Juana Gaviria Loaiza (1), Liliana Calderon-Delgado (2), Mauricio Barrera-Valencia (3)

(1,2) Universidad CES, (3) Universidad de Antioquia, Medellin, Colombia

(1) Psicologa, Universidad CES. Estudiante de Doctorado en Desarrollo Humano y Estudios Familiares, Universidad de Delaware, E.U.

(2) Psicologa, Especialista en Salud Mental del Nino y del Adolescente, Universidad CES, Doctora en Psicologia con Orientacion en Neurociencia Cognitiva Aplicada. Docente e investigadora, Universidad CES, Medellin, Colombia. lcalderon@ces.edu.co

(3) Psicologo. Magister en Neuropsicologia, Universidad De San Buenaventura, sede Medellin. Doctor en Psicologia con Orientacion en Neurociencia Cognitiva Aplicada. Coordinador Linea de Neurodesarrollo y Neuropsicologia Grupo de Investigacion en Psicologia Cognitiva, Universidad de Antioquia.

Table 1. Efficacy ratings for Neurofeedback studies, according
to AAPB and the Society for Neuronal Regulation

Level     Type of     Description
          efficacy

Level 1   No          It only has anecdotal reports and case
          empirical   studies
          support

Level 2   Possible    At least one study with enough statistical
          efficacy    power with well-defined outcome measures,
                      but without a random assignment to a
                      condition of internal control for the
                      study

Level 3   Probable    Multiple observational studies, clinical
          efficacy    trials, controlled studies on the waiting
                      list and responses in the inter-and
                      intra-subject studies demonstrating
                      efficacy

Level 4   Efficacy    a. Compared to an untreated control group,
                      alternative treatment group or placebo
                      control group using random assignment, the
                      treatment to be investigated is
                      significantly superior to the control
                      condition or the investigated treatment
                      is equivalent to a previously established
                      treatment of efficacy.

                      b. Studies are conducted in a population
                      treated for a specific problem and the
                      inclusion criteria are drafted in a
                      reliable way, and defined operationally.

                      c. The study uses specific, clear and
                      valid outcome measures.
                      d. Data are subject to a proper analysis
                      result.

                      e. The diagnosis and treatment variables,
                      as well as procedures, are defined in a
                      clear way that allows replication of the
                      study by independent investigators.

                      f. The superiority or equivalence of the
                      investigated subject has been shown at
                      least in two independent research areas.

Level 5   Effective   The investigated treatment showed to be
          and         statistically superior to medication or
          specific    treatment, in at least two independent
                      fields of research.

Table 2. Training protocols in NF, study design and main
conclusions reported in the selected papers.

                                      Country
Study                Authors         and year         Sample

Neuro-feedback       Wangler          Germany          102
in children          et al.            2011          children
with ADHD:                                             with
Specific                                               ADHD
event-related                                         aged 8
potential                                             to 12
findings of                                           years.
a randomized
controlled
trial

Neuro-feedback    Bakhshayesh,        Germany           35
in ADHD: a           Hansch,           2011          children
single-blind     Wyschkon-Rezai,                       with
randomized          & Esser.                          ADHD,
controlled                                            aged 6
trial                                                 to 14
                                                      years.

Neuro-feedback     Gevensleben,       Germany           61
training in           Holl,            2010          children
children            Albretch,                          with
with ADHD:          Schlamp,                          ADHD,
6-month              et al.                           aged 8
follow-up                                             to 12
of a                                                  years
randomized
controlled
trial

Distinct           Gevensleben,       Germany          102
EEG effects           Holl,            2009          children
related to          Albretch,                         (72 at
neuro-feedback      Schlamp,                           the
training in          Kratz,                            end)
children             Studer,                          aged 8
with ADHD:          Wangler,                          to 12
A randomized         et al.                           years,
controlled                                             with
trial                                                  ADHD

Is                 Gevensleben,       Germany          102
Neuro-feedback       Holl,             2009         children
an efficacious      Albretch,                         (94 at
treatment           Vogel, et                          the
for ADHD?              al.                             end)
A randomized                                           with
controlled                                            ADHD,
clinical trial                                      aged 8 to
                                                     12 years

Neuro-feedback      Leins et          Germany           38
for Children           al.             2007          children
with ADHD:                                             with
A Comparison                                           ADHD
of SCP and                                            aged 8
Theta/Beta                                            to 13
Protocols                                             years.

Self-regulation     Strehl et         Germany           23
of Slow                al.             2005          children
Cortical                                               with
Potentials:                                            ADHD
A New                                                between
Treatment                                              8 and
for Children                                         13 years
With                                                   old.
Attention-
Deficit/
Hyperactivity
Disorder

Neuro-feedback       Fuchs,           Germany           34
Treatment for      Birbaumer,          2003          children
Attention-        Lutzenberger,                       aged 8
Deficit/            Gruzelier                         to 12
Hyperactivity       & Kaiser.                          with
Disorder in                                            ADHD
Children: A
Comparison
with
Methylphenidate

Neurofeedback    Pop-Jordanova,      Macedonia          12
treatment          Markovska-          2005          children
of children          Simoska                          aged 7
with                & Zorcec.                         to 13
Attention                                             years
Deficit                                                with
Hyperactivity                                          ADHD
Disorder

Controlled         Drechsler,      Switzerland,         30
evaluation           Straub,           2007          children
of a                Doehnert                           with
neurofeedback                                          ADHD
training of         Heinrich,                         aged 9
slow              Steinhausen,                        to 13
cortical                &                             years.
potentials          Brandeis.
in children
with
Attention
Deficit/
Hyperactivity
Disorder
(ADHD)

ADHD and EEG-      Lansbergen,     Netherlands          14
neurofeedback:   Dongen-Boomsma,       2011          children
a double-blind      Buitelaar                          with
randomized          & Slaats-                      ADHD between
placebo-            Willemse.                       8 and 15
controlled                                          years old.
feasibility
study

                  Neuro-feedback                            Control
Study                Protocol             Design             group

Neuro-feedback          36               ERP pre,             28
in children        Theta/Betha          during and         children
with ADHD:           training          post-training         with
Specific             sessions                                ADHD
event-related        and SCP               With
potential                                 control          Protocol
findings of                              group and          36 AST
a randomized                              random           sessions
controlled                                 group
trial                                   assignment

Neuro-feedback          30          Psycophysiological,       17
in ADHD: a         Theta/Betha      neuropsycological      children
single-blind         training              and              with
randomized           sessions         psychometric          ADHD.
controlled                             measurement
trial                                   pre- and
                                       post-training.       Protocol

                                           With            Elecromyo-
                                          control           graphy
                                         group and        biofeedback
                                          random           training.
                                           group
                                        assignment

Neuro-feedback         The               Follow-up            23
training in          children              study           children
children            completed                                with
with ADHD:         36 sessions                               ADHD
6-month                 of                                   with
follow-up          Theta/Betha                             previous
of a                 training                              training
randomized          and SCP in                              on AST.
controlled          a previous
trial                phase of
                    the study.

Distinct                36               EEG pre,             26
EEG effects          sessions           during and         children
related to              of            post-training.         with
neuro-feedback     Theta/Betha                               ADHD
training in          training
children             and SCP                               Protocol
with ADHD:                                                  36 AST
A randomized                                               sessions.
controlled
trial

Is                      36             Psychometric           35
Neuro-feedback       sessions          measurement         children
an efficacious          of                pre and            with
treatment          Theta/Betha        post-training.         ADHD.
for ADHD?            training
A randomized         and SCP               With            Protocol
controlled                                control
clinical trial                           group and          36 AST
                                          random           sessions.
                                           group
                                        assignment

Neuro-feedback          30             Psychometric         Absent
for Children         sessions          measurement
with ADHD:              of                 pre,
A Comparison       Theta/Betha         post-training
of SCP and          training,         and follow-up.
Theta/Beta            or 30
Protocols            sessions             Random
                      of SCP               group
                    training.           assignment

Self-regulation       30 SCP           Psychometric         Absent
of Slow             sessions.             and
Cortical                                neurologic
Potentials:                             evaluation
A New                                     pre and
Treatment                             post-treatment.
for Children
With
Attention-
Deficit/
Hyperactivity
Disorder

Neuro-feedback          36              Neuropsyco-          12
Treatment for        sessions           logical and        children
Attention-              of             psychometric          with
Deficit/         Neurocybernetics      measurement           ADHD
Hyperactivity          EEG               pre- and
Disorder in        Biofeedback        post-treatment,
Children: A           System           or training.        Protocol
Comparison            C4 and            Intentional        Treatment
with                 SMR were           assignment           with
Methylphenidate      used in             to groups          methyl-
                   hyperactive           according         phenidate
                     children          to choice of        (10 to 60
                    and C3 en            parents.         mg daily).
                    beta1 was             Control
                     used in               group
                 predominantly            missing
                   inattentive       due to ethical
                    children.         considerations.

