?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 reviewIntroduction
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 |
| Words: | 7543 |
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