Neurofeedback, behavior therapy, and pharmacological treatment are interventions used to manage attention-deficit hyperactivity disorder (ADHD) symptoms.
Neurofeedback trains individuals to regulate brain activity through real-time feedback. Behavior therapy teaches strategies to improve focus, organization, andimpulse controlthrough techniques like parent training and skill-building. Pharmacological treatment, typically stimulant medication, targets chemical imbalances to enhance attention and reduce hyperactivity.
Each approach has unique mechanisms of action, but all aim to alleviate ADHD symptoms and improve functioning.
Combining these therapies may provide complementary benefits, targeting neurological, behavioral, and physiological aspects of ADHD. Treatment plans should be individualized based on symptom presentation and patient preferences
Key Points
Rationale
Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in childhood that impairs functioning.
Pharmacological treatmentwith stimulants is frequently recommended but has drawbacks like adverse effects and lack of acceptance (Peterson, McDonagh, & Fu, 2008). Research has shown the efficacy of combining behavioral interventions with medication (Eiraldi, Mautone, & Power, 2012; Leung & Hung, 2008; Murray et al., 2008).
Non-pharmacological treatments likeneurofeedbackandbehavioral therapyhave also demonstrated effectiveness for ADHD (Arns, Heinrich, & Sthehl, 2014; Coates, Taylor & Sayal, 2015).
However, conclusions about the comparative effectiveness of neurofeedback, pharmacology, and behavior therapy remain controversial, with some considering neurofeedback an efficacious first-line treatment (Pigott & Cannon, 2014) and others still uncertain (Loo & Makeig, 2012).
Examining the differential effects can provide insight into whichtreatmentsmay be most suitable.
Method
Thisrandomized controlled trialcompared neurofeedback, pharmacology, and behavior therapy treatments for ADHD.
Procedure
Children were randomly assigned to the neurofeedback, pharmacology, or behavior therapy treatment group.
The behavior therapy group received parent training, which taught parents strategies to reinforce positive behaviors and manage challenging ones; teacher training, which provided educators with tools to support the child’s academic and behavioral functioning; and individual cognitive therapy sessions, which helped children develop skills in problem-solving,emotional regulation, and self-control.
ADHD assessments occurred 1 week before treatment and after the 20-week treatment period.
Sample
The 59 participants were 7-14 years old (mean age 8.8) and 77% male. They met DSM-V criteria for ADHD and scored above cutoffs on parent and teacher ADHD rating scales.
Exclusionary criteria included comorbid disorders, contraindications for medication, and intellectual disability.
Measures
Below are the specific measures used and what they are:
Statistical Analysis
Pre-post changes for each treatment were analyzed using paired t-tests or Wilcoxon tests. Between-treatment comparisons usedANOVAon pre-post change scores with Bonferroni-corrected post-hoc tests. Effect sizes were calculated using Cohen’s d.
Results
All three treatments led to significant pre-post improvements on most IVA/CPT and rating scale measures, with some differential effects:
Between-treatment ANOVAs on pre-post change scores found pharmacology superior to neurofeedback and behavior therapy on 5 IVA/CPT attention measures.
Neurofeedback and behavior therapy each surpassed pharmacology on 1-2 IVA/CPT measures. There were no significant differences on rating scales, but behavior therapy consistently had the largest effect sizes.
In summary, all treatments improved ADHD symptoms, but pharmacology had greater effects on attention, while neurofeedback and behavior therapy showed more improvement in impulsivity/hyperactivity.
Behavior therapy produced the broadest enhancements across neuropsychological and rating scale measures.
Insight
This study provides valuable insight into the differential impact of neurofeedback, pharmacological, and behavioral treatments for childhood ADHD. While all three treatments were beneficial, they showed distinct patterns of improvement.
Pharmacology, as the mainstream treatment, demonstrated the largest gains in attention on a computerized test.
However, neurofeedback matched or exceeded medication’s effects on measures of impulsivity and hyperactivity, especially when visual stimuli were involved. This suggests neurofeedback training may uniquely strengthen self-control.
The broad efficacy may stem from behavior therapy’s multi-pronged approach of child, parent, and teacher training targeting multiple environments.
Pragmatically, the results imply that treatment choice should consider the specific deficits of each child. Medication may be preferred for severe inattention, neurofeedback for impulsivity, and behavior therapy for global improvement.
Combining treatments may be optimal, with medication augmenting attention while neurofeedback and behavior therapy buttress self-regulation and implement skills across settings.
Future studies should replicate these comparisons in larger samples and examine longer-term outcomes. Best practices may involve tailored treatment plans integrating pharmacological and behavioral interventions to maximize benefits for children with ADHD.
