Editorial: Neurofeedback in Attention-Deficit/Hyperactivity Disorder: Still No Evidence of Specific Effects

The Neurofeedback Collaborative Group presents the results from a 25-month follow-up, randomized controlled study of theta/beta ratio (TBR) down-training electroencephalography neurofeedback (EEG-NF).¹ NF is a computer-based training with real-time brain activity- contingent feedback in the form of a game with audio-visual rewards. These rewards aim to reinforce learning of neural activity patterns related to attention or behavioral control. The down-training of the TBR is considered a standard protocol of EEG-NF. The same group has previously published their findings about effects at the end of treatment and 13-month follow-up without evidence of specific NF effects on the primary outcome, a composite score of parent and teacher ratings of inattention. However, participants in the NF group had less need for medication than those in the control group.² This randomized controlled trial has several strengths, including a sophisticated "sham NF," excellent blinding of parents and investigators, fidelity procedures, and the use of a standard protocol in a population with elevated TBR. The control group was designed to overcome some of the downsides of previous sham-NF protocols by matching the patient's artifacts on the control electroencephalogram. In their current publication, the Neurofeedback Collaborative Group focuses on the possibility of delayed therapeutic NF effects that are thought to be due to the progressive learning of brain activity control.³ These putative delayed effects and lasting benefits are essential issues in determining the utility of NF in ADHD, because previous studies with blinded or probably-blinded assessments showed no short-term differences between NF and control conditions.⁴ Results confirm the pre-post effect sizes of previous studies, without significant group differences at the 25-month assessment, indicated that there are no specific effects of the NF training paradigm. This is in line with another recent randomized sham-controlled trial with functional magnetic resonance imaging-NF showing no group differences either on the clinical primary outcome or on cognitive functioning in children with attention-deficit/hyperactivity disorder (ADHD).⁵.