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4. Non-Pharmacological interventions

4.4 Neurofeedback

Neurofeedback (NF), also known as EEG (electroencephalography) Biofeedback, applies principles of operant conditioning to teach self-modification of cortical electrical activity. Neurofeedback requires EEG electrodes to be placed on the scalp to detect neural activity which is transferred through to a computer. The software converts the EEG patterns into visual and auditory rewards, which are ‘fed back’ to the participant to learn to inhibit or increase specific EEG frequencies of neural firing. There are several different types of neurofeedback and various treatment regimes.

Neurofeedback treatment technologies has given rise to two principal intervention approaches for ADHD: Sensori-Motor Rhythm or Beta-Wave (SMR) NF and Slow Cortical Potentials (SCP) NF. While the term neurofeedback has been used below please refer to the Technical Report for more detail on the neurofeedback approach used in each study.

Summary of evidence review

No evidence was identified to assess effectiveness of neurofeedback in this age group.

Neurofeedback versus waitlist/usual care
One new RCT of low certainty was identified (Lim et al., 2019). NICE reported a statistically significant benefit of neurofeedback over waitlist/usual care for ADHD inattention symptoms by parent rating (2 RCTs, moderate certainty) (Steiner, Frenette, Rene, Brennan, & Perrin, 2014; Steiner, Sheldrick, Gotthelf, & Perrin, 2011). There were no statistically significant benefits of neurofeedback over waitlist/usual care for: ADHD inattention symptoms by teacher rating (2 RCTs, moderate certainty: Steiner 2011, Steiner 2014) or clinician rating (one RCT, moderate certainty: Lim 2019).

Neurofeedback versus non-specific supportive therapy
New evidence was identified for a new comparison consisting of one RCT with high risk of bias and low certainty evidence (Alegria et al., 2017). No statistically significant benefits of neurofeedback over non-specific supportive therapy were found for parent-rated ADHD total, inattention, hyperactivity symptoms or other symptoms.

Neurofeedback versus active control
New evidence was identified for a new comparison consisting of one RCT reported in 2 studies with low risk of bias and moderate certainty (Aggensteiner et al., 2019; Strehl et al., 2017). No statistically significant benefits of neurofeedback over active control were found for parent-rated ADHD total, inattention, hyperactivity symptoms.

Neurofeedback versus sham
No new evidence was found. NICE previously identified 2 studies with very low- to low-quality evidence, which found a clinically important benefit for investigator-rated Clinical Global Impression scale, and no clinically important benefits for parent-rated total ADHD symptoms or serious adverse events.

Neurofeedback versus Exercise
No new evidence was found. NICE previously identified one study with low to moderate quality evidence which found no clinically important benefits for parent and teacher-rated ADHD inattention, hyperactivity symptoms and other symptoms.

Neurofeedback versus cognitive training
New evidence was identified in one study (Minder, Zuberer, Brandeis, & Drechsler, 2018) and integrated into the NICE evidence consisting of 3 studies (Gevensleben et al., 2009; Steiner et al., 2014; Steiner et al., 2011) resulting in 4 studies with low- to moderate-certainty evidence.

There were statistically significant benefits of neurofeedback over cognitive training for ADHD symptoms total (parent-rated, one RCT, low certainty: Gevensleben 2009 (NICE)); ADHD symptoms inattention – clinic setting (parent-rated, 2 RCTs, low certainty: Gevensleben 2009 (NICE), Minder 2018); ADHD symptoms inattention – clinic setting (teacher-rated, 2 RCTs, moderate certainty: Gevensleben 2009 (NICE), Minder 2018).

There were statistically significant benefits of cognitive training over neurofeedback for ADHD symptoms inattention – school setting (parent-rated, 3 RCTs, moderate certainty: Minder 2018, Steiner 2011 (NICE), Steiner 2014 (NICE)).

There were no statistically significant differences between neurofeedback and cognitive training for:

ADHD total symptoms (teacher-rated, one RCT, moderate certainty: Gevensleben 2009 (NICE)); ADHD inattention symptoms – school setting (teacher-rated, 3 RCTs, moderate certainty: Minder 2018, Steiner 2011 (NICE), Steiner 2014 (NICE)); ADHD hyperactivity/impulsivity symptoms – clinic setting (parent-rated, 2 RCTs, moderate certainty: Gevensleben 2009 (NICE), Minder 2018); ADHD hyperactivity/impulsivity symptoms- clinic setting (teacher-rated, 2 RCTs, moderate certainty: Gevensleben 2009 (NICE), Minder 2018); ADHD hyperactivity/impulsivity symptoms – school setting (parent-rated, 3 RCTs, moderate certainty: Minder 2018, Steiner 2011 (NICE), Steiner 2014 (NICE); ADHD hyperactivity/impulsivity symptoms – school setting (teacher-rated, 2 RCTs, low certainty: Minder 2018, Steiner 2011 (NICE)); Functional outcomes – clinic setting and school setting (parent-rated, 2 RCTs, moderate certainty; teacher-rated, 2 RCTs, moderate certainty); Functional outcomes (metacognition) – both school setting and clinic setting (parent-rated, one RCT of low certainty; teacher-rated, one RCT of low certainty Minder 2018); Functional outcomes (Behavioral Observation of Students in Schools (BOSS) engagement and off-task) – both school setting and clinic setting (investigator-rated, one RCT, low certainty: Minder 2018).

Neurofeedback versus Behaviour therapy
No new evidence was found. NICE previously identified one RCT (Christiansen, Reh, Schmidt, & Rief, 2014) with very low-quality evidence. There was no clinically important benefit for parent-reported ADHD inattention symptoms of neurofeedback compared with behaviour therapy.