Strengths
The study had many methodological strengths, enhancing the reliability and generalizability of the findings:
Limitations
While the study had notable strengths, some limitations should be considered when interpreting the results:
Implications
The results of this study have important clinical implications for the treatment of childhood ADHD. By directly comparing three empirically-supported treatments, the findings offer guidance for practitioners in selecting interventions best suited for a child’s symptomatic profile.
Pharmacological treatment with stimulant medication, the most widely used approach, was especially effective in improving attentional capacities. This suggests that for children whose primary difficulties lie in inattention, medication may be the frontline treatment of choice.
However, the study also highlighted the unique strengths of non-pharmacological approaches. Neurofeedback yielded larger gains in impulse control and hyperactivity, particularly when visual stimuli were involved.
This implies that neurofeedback may be indicated for children who struggle with behavioral self-regulation and impulsivity.
Behavior therapy, incorporating parent, teacher, and child training, showed the broadest impact, with improvements across neuropsychological and rating scale measures.
The pervasive benefits suggest that behavior therapy may be optimal when a more comprehensive treatment targeting multiple domains of functioning is desired.
Importantly, all three treatments were effective to some degree, implying that each has a role in ADHD management.
A multifaceted treatment plan integrating medication to target attention with neurofeedback and/or behavior therapy to enhance self-control and implement skills across settings may be a promising approach.
Clinicians should consider a child’s specific deficits, family preferences, and response to interventions in crafting an individualized treatment plan to optimize outcomes.
Further research is needed to replicate these findings, elucidate mechanisms of action, and evaluate long-term effects. Additionally, studies should examine factors influencing treatment response and develop algorithms for optimally combining and sequencing interventions.
As the present study suggests, leveraging the relative strengths of different modalities may lead to the most powerful, synergistic benefits for children with ADHD.
References
Primary reference
Moreno-García, I., Meneres-Sancho, S., Camacho-Vara de Rey, C., & Servera, M. (2019). A randomized controlled trial to examine the posttreatment efficacy of neurofeedback, behavior therapy, and pharmacology on ADHD measures.Journal of attention disorders,23(4), 374-383.https://doi.org/10.1177/1087054717693371
Other references
Arns, M., Heinrich, H., & Strehl, U. (2014). Evaluation of neurofeedback in ADHD: the long and winding road.Biological psychology,95, 108-115.https://doi.org/10.1016/j.biopsycho.2013.11.013
Coates, J., Taylor, J. A., & Sayal, K. (2015). Parenting interventions for ADHD: A systematic literature review and meta-analysis.Journal of attention disorders,19(10), 831-843.https://doi.org/10.1177/1087054714535952
Eiraldi, R. B., Mautone, J. A., & Power, T. J. (2012). Strategies for implementing evidence-based psychosocial interventions for children with attention-deficit/hyperactivity disorder.Child and Adolescent Psychiatric Clinics,21(1), 145-159.https://doi.org/10.1016/j.chc.2011.08.012
Bitsakou, P., Psychogiou, L., Thompson, M., & Sonuga-Barke, E. J. (2009). Delay aversion in attention deficit/hyperactivity disorder: an empirical investigation of the broader phenotype.Neuropsychologia,47(2), 446-456.https://doi.org/10.1016/j.neuropsychologia.2008.09.015
Loo, S. K., & Makeig, S. (2012). Clinical utility of EEG in attention-deficit/hyperactivity disorder: a research update.Neurotherapeutics,9(3), 569-587.https://doi.org/10.1007/s13311-012-0131-z
Murray, D. W., Arnold, L. E., Swanson, J., Wells, K., Burns, K., Jensen, P., Hechtman, L., Paykina, N., Legato, L., & Strauss, T. (2008). A clinical review of outcomes of the multimodal treatment study of children with attention-deficit/hyperactivity disorder (MTA).Current psychiatry reports,10(5), 424-431.https://doi.org/10.1007/s11920-008-0068-4
Peterson, K., McDonagh, M. S., & Fu, R. (2008). Comparative benefits and harms of competing medications for adults with attention-deficit hyperactivity disorder: a systematic review and indirect comparison meta-analysis.Psychopharmacology,197, 1-11.https://doi.org/10.1007/s00213-007-0996-4
Pigott, H. E., & Cannon, R. (2014). Neurofeedback is the best available first-line treatment for ADHD: What is the evidence for this claim?.NeuroRegulation,1(1), 4-4.
Keep Learning
Here are some reflective questions related to this study that could prompt further discussion:
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
