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To examine delayed effects of theta-beta ratio (TBR) neurofeedback (NF) for attention-deficit/hyperactivity disorder (ADHD) 25 months after baseline, ∼21 months after end of treatment.Children aged 7-10 with rigorously diagnosed ADHD had been randomized to 38 sessions of TBR NF (n=84) or control treatment (n=58) of identical appearance, intensity/frequency, and duration, differing only in that reinforcement for controls was based on a pre-recorded EEG of another child. Child, parent, and all site staff were blind until after 25-month assessments, with only one-fourth able to guess the control treatment correctly. Baseline assessments were repeated off medication after 25 months.Of the 142, 120 had 25-month follow-up (84.5% retention). Only 12 (6 controls) had NF after the study treatment, greatly retaining the randomization. The primary outcome, parent-rated inattention, was not significantly different between treatments despite large pre-post effect sizes (NF, d=1.63; controls, d=1.42). Most secondary measures showed the same pattern. Response rates (CGI-I≤2) were 58.6% of NF and 66% of controls (non-significant). Marginally more controls than NF recipients needed medication (57.1% vs 38.6%, p=0.059); specifically, 7.1% of NF and 4% of controls had reduced medication need while 34.3% of NF and 50% of controls needed more medication (p=0.084).Most of the large within-group improvement from the NF treatment package reported by unblinded studies and replicated in this blinded study reflects nonspecific effects, not specific effects of deliberate downtraining of EEG theta-beta power ratio. At 25-month follow-up it appears comparable to the evidence-based MTA treatments, suggesting a psychotherapeutic/behavioral effect.

Introduction: We examined psychiatric comorbidities moderation of a 2-site double-blind randomized clinical trial of theta/beta-ratio (TBR) neurofeedback (NF) for attention deficit hyperactivity disorder (ADHD). Methods:Seven-to-ten-year-olds with ADHD received either NF (n=84) or Control (n=58) for 38 treatments. Outcome was change in parent-/teacher-rated inattention from baseline to end-of-treatment (acute effect), and 13-month-follow-up. Seventy percent had at least one comorbidity: oppositional defiant disorder (ODD) (50%), specific phobias (27%), generalized anxiety (23%), separation anxiety (16%). Comorbidities were grouped into anxiety alone (20%), ODD alone (23%), neither (30%), or both (27%). Results: Comorbidity (p=0.043) moderated acute effect; those with anxiety-alone responded better to Control than to TBR NF (d=-0.79, CI -1.55- -0.04), and the other groups showed a slightly better response to TBR NF than to Control (d=0.22~0.31, CI -0.3-0.98). At 13-months, ODD-alone group responded better to NF than Control (d=0.74, CI 0.05-1.43). Discussion: TBR NF is not indicated for ADHD with comorbid anxiety but may benefit ADHD with ODD.

This study explores how EEG connectivity measures in children with ADHD ages 7-10 (n = 140) differ from an age-matched nonclinical database. We differentiated connectivity in networks, Brodmann area pairs, and frequencies. Subjects were in the International Collaborative ADHD Neurofeedback study, which explored neurofeedback for ADHD. Inclusion criteria were mainly rigorously diagnosed ADHD and a theta/beta power ratio (TBR) ≤ 4.5. Using statistical and machine learning algorithms, connectivity values were extracted in coherence, phase, and lag coherence at all Brodmann, subcortical, and cerebellar areas within the main networks in all EEG frequencies and then compared with a normative database. There is a higher rate of dysregulation (more than ± 1.97SD), in some cases as much as 75%, of the Brodmann pairs observed in coherence and phase between BAs 7, 10, and 11 with secondary connections from these areas to BAs 21, 30, 35, 37, 39, and 40 in the ADHD children as compared to the normative database. Left and right Brodmann areas 10 and 11 are highly disconnected to each other. The most dysregulated Brodmann Areas in ADHD are 7, 10, and 11, relevant to ADHD executive-function deficits and provide important considerations when developing interventions for ADHD children.

Objective: To determine whether theta/beta-ratio (TBR) electroencephalographic biofeedback (neurofeedback [NF]) has a specific effect on attention-deficit/hyperactivity disorder (ADHD) beyond nonspecific benefit. Method: In a 2-site double-blind randomized clinical trial, 144 children aged 7 to 10 years with rigorously diagnosed moderate/severe ADHD and theta/beta-ratio (TBR) ≥4.5 were randomized 3:2 to deliberate TBR downtraining versus a control of equal duration, intensity, and appearance. Two early dropouts left 142 children for modified intent-to-treat analysis. The control used prerecorded electroencephalograms with the participant's artifacts superimposed. Treatment was programmed via Internet by an off-site statistician-guided co-investigator. Fidelity was 98.7% by trainers/therapists and 93.2% by NF expert monitor. The primary outcome was parent- and teacher-rated inattention; analysis was mixed-effects regression. Because the expense and effort of NF can be justified only by enduring benefit, follow-ups were integrated. Results: Blinding was excellent. Although both groups showed significant improvement (p