Neurofeedback versus CBT & parent/family training
New evidence was identified for a new comparison consisting of a single small RCT (Moreno-Garcia, Meneres-Sancho, Camacho-Vara de Rey, & Servera, 2019), with high risk of bias and low certainty evidence, conducted in children with ADHD, comparing neurofeedback and child CBT and parent behaviour training over 20 weeks. There were statistically significant benefits of CBT & parent/family training over neurofeedback for parent-rated ADHD hyperactivity/impulsivity symptoms. There were no statistically significant differences between neurofeedback and CBT and parent/family training for parent and teacher-rated ADHD total and inattention symptoms and teacher-rated hyperactivity/impulsivity symptoms.

Neurofeedback plus cognitive training versus waitlist/usual care
New evidence was identified for a new comparison consisting of a single very small RCT (Rajabi, Pakize, & Moradi, 2020) conducted in boys with ADHD, comparing neurofeedback plus cognitive training and waitlist. Given the very low certainty of the outcome data in this study with very serious risk of bias and very serious imprecision, there is insufficient evidence to support or refute the intervention for ADHD inattention and hyperactivity symptoms, whether parent or teacher rated.

Neurofeedback versus waitlist/usual care
No new evidence was found. NICE previously identified one RCT of low quality (Cowley, Holmstrom, Juurmaa, Kovarskis, & Krause, 2016). There was a clinically important benefit of neurofeedback for self-rated ADHD inattention and hyperactivity symptoms.

Neurofeedback versus sham
New evidence was identified for a new comparison consisting of a single RCT (Schonenberg et al., 2017), with low risk of bias and moderate certainty of evidence, conducted in adults with ADHD, comparing neurofeedback and neurofeedback sham over 15 weeks. There were no statistically significant differences for self-reported ADHD symptoms using the Conners’ ADHD rating scale.

Neurofeedback versus CBT
New evidence was identified for a new comparison consisting of a single RCT (Schonenberg et al., 2017) with low risk of bias, moderate certainty of evidence conducted in adults with ADHD, comparing neurofeedback and CBT over 15 weeks. There were no statistically significant differences between neurofeedback and CBT for self-reported ADHD symptoms using the Conners’ ADHD rating scale.

Evidence-to-recommendation statement

Additional evidence was suggested during the public consultation process and is briefly summarised here. One study explored additive effects on neurofeedback in addition to methylphenidate in children and found no additional benefits of neurofeedback for ADHD symptoms and cognitive functioning (Lee & Jung, 2017) (included in NICE combined evidence review).

A very small study (n=7 per group) compared yoga, neurofeedback and a control group, finding yoga and neurofeedback resulted in similar improvements in sustained attention and memory (Rezaei, Salarpor Kamarzard, & Najafian Razavi, 2018) (not identified by our search; does not meet inclusion criteria). Sudnawa and colleagues (2018) (identified by our search but did not meet inclusion criteria) compared neurofeedback to methylphenidate in children, finding larger effects in the methylphenidate groups.

A recent study (Hasslinger, Bölte, & Jonsson, 2021), published after search completed, in children and adolescents, compared standard and non-standard neurofeedback to working memory training and waitlist control. They reported standard and non-standard neurofeedback were not superior to working memory training. They noted ‘Overall, the results from this pragmatic trial do not provide convincing support for broad implementation of [neurofeedback] in child and adolescent psychiatric services.’

Finally, in children, The Neurofeedback Collaborative Group (Arnold et al., 2021), published after the search was completed, compared theta/beta-ratio (TBR) electroencephalographic biofeedback (neurofeedback) to a control of equal duration, intensity, and appearance, in children. There were similar improvements in parent and teacher reported inattention in both groups. The authors concluded the findings did not support a specific effect of deliberate neurofeedback at either treatment end or 13-month follow-up.

In adults Barth and colleagues (2021) (published after the search was completed) explored slow cortical potential (SCP)- and functional near-infrared spectroscopy (fNIRS) neurofeedback compared with a semi-active electromyography biofeedback (EMG-BF) control condition. The authors reported: ‘All three groups showed equally significant symptom improvements suggesting placebo- or non-specific effects on the primary outcome measure’.

Two systematic reviews and meta-analyses were also noted during public consultation (Garcia Pimenta, Brown, Arns, & Enriquez-Geppert, 2021; Van Doren et al., 2019). Van Doren et al., (2019) was excluded because risk bias of the included studies was not reported and the diagnostic method of included studies was unclear or not reported. Discussion regarding the validity of the Schonenberg et al study (2017) was also highlighted. This included responses from Pigott (2017; 2021) and the authors response to Pigott and colleagues (Thibault, Veissière, Olson, & Raz, 2018).

Based on the evidence review, the evidence of benefits of neurofeedback over waitlist/usual care for parent- or teacher-reported ADHD was inconsistent in children and adolescents. There were benefits for ADHD inattention symptoms based on parent-report but not teacher or clinician report; and no benefits for parent or teacher-reported ADHD hyperactivity/impulsivity symptoms. In adults, the evidence was inconclusive.

The GDG debated whether to include a recommendation regarding neurofeedback. There was no new evidence identified that suggested a deviation from the NICE recommendation, where no recommendation regarding neurofeedback was included. This review did not identify sufficient evidence to support a recommendation of neurofeedback, and there was not a body of evidence showing no effect of these interventions. The GDG agreed not to include a recommendation regarding neurofeedback. The GDG agreed that further research may provide greater clarity and allow for recommendations in the future.

See Technical Report, section 5.1 for further details

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