We Understand the Reluctance to Treat a Child’s ADHD with Medication
Well, we sort of understand. That is, we’ve talked to many, many parents of children with ADHD through the years and have heard their concerns, their anguish, even, at the idea of giving their child a medication. (See our free page on ADHD Treatment.) In their search for anything else to treat their child’s ADHD they find discussions of dietary changes, behavior therapies, training for parents, herbal “medicines”, dietary supplements, minerals, meditation, massage therapy, computer training, app-based programs, and neurofeedback, that is, biofeedback. Neurofeedback is usually in the list and it has the appeal of sounding “scientific” but the child doesn’t have to swallow a pill. But the reality is that, with rare exception, a person with moderate-to-severe ADHD needs a medication. Skipping a needed medication means that the ADHD is not treated. Untreated ADHD is a setback for the child, both in the short run and life-long.
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Neurofeedback (Biofeedback) Doesn’t Work
Because it seems scientific and because it’s not medication, thousands of researchers have tried for almost half a century to find a neurofeedback of some sort that works. There are sensorimotor rhythm neurofeedback, theta/beta ratio protocol neurofeedback, and brain imaging neurofeedback approaches. But despite all this research, modifying the patterns of underlying brain activity has never been shown improvements in ADHD behaviors or cognition. Through the past forty years neurofeedback has never received FDA approval as a treatment that works for ADHD. The claims of ADHD treatment success have been based on case reports and small non-blinded, uncontrolled studies. Recently Dr. Lam at King’s College London and her colleagues completed a remarkably well-designed and carefully run study of functional magnetic resonance imaging neurofeedback as a treatment for children with ADHD (reference below). The study showed that sham, that is, fake neurofeedback, worked just as well as the real, active neurofeedback.
Even the Most Sophisticated and Elegant Neurofeedback for ADHD Finds No Benefit
This study is of the highest quality, with a carefully determined brain area target and the best research design. It showed that the active neurofeedback did not treat the ADHD. This study is one of many studies of equal quality showing neurofeedback to be of no use in treating ADHD. The wide variety of studies showing no benefit from neurofeedback means that the supposed treatment effect of neurofeedback does not arise from any specific type of neurofeedback choice or a change in brain activity target. The false flag of possible benefit comes from the nonspecific efforts like the supportive coaching, the effect of positive reinforcement for sitting still, and other efforts that are also in the placebo arm of each study. At some point we have to stop doing more dead end research. And clinical practitioners, in good conscience, need to stop offering it as a valid treatment.
One of our Readers in New Orleans (Louisiana, USA) commented:
Everywhere I look and read it all says that biofeedback works really well, that you just have to have the right kind.
This is true and sadly happens a lot. There’s a saying at the fringes of science: “If you can’t dazzle with data then bury with tons of baloney.” With forty years of information and misinformation mixed together, often copied, republished, repeated, and piled high, if one reads through the whole mess without a high level of knowledge and skepticism we see how it could make one a believer, even if a bewildered believer.
Lumped into the jumble are studies of little value, retrospective reports, case series, and studies with small samples. Often the diagnoses are uncertain and the children’s other medical conditions are multiple and varied. Study protocols, if they exist, or not standardized and the studies don’t have blinded comparison groups. Some of the studies that supposedly show the benefit of biofeedback chose people to rate the treatment’s success who have a high “positive expectation bias” and are really invested (sometimes financially invested) in the treatment working. If the raters are properly blinded and not biased the study’s success goes away.
Meta-analysis after meta-analysis that include only quality studies continue to show that neurofeedback does not treat ADHD, does not help children with ADHD to focus better or perform better. On the other hand, meta-analyses that grab any studies they can find, regardless of quality, sometimes come out with a different answer. But, there’s no way around the fact that the total, unfiltered information pool on treating ADHD with neurofeedback or biofeedback is a mess.
A Summary Statement by an Experienced ADHD Clinician
James J. McGough, MD, MS, is a Professor of Clinical Psychiatry in the University of California, Los Angeles, School of Medicine. He’s the Director of the Clinical Programs for ADHD and is Board Certified in Child and Adolescent Psychiatry. He wrote the first of the two published papers listed below. He makes several good points. A central point is, is it appropriate for clinicians to keep recommending and for parents to keep trying to use neurofeedback as though it actually treats ADHD when there is so much evidence that it does not treat ADHD? The fact that it’s a low-risk treatment is meaningless if it’s not a treatment at all. Parents might not like the idea of medications but there’s over half a century of experience showing that they work short-term and long-term and have a good safety profile.
While Ineffective Treatments Are Pursued the Clock Keeps Ticking
ADHD is a developmental disorder, meaning that as the child grows and develops the existence of ADHD shapes that development. And if the ADHD bends the development the wrong direction, that bend exists and doesn’t go away. Not treating ADHD in the right way at the right time has life-long consequences. So to spend six months, or a year, or two years trying a treatment that doesn’t work instead of trying a treatment that does work damages the child during critically-important stages of growth and maturation. We do need to have, and it’s great to have, research into new and better ways to treat ADHD. But neurofeedback is not one of them. Don’t waste a child’s time. They don’t have time to waste. We understand that there are rare instances when a parent just can’t get a medication to work. But is a treatment that doesn’t work the right answer?
James J. McGough MD MS. Neurofeedback for ADHD: Time to Call It Quits? American Journal of Psychiatry, Vol. 179 No. 12, December 2022, pp. 888-889.
Sheut-Ling Lam, Marion Criaud, Steve Lukito, Samuel J Westwood, Deborah Agbedjro, Olivia S Kowalczyk, Sarah Curran, Nadia Barret, Chris Abbott, Holan Liang, Emily Simonoff, Gareth J Barker, Vincent Giampietro, Katya Rubia. Double-blind, sham-controlled randomized trial testing the efficacy of fMRI neurofeedback on clinical and cognitive measures in children with ADHD. American Journal of Psychiatry, Vol. 179 No. 12, December 2022, pp. 947–958.
Pediatrics and Child Health on the efficacy of neurofeedback in the management of children with ADHD
Journal of Attention Disorders: What Do Meta-Analyses Have to Say About the Efficacy of Neurofeedback Applied to Children With ADHD?