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What is the evidence that Neurofeedback really works?

The Association for Applied Psychophysiology and Biofeedback and the Society for Neuronal Regulation developed guidelines for the evaluation of clinical efficacy of psychophysiological interventions in 2001. The criteria are described below:

  • Level 1: Not Empirically Supported
    Supported only by anecdotal reports and/or case studies in non-peer-reviewed venues. Not empirically supported.
  • Level 2: Possibly Efficacious
    At least one study of sufficient statistical power with well-identified outcome measures but lacking randomised assignment to a control condition internal to the study.
  • Level 3: Probably Efficacious
    Multiple observational studies, clinical studies, wait-list controlled studies, and within-subject and intrasubject replication studies that demonstrate efficacy.
  • Level 4: Efficacious
    In a comparison with a no-treatment control group, alternative treatment group, or sham (placebo) control utilising randomised assignment, the investigational treatment is shown to be statistically superior to the control condition, or the investigational treatment is equivalent to a treatment of established efficacy in a study with sufficient power to detect moderate differences, and
  1. The studies have been conducted with a population treated for a specific problem, for whom inclusion criteria are delineated in a reliable, operationally defined manner, and
  2. The study used valid and clearly specified outcome measures related to the problem being treated, and
  3. The data are subjected to appropriate data analysis, and
  4. The diagnostic and treatment variables and procedures are clearly defined in a manner that permits replication of the study by independent researchers, and
  5. The superiority or equivalence of the investigational treatment has been shown in at least two independent research settings.
  • Level 5: Efficacious and Specific
    Evidence for Level 5 efficacy meets all the criteria for Level 4. In addition, the investigational treatment has been shown to be statistically superior to credible sham therapy, pill, or alternative bona fide treatment in at least two independent research settings.

What conditions may be helped by Neurofeedback?

  • Anxiety and Anxiety Disorders = Level 4: Efficacious
  • Attention Deficit Hyperactivity Disorder = Level 5: Efficacious and Specific
  • Autism = Level 3: Probably Efficacious
  • Depressive Disorders = Level 4: Efficacious
  • Post Traumatic Stress Disorder = Level 3: Probably Efficacious
  • Epilepsy = Level 4: Efficacious
  • Insomnia = Level 3: Probably Efficacious

Anxiety

Anxiety is the excessive anxiety or worry about a number of events or activities, that is difficult to control or manage and interferes with everyday activities of daily living. Symptoms may include: restlessness, feeling of edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbances such as difficulty going to sleep, staying asleep, or having unsatisfying restless sleep, and/or persistent intense worry about social situations for fear of negative judgment.

Neurofeedback is classed as Level 4: Efficacious for treating Anxiety and Anxiety Disorders, according to the criteria for levels of evidence of efficacy as developed by a Task Force of the Association for Applied Psychophysiology and Biofeedback and the Society for Neuronal Regulation (ISNR) in 2001.

Below are some research articles about Neurofeedback and Anxiety Disorders:

ADHD

Neurofeedback has the highest level of efficacy for the treatment of attention deficit hyperactivity disorder (ADHD). The ISNR (International Society for Neuroregulation and Research) considers Neurofeedback to be Efficacious and Specific (Level 5) which means there is quality research designs showing positive outcomes for improved attention, and decreased hyperactivity and impulsivity. This level 5 efficacy rating has been supported and endorsed by the American Academy of Pediatrics’ although is yet to be endorsed by Australian Standards.

There has been a growing body of evidence over the past 40 years documenting the effectiveness of neurotherapy for ADHD, including peer reviewed RCT trials and published journal articles. In at least three of these studies, Neurofeedback was found to be equivalent to stimulant medication in treating the core symptoms of ADHD and there are 5 studies which assessed whether there were sustained benefits of NFB after treatment ended, including two studies that conducted a two year follow up assessment. Each follow up assessment found that gains from neurofeedback were maintained.

Steiner et al (2014) found significant improvements with NFB including a strong reduction in ADHD symptoms such as increased attention and executive function compared to the control group and cognitive training group at a six month follow up. This study also found children already taking methylphenidate (Ritalin) required significant dosage increases over time to maintain outcomes if they were in the control or cognitive training group but there no significant dosage increase for children in the NFB group. This supports Neurofeedback as an effective standalone therapy as well as an adjunct treatment for ADHD.

You can access more information using the references and links to publications on Neurofeedback and ADHD:

  • Arns, M., de Ridder, S., Strehl, U. Breckler, M. and Coenan, A. (2009). Efficacy of neurofeedback treatment in ADHD: the effects of inattention, impulsivity and hyperactivity: a meta-analysis. Clinical EEG Neuroscience, 40(3): 180-9.
  • Piggot, E.H., De Biase, L., Bodenhamer-Davis, E. and Davis, R.E. (2013). The Evidence-Base for Neurofeedback as a reimbursable healthcare service to treat attention deficit hyperactivity disorder. White paper – International Society of Neurofeedback and Research.
  • Steiner, N. J., Frenette, E. C., Rene, K. M., Brennan, R. T., & Perrin, E. C. (2014, January). Neurofeedback and Cognitive Attention Training for Children with Attention-Deficit Hyperactivity Disorder in Schools. Journal of Developmental & Behavioral Pediatrics, 35(1), 18–27.  Link to study
  • Brain Futures - Report. Neurofeedback. An efficacious treatment for behavioural health – Summary of the evidence.
  • Perl, M. (2003) Neurofeedback training: Outcomes Analysis - NFB - Outcome Analysis document

For a full bibliography on the efficacy of Neurofeedback and ADHD Click Here

Autism

Neurofeedback is a non-invasive treatment modality that offers a viable alternative and/or complementary treatment to the traditional medical model and therapies for Autism, especially where medication is not an option, when it is only partially effective, has unwanted side effects, or where compliance is low (Rossiter and La Vague, 1995, p.11).

