Theta beta ratio in attention deficit hyperactivity disorder using a multiverse analysis

Attention deficit hyperactivity disorder (ADHD) affects 5-7% of children worldwide, yet diagnosis continues to rely on clinical-behavioral assessments. The theta/beta ratio (TBR) derived from electroencephalography (EEG) has long been proposed as a complementary neurobiological marker of ADHD based on reports of elevated TBR in affected children. However, accumulating evidence has raised concerns about the robustness and generalizability of these findings, pointing to a strong sensitivity to methodological choices. Here, we used multiverse analyses to systematically quantify how researcher degrees of freedom shape conclusions about associations between TBR and ADHD. Across two large, independent datasets (Healthy brain network: N=1499; validation sample: N=381), we evaluated 576 theoretically plausible analytical specifications, varying recording conditions, reference scheme, frequency band definitions, treatment of aperiodic (1/f) activity, regions of interest, sample inclusion criteria, and covariate specifications. Across the multiverse, we found that group differences in TBR were highly contingent on analytical choices, with no evidence for robust main effects of diagnosis, indicating no reliable differences between healthy controls, ADHD-inattentive, and ADHD-combined subtypes. Instead, significant effects emerged primarily as interactions with age and individual alpha frequency (IAF), particularly when TBR was derived from aperiodic-uncorrected power or from the aperiodic signal itself. These interaction patterns replicated across both independent samples and were observed using both categorical and dimensional definitions of ADHD. Together, these findings indicate that previously reported TBR effects are largely driven by variability in aperiodic activity and IAF rather than genuine differences in oscillatory theta-beta dynamics. Our results challenge the interpretation of TBR as a reliable standalone biomarker for ADHD and underscore the importance of multiverse approaches for evaluating candidate neurobiological markers in heterogeneous clinical populations.