Neurofeedback           40           Neuropsycological      Absent
treatment           Biograph/           measurement
of children          ProComp              pre and
with                   2.0            post-treatment.
Attention            sessions
Deficit              and EEG
Hyperactivity        ratings
Disorder               SMR

Controlled             SCP              Scales and            13
evaluation           training       neuropsycholofical     children
of a                                    assessment           with
neurofeedback                             pre and            ADHD.
training of                           post-training.
slow
cortical                                                   Protocol
potentials                                                   Group
in children                                               cognitive-
with                                                      behavioral
Attention                                                   therapy
Deficit/
Hyperactivity
Disorder
(ADHD)

ADHD and EEG-        30 Theta            Clinical         6 children
neurofeedback:      supression          neuropsycho-        with
a double-blind         SMR               logical,           ADHD.
randomized          sessions.             pre and
placebo-            Individual        post-training.       Protocol
controlled              NF                                  Placebo
feasibility         protocols             Control          feedback
study                                    group and
                                          random
                                           group
                                        assignment

Study                  Results               Conclusions

Neuro-feedback     In both groups,       The effects of CNV
in children         there were an          reflect on the
with ADHD:          improvement in        underlying neural
Specific               the test            circuits to the
event-related     performance and a          sources of
potential          decrease in the       assigned resources
findings of        p300 component,        in the cognitive
a randomized     possibly due to the        preparation,
controlled        adaptation to the         related to a
trial              attention test.          successful NF
                                        training in children
                     After the NF           with ADHD. A
                 training, there was     neuropsychological
                  an increase in the        assessment is
                   CNV specific for         suggested to
                   SCP. A greater           optimize and
                 pre-training in CNV      individualize NF
                    was associated            training.
                 with a decreased in
                       the ADHD
                   symptoms in the
                    SCP training.

Neuro-feedback     The Theta/Betha       It is important to
in ADHD: a         rate and the EMG        discuss if the
single-blind         levels were             therapeutic
randomized          reduced in the       alliance may result
controlled           groups. The            by itself in
trial              parents reported          changes in
                      important           cerebral activity
                    reductions in
                   primary symptoms         The behavior
                   of ADHD and the         contingencies,
                     inattention           self-efficacy,
                     improvements          relaxation, the
                 were greater in the     structured learning
                  NF group, in which        environment,
                    an improvement         routines, among
                 was also noticed in       others factors,
                  the reaction time        should be taken
                        at the              into account.
                 neuropsychological
                     assessment.

Neuro-feedback    50% of the sample        Improvement in
training in        responds to the        behavior related
children         follow-up, versus a      with NF training
with ADHD:           30.4% in the         was remained for
6-month             control group.         six months and
follow-up                                 being higher than
of a                                     the control group.
randomized
controlled                                  The NF may be
trial                                        considered
                                          effective in the
                                           ADHD treatment.

Distinct            A reduction in         Theta and Betha
EEG effects       Theta activity in         differential
related to           the EEG was          patterns in EEG,
neuro-feedback    evident in the NF        show the neural
training in         trained group.         mechanisms that
children          Also, an increased         could cause
with ADHD:       in the alfa activity      improvements in
A randomized       central midline,          behavior on
controlled            which was             children with
trial             correlated with an            ADHD.
                    improvement in
                   the ADHD scale.

Is                    51% of the           Combination of
Neuro-feedback       experimental          protocols in NF
an efficacious     groups responds         training has an
treatment          to the treatment      effective effect in
for ADHD?            (Theta waves           children with
A randomized          decrease)             ADHD, however
controlled         compared with a        more studies are
clinical trial    2% in the control            needed.
                        group.

                     According to
                     parents and
                 teachers, there was
                  an improvement in
                      behavior.
Neuro-feedback       Intentional          NF training has a
for Children        regulation of           positive and
with ADHD:       cortical activity in      lasting effect.
A Comparison         both groups,
of SCP and            improving           Limitations: Lack
Theta/Beta        attention and IQ.       of control group,
Protocols            Parents and            sample size,
                    teachers also            control of
                  reported important    nonspecific effects.
                   improvements in
                     behavior and
                   cognitive level.
                   Clinical effects
                   were maintained
                  during six months
                   posterior to the
                  treatment and the
                    groups did not
                   differ from each
                        other.

Self-regulation      The children         Evidence supports
of Slow             learned how to      a SCP efficacy level
Cortical             regulate the        2. Future research
Potentials:        negative SCP. An        should control
A New               improvement in           medication,
Treatment        attention, behavior     nonspecific effects
for Children       and IQ score was       and subtypes, in
With              observed. Changes       order to know if
Attention-         remained the six           SCP is an
Deficit/            months after.            alternative
Hyperactivity                                treatment to
Disorder                                        ADHD.

                                             Limitation:
                                             Sample size

Neuro-feedback     Both treatments        A greater sample
Treatment for      reduced the ADHD     size is necessary to
Attention-            symptoms.               determine
Deficit/                                     equivalence
Hyperactivity         There were           between groups,
Disorder in        improvements in        because both led
Children: A        d2 and TOVA. No         to significant
Comparison           significant           improvement in
with                differences in         many variables,
Methylphenidate       Conners or            although the
                   Weschler results       equivalence test
                      were found         was not significant
                   between groups.        for all dependent
                                             variables.
                                             Changes in
                                          electroencephalo-
                                          graphic bands were
                                            not monitored
                                         after NF training.

Neurofeedback     Increase in Betha         NF is a good
treatment         waves activity and       choice to ADHD
of children       decrease in Theta          treatment.
with                    waves.
Attention                                  Cooperation of
Deficit             Improvement in           parents and
Hyperactivity       school grades,           teachers is
Disorder          social adaptation          essential.
                   and self-esteem
                    was observed.
                    ADHD symptoms
                    were reduced.

Controlled           Both groups           Improvement in
evaluation              showed             behavior may be
of a                improvement in         related to NF,
neurofeedback            the               especially at a
training of       neuropsychological      regulated level,
slow                 assessment.            but the found
cortical                                    advantage in
potentials        Less than half of          parents and
in children      the NF participants     teacher's scale in
with                 were able to           the NF groups
Attention        differentiate their          cannot be
Deficit/         cortical activity on       explained by
Hyperactivity    transference trials,    electrophysiologic
Disorder            so the effects        al mechanisms in
(ADHD)                cannot be           the entire group,
                      completely         however, it can be
                  attributed to the         influenced by
                  electrophysiologic     mediated variables
                     al training.         such as parental
                                              support.

ADHD and EEG-        Changes were           Improvements
neurofeedback:     similar in both        after NF could be
a double-blind      groups, with a          attributed to
randomized          significantly        nonspecific effects
placebo-            decreasing in           such as time
controlled          ADHD symptoms.          spent, given
feasibility                                  attention,
study                                        therapeutic
                                           interaction or
                                            expectations,
                                           rather than the
                                          ability to have
                                        self-control cerebral
                                              activity
                                           The sample size
                                         was limited. It is
                                             possible to
                                         conduct a rigorous
                                          study controlled
                                             by placebo
                                              feedback.

* Considered Absent group because there were two groups, each one
with a different protocol Neurofeedback: untrained or alternative
treatment

Table 3. Efficacy levels evaluation in the selected studies,
based in the criteria of the AAPB and the Neuronal Regulation
Society

                                       Specific,
                                       clear and
                                         valid
                        The sample    measurement,
                        is specific       with       A control
                           to a        exclusion     group is
                        particular        and        included
                         clinical      inclusion      in the
Study                    condition      criteria      design.

Neurofeedback in            Yes       Appropriate       Yes
children with
ADHD: Specific
event-related
potential findings
of a randomized
controlled trial

Neurofeedback in            Yes           Yes           Yes
ADHD: a single-
blind randomized
controlled trial

Neurofeedback               Yes           Yes           Yes
training in children
with ADHD:
6-month follow-up of
a randomised
controlled trial

Is Neurofeedback            Yes           Yes           Yes
an efficacious
treatment for
ADHD? A
randomized
controlled clinical
trial

Distinct EEG                Yes           Yes           Yes
effects related to
neurofeedback
training in children
with ADHD: A
randomized
controlled trial

Neurofeedback for           Yes           Yes           No
Children with
ADHD: A
Comparison of
SCP and
Theta/Beta
Protocols

Self-regulation of          Yes           Yes           No
Slow Cortical
Potentials: A New
Treatment for
Children With
Attention Deficit/
Hyperactivity
Disorder

Neurofeedback               Yes           Yes           Yes
Treatment for
Attention-Deficit
/Hyperactivity
Disorder in
Children: A
Comparison
between
Methylphenidate

Neurofeedback               Yes           Yes           No
treatment of
children with
Attention Deficit
Hyperactivity
Disorder, and a

Controlled                  Yes           Yes           Yes
evaluation of a
neurofeedback
training of slow
cortical potentials
in children with
Attention
Deficit/Hyperactivity
Disorder (ADHD)

ADHD and                    Yes           Yes           Yes
EEG-neurofeedback:
a double-blind
randomized
placebo-controlled
feasibility study

                                        Results
                                       compared      Intra and
                                         with          inter
                          Random      established   individuals
                        participant    efficacy     statistical
Study                   assignment    treatments     analysis.

Neurofeedback in            Yes        Partially        Yes
children with
ADHD: Specific
event-related
potential findings
of a randomized
controlled trial

Neurofeedback in            Yes           No            Yes
ADHD: a single-
blind randomized
controlled trial

Neurofeedback               Yes       Appropriate       Yes
training in children
with ADHD:
6-month follow-up of
a randomised
controlled trial

Is Neurofeedback            Yes       Appropriate       Yes
an efficacious
treatment for
ADHD? A
randomized
controlled clinical
trial

Distinct EEG                Yes       Appropriate       Yes
effects related to
neurofeedback
training in children
with ADHD: A
randomized
controlled trial

Neurofeedback for          Yes *          No            Yes
Children with
ADHD: A
Comparison of
SCP and
Theta/Beta
Protocols

Self-regulation of          No            No            Yes
Slow Cortical
Potentials: A New
Treatment for
Children With
Attention Deficit/
Hyperactivity
Disorder

Neurofeedback               No            Yes           Yes
Treatment for
Attention-Deficit
/Hyperactivity
Disorder in
Children: A
Comparison
between
Methylphenidate

Neurofeedback               No            No            Yes
treatment of
children with
Attention Deficit
Hyperactivity
Disorder, and a

Controlled               Partially        Yes           Yes
evaluation of a
neurofeedback
training of slow
cortical potentials
in children with
Attention
Deficit/Hyperactivity
Disorder (ADHD)

ADHD and                    Yes          No**           Yes
EEG-neurofeedback:
a double-blind
randomized
placebo-controlled
feasibility study

                            The
                        information
                         given by
                         the paper
                         allows to
                         replicate    Efficacy
Study                    the study     levels

Neurofeedback in            Yes         III
children with
ADHD: Specific
event-related
potential findings
of a randomized
controlled trial

Neurofeedback in            Yes         III
ADHD: a single-
blind randomized
controlled trial

Neurofeedback               Yes          IV
training in children
with ADHD:
6-month follow-up of
a randomised
controlled trial

Is Neurofeedback            Yes          IV
an efficacious
treatment for
ADHD? A
randomized
controlled clinical
trial

Distinct EEG                Yes          IV
effects related to
neurofeedback
training in children
with ADHD: A
randomized
controlled trial

Neurofeedback for        Partially       II
Children with
ADHD: A
Comparison of
SCP and
Theta/Beta
Protocols

Self-regulation of       Partially       II
Slow Cortical
Potentials: A New
Treatment for
Children With
Attention Deficit/
Hyperactivity
Disorder

Neurofeedback               Yes         III
Treatment for
Attention-Deficit
/Hyperactivity
Disorder in
Children: A
Comparison
between
Methylphenidate

Neurofeedback               Yes          II
treatment of
children with
Attention Deficit
Hyperactivity
Disorder, and a

Controlled                  Yes         III
evaluation of a
neurofeedback
training of slow
cortical potentials
in children with
Attention
Deficit/Hyperactivity
Disorder (ADHD)

ADHD and                    Yes          IV
EEG-neurofeedback:
a double-blind
randomized
placebo-controlled
feasibility study

* Participants were randomly assigned to two different
experimental conditions with no control group

** In this study the control group used a placebo neurofeedback
protocol
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Title Annotation:Original Research Article
Author:Gaviria Loaiza, Juana; Calderon-Delgado, Liliana; Barrera-Valencia, Mauricio
Publication:Revista CES Psicologia
Date:Jan 1, 2014
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