Objective: To examine whether trainer continuity and experience impacted the significantly improved inattention scores (pre-post d = 1.44–1.53) seen in both the control and active treatment groups of “Double-Blind Placebo-Controlled Randomized Clinical Trial of Neurofeedback for Attention-Deficit/Hyperactivity Disorder” (2021). Methods: The primary trainer was the one who coached the most treatment sessions with a participant. A trainer was considered experienced after coaching 100 sessions. The percentage of sessions each participant had with their primary trainer and percentage with an experienced trainer were entered as independent variables into linear mixed models in SASv.9.4 with improvement in inattention ratings by parents and teachers (primary outcome) as dependent variable. Results: Effect of trainer continuity on primary outcome was not significant ( B = −0.016, SE = 0.153, t(123) = −0.11, p = .916). However, percent of sessions with an experienced trainer correlated with increased improvement ( B = 0.238, SE = 0.095, t(123) = 2.51, p = .013). Conclusion: Neurofeedback trainer continuity does not appear important, while trainer experience with at least 100 sessions correlates with better outcomes.

There has been ongoing research on the ratio of theta to beta power (Theta/Beta Ratio, TBR) as an EEG-based test in the diagnosis of ADHD. Earlier studies reported significant TBR differences between patients with ADHD and controls. However, a recent meta-analysis revealed a marked decline of effect size for the difference in TBR between ADHD and controls for studies published in the past decade. Here, we test if differences in EEG processing explain the heterogeneity of findings. We analyzed EEG data from two multi-center clinical studies. Five different EEG signal processing algorithms were applied to calculate the TBR. Differences between resulting TBRs were subsequently assessed for clinical usability in the iSPOT-A dataset. Although there were significant differences in the resulting TBRs, none distinguished between children with and without ADHD, and no consistent associations with ADHD symptoms arose. Different methods for EEG signal processing result in significantly different TBRs. However, none of the methods significantly distinguished between ADHD and healthy controls in our sample. The secular effect size decline for the TBR is most likely explained by factors other than differences in EEG signal processing, e.g. fewer hours of sleep in participants and differences in inclusion criteria for healthy controls.

The quantitative electroencephalographic (QEEG) theta/beta power ratio (TBR) has been shown to have an association with attention-deficit hyperactivity disorder (ADHD), with a previous tacit assumption of equivalence across hardware and software systems. Therefore, the International Collaborative ADHD Neurofeedback (ICAN) randomized clinical trial used a fixed TBR ≥ 4.5 cutoff as measured by the Thought Technology Monastra-Lubar Assessment Suite as an inclusion criterion, 1.5 SD above norms collected with that system. However, a difference was noted between the TBR calculated by that assessment suite and the TBR computed by EEGer, the neurofeedback software used for treatment, leading us to investigate the discrepancy. The difference may arise from different calculation methods. This article explains and compares various computational methods used to calculate and display EEG values, including TBR, elucidating why the values are not equivalent across equipment and software programs. Two major sources of variance are (1) how “spectral leakage” at the ends of bands is handled and (2) whether voltages of bins within a band are first averaged and then squared to get bandwidth power or are first squared to get power (turning negative voltages into positive power) and then averaged to get the bandwidth power; the latter method results in higher band power. This article compares methods of computing the TBR. Biofeedback practitioners and investigators should be aware of the algorithms their systems use when interpreting TBRs and require normative comparison data collected with the same system.

Research in the field of biofeedback has suffered both for lack of adequate methodological rigor and lack of adequate funding. The ISNR Research Foundation and the AAPB Foundation for Education and Research in Biofeedback are nonprofit foundations developed to promote and support a broad program of research in biofeedback and neurofeedback. A previous article featured an interview with the director of the ISNR Research Foundation, David Trudeau. The present article provides an interview with Paul Lehrer, Chair of the AAPB Foundation for Education and Research in Biofeedback. This interview series provides insight into the two foundations and invites professionals in the broad field of self-regulation therapies to support both.

Research in the field of biofeedback is not always effective for the development of the field. In particular, neurofeedback has had spotty success, with many studies failing to meet rigorous methodological standards. Many researchers are lacking in the basic understanding of neuromodulation and its inherent learning model. And many clinicians, while knowledgeable in clinical applications, lack understanding of the rigors of good research. However, the International Society for Neurofeedback and Research (ISNR) Foundation and the Association for Applied Psychophysiology and Biofeedback (AAPB) Foundation for Education and Research in Biofeedback are rich in expertise, yet that expertise is seldom tapped. The following interview with the president of the ISNR Research Foundation, David Trudeau, will spotlight the foundation's impact on the field of neurofeedback. A second interview with Paul Lehrer, Chair of AAPB's Foundation for Education and Research in Biofeedback (FERB) will appear in the summer 2014 issue of Biofeedback. It is hoped that this interview series will provide insight to both foundations and facilitate future collaboration.

Objective: Additional treatments with persisting benefit are needed for ADHD. Because ADHD often shows excessive theta electroencephalogram (EEG) power, low beta, and excessive theta-beta ratio (TBR), a promising treatment is neurofeedback (NF) downtraining TBR. Although several nonblind randomized clinical trials (RCTs) show a medium-large benefit for NF, a well-blinded, sham-controlled RCT is needed to differentiate specific from nonspecific effects. Method: Experts in NF, ADHD, clinical trials, and statistics collaborated to design a double-blind multisite RCT. Results/Conclusion: At four sites, 180 children aged 7 to 10 years with rigorously diagnosed ADHD and TBR ≥ 5 will be randomized to active TBR-NF versus sham NF of equal duration, intensity, and appearance. Sham, utilizing prerecorded EEGs with participant artifacts superimposed, will keep participants and staff blind. Treatment fidelity will be trained/monitored by acknowledged NF leaders. Multidomain assessments before, during, and after treatment (follow-up to 2 years) will also include tests of blinding and sham inertness.

Intrinsic functional connectivity within the default mode network (DMN) of the brain has gained growing interest in attention deficit/hyperactivity disorder (ADHD). The DMN is proposed to support such core functions as theory of mind, self-related activities such as autobiographical self, stimulus independent thought, self-projection, self-reference, and introspective processes as well as central features of self-regulation, task compliance, and executive functions. Based on prior data showing that sLORETA and fMRI localize DMN regions with complementary accuracy, we hypothesized that this combination of methods could provide important information about the functional integrity of DMN connectivity with special attention between parietal and medial prefrontal regions. This study was conducted with 6 adults with ADHD and 7 age-similar, nonclinical controls. The present study recorded brain activity using both EEG and fMRI during rest and a Stroop paradigm. For this study only the eyes-opened rest data were ...

Attention deficit hyperactivity disorder (ADHD) is a developmental psychiatric disorder thought to affect approximately 5 to 10% of school-age children, of whom 30 to 65% continue to exhibit symptoms into adulthood. The prevalence of ADHD in adults is also an estimated 4%, second only to depression. Across studies there appear to be significant network dysfunctions involved in ADHD. Typically the foci of interest in ADHD included the insular cortices, frontal lobes, basal ganglia, and cerebellum. More recently, attention has been directed to the default network of the brain and its functional integrity in ADHD with focus on the precuneus and parietal lobes and interactions with medial prefrontal cortices. Functional magnetic resonance imaging (fMRI) measures neurovascular coupling as measured by the blood oxygenated level dependent signal (BOLD). Electroencephalogram (EEG) measures brain electrical information. Because fMRI is an indirect measure of neuronal activity and EEG is a direct measure, combining...

Brain activity assessed by electroencephalography (EEG) has been demonstrated to respond to conditioning techniques. The concept of modulating this activity has been called EEG biofeedback, more recently neurofeedback, and is based on operant learning principles. Technological advancements have significantly enhanced the ease and affordability of recording and analyzing brain activity. Thus, properly trained practitioners can implement these conditioning strategies in their practice. Recent research indicating evidenced-based efficacy has made this technique a more viable option for clinical intervention. The objective of this article is to highlight the learning principles that have provided the fundamentals of this neuromodulatory approach. In addition, it is recommended that future applications in clinical work, research, and development adhere to these principles.

Introduction. Twenty-eight anxious adults were assessed for frontal lobe alpha asymmetry, a brain state associated with depression and anxiety. Fifteen of the 28 exhibited significant asymmetry and 12 agreed to participate in a biofeedback program addressed at reducing frontal alpha asymmetry. Method. The program consisted of earlobe temperature biofeedback (ETB) and two forms of neurofeedback, alpha suppression and alpha symmetry training. Individuals were instructed to warm their right earlobe for six sessions, and half succeeded, though success was not required to advance to the next stage of training. For subsequent EEG training, two anterior sites were selected on the basis of poor alpha coherence. Individuals were trained to reduce alpha magnitude at these sites by 10% for 30 min or more, which took from 6 to 16 sessions to achieve. Once successful with alpha suppression, individuals were trained to improve alpha symmetry between the sites by 15% for 30 min or more. Results. This feat took ...