At this time, Neurofeedback has been assigned a Level 3: Probably Efficacious rating for evidence-based practice (Cohen, R and Ricca R. 2016: Evidence-based practice in Biofeedback & Neurofeedback 3rd ed). This rating is based on the type of studies that have been conducted so far and they include: observational studies, clinical studies, wait list-controlled studies and within subject and intra-subject replication studies that demonstrate efficacy. These studies demonstrated improvements in the following areas: socialisation, vocalisation, anxiety, school work, tantrums and sleep.  Research also found significant improvements in tasks measuring attention skills, cognitive flexibility, set shifting, concept generation/inhibition and planning as well as general improvements in communication, social interactions and stereotyped and repetitive behaviour (Koujzer, de Moor, Gerrits, Congedo & van Schie, 2009).

These promising outcomes have generated enthusiasm and greater need for further research using randomised, double-blinded, placebo-controlled trials, to continue to increase the quality of the evidence base demonstrating the efficacy of treatment for Autism in the future.

Here are some links to publications on Neurofeedback and Autism:

For a full bibliography of Neurotherapy and Autism: click here

Depression

Depression is characterised by a depressed mood for two weeks or more, loss of interest or pleasure in all or nearly all activities including those that used to be pleasurable or interesting, weight changes – loss or gain, insomnia or hypersomnia (feeling excessively tired or sleeping longer than usual), fatigue or loss of energy, difficulty concentrating on a task, feeling worthless of excessive or inappropriate guilt, psychomotor agitation or retardation, impaired functioning in relationships, work and/or other activities of daily living.

Neurofeedback is classed as Level 4: Efficacious for treating Depressive Disorders, according to the criteria for levels of evidence of efficacy as developed by a Task Force of the Association for Applied Psychophysiology and Biofeedback and the Society for Neuronal Regulation (ISNR) in 2001.

Below are some research articles about Neurofeedback and Depressive Disorders:

For futher readings click on the link below for a full bibliography:

PTSD

The use of neurofeedback training in treating PTSD can be considered a Level 3: Probably Efficacious treatment using the criteria commissioned by the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neurofeedback and Research (ISNR). This is based on the available evidence which shows positive responses in improving PTSD symptoms. However, there is a need for ongoing research which includes larger sample sizes, randomised control trials and neurofeedback as a single form of treatment rather than in combination with other treatment modalities, to strengthen the quality of evidence and level of efficacy (Tan et al, 2016). There needs to be more studies like those above, however, it can be difficult ethically and practically doing controlled randomised trials with PTSD.

Efficacy vs. Clinical Effectiveness according to the Applied Neuroscience Society of Australasia:

“Efficacy is determined by evaluating formal studies done on each disorder. When a study is done, the treatment is very carefully standardized, the people doing the interventions should have great expertise in the treatment and the disorder, and patients are very carefully selected. In the real clinical environment, the patients may have many problems in addition to the one they are being treated for (which would affect the chances of the treatment doing well), may be given many overlapping treatments at once (so you can't tell how much help any one treatment was), and the therapist may not be as experienced as the people running the research study. Thus, a treatment's efficacy may be greater or lesser than its effectiveness in the real clinical world.”

The following summary is extracted from the attached research paper by Van der Kolk et.al:

Twenty-four sessions of NF produced significant improvements in PTSD symptomatology in multiple traumatized individuals with PTSD who had not responded to at least six months of trauma-focused psychotherapy, compared to a waitlist control group that continued to receive treatment as usual. The effect sizes of NF in this study (d = -2.33 within, d = - 1.71 between groups) is comparable to the results reported for the best evidence based treatments for PTSD: Prolonged Exposure, CBT and EMDR, which, like this study, also generally have employed TAU control groups, and better than any published drug intervention for PTSD [51]. The rate of completion of the NF protocol (79%) was comparable to reported exposure-based PTSD treatments (76%) [52]. In this study 72.7% of the NF sample no longer met criteria for PTSD. This is comparable to the 62% reported in metanalyses of other treatment studies [53]. Only one participant in the active treatment condition (4%) reported significant side effects, an increase in flashbacks.

The NF subjects also had statistically significant improvements in measures of affect regulation, identity impairment, abandonment concerns, and tension reduction activities. In contrast with most evidence-based therapies for PTSD, which focus on processing memories of traumatic events, the target of NF is neural regulation and stabilization. Since lack of self-regulation has been identified as a principal cause of failure of exposure-based treatments [27–30], NF may be particularly helpful for traumatized individuals who are too anxious, dissociated or dysregulated to tolerate exposure-based treatments. Finding cost-effective treatments for PTSD and other psychiatric conditions is particularly important in light of the limitations of existing treatments. Our results suggest that NF deserves further investigation for its potential to improve affect regulation, executive functioning and attention.

If you would like to read more on Neurofeedback for the treatment of PTSD:

For a full and comprehensive bibliography click here

Epilepsy

“Epilepsy is a chronic, non-communicable (not contagious) neurological condition that can affect anyone, at any time point in their life. There are many causes, however in 50% of cases, the cause is unable to be determined.” (www.epilepsyqld.com.au)

Neurofeedback is classed as Level 4: Efficacious for treating Depressive Disorders, according to the criteria for levels of evidence of efficacy as developed by a Task Force of the Association for Applied Psychophysiology and Biofeedback and the Society for Neuronal Regulation (ISNR) in 2001.

Below are some research articles about Neurofeedback and Epilepsy:

For a full bibliography: