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Objective: To evaluate sustained improvements six months after a 40-session, in-school computer attention training intervention using neurofeedback (NF) or cognitive training (CT) administered to 7–11 year olds with attention-deficit/hyperactivity disorder (ADHD). Methods: One hundred four children were randomly assigned to receive NF, CT, or a control condition, and evaluated six months post-intervention. A three-point growth model assessed change over time across the conditions on: Conners 3-Parent report (Conners 3-P), Behavior Rating Inventory of Executive Function (BRIEF) Parent Rating Scale, and a systematic doubleblinded classroom observation (Behavioral Observation of Students in Schools; BOSS). ANOVA assessed community-initiated changes in stimulant medication. Results: Parent response rates were 94% pre- to post-intervention and 90% at the six-month follow-up. Six months post-intervention, NF participants maintained significant gains on Conners 3-P (Inattention ES=0.34, Executive Functioning ES=0.25, Hyperactivity/Impulsivity ES=0.23) and BRIEF subscales including the composite (ES=0.31), which remained significantly greater than gains found among children in CT and control conditions. Children in the CT condition showed delayed improvement over immediate post-intervention ratings on Conners 3-P Executive Functioning (ES=0.18) and two BRIEF subscales. At the six-month follow-up, NF participants maintained the same stimulant medication dosage, while participants in both CT and control conditions showed statistically and clinically significant increases (9mg, p=0.002 and 13mg, p<0.001 respectively). Conclusion: NF participants made more prompt and greater improvements in ADHD symptoms, sustained at six-month follow-up, than did CT participants or those in the control group. This finding suggests that NF is a promising attention training treatment for children with ADHD.
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DOI: 10.1542/peds.2013-2059
; originally published online February 17, 2014;Pediatrics Ellen C. Perrin
Naomi J. Steiner, Elizabeth C. Frenette, Kirsten M. Rene, Robert T. Brennan and
Randomized Control Trial
In-School Neurofeedback Training for ADHD: Sustained Improvements From a
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
publication, it has been published continuously since 1948. PEDIATRICS is owned,
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In-School Neurofeedback Training for ADHD: Sustained
Improvements From a Randomized Control Trial
WHATS KNOWN ON THIS SUBJECT: An estimated 9.5% of children
are diagnosed with attention-decit/hyperactivity disorder
(ADHD), which affects academic and social outcomes. We
previously found signicant improvements in ADHD symptoms
immediately after neurofeedback training at school.
WHAT THIS STUDY ADDS: This randomized controlled trial included
a large sample of elementary school students with ADHD who received
in-school computer attention training with neurofeedback or cognitive
training. Students who received neurofeedback were reported to have
fewer ADHD symptoms 6 months after the intervention.
OBJECTIVE: To evaluate sustained improvements 6 months after a 40-
session, in-school computer attention training intervention using
neurofeedback or cognitive training (CT) administered to 7- to 11-
year-olds with attention-decit/hyperactivity disorder (ADHD).
METHODS: One hundred four children were randomly assigned to receive
neurofeedback, CT, or a control condition and were evaluated 6 months
postintervention. A 3-point growth model assessed change over time across
the conditions on the Conners 3Parent Assessment Report (Conners 3-P),
the Behavior Rating Inventory of Executive Function Parent Form (BRIEF),
and a systematic double-blinded classroom observation (Behavioral
Observation of Students in Schools). Analysis of variance assessed
community-initiated changes in stimulant medication.
RESULTS: Parent response rates were 90% at the 6-month follow-up.
Six months postintervention, neurofeedback participants maintained
signicant gains on Conners 3-P (Inattention effect size [ES] = 0.34,
Executive Functioning ES = 0.25, Hyperactivity/Impulsivity ES = 0.23) and
BRIEF subscales including the Global Executive Composite (ES = 0.31),
whichremainedsignicantly greater than gains found among children in
CT and control conditions. Children in the CT condition showed delayed
improvement over immediate postintervention ratings only on Conners 3-
P Executive Functioning (ES = 0.18) and 2 BRIEF subscales. At the 6-
month follow-up, neurofeedback participants maintained the same
stimulant medication dosage, whereas participants in both CT and
control conditions showed statistically and clinically signicant increases
(9 mg [P=.002]and13mg[P,.001], respectively).
CONCLUSIONS: Neurofeedback participants made more prompt and
greater improvements in ADHD symptoms, which were sustained at the
6-month follow-up, than did CT participants or those in the control
group. This nding suggests that neurofeedback is a promising attention
training treatment for children with ADHD. Pediatrics 2014;133:483
AUTHORS: Naomi J. Steiner, MD,
Elizabeth C. Frenette,
Kirsten M. Rene, MA,
Robert T. Brennan, EdD,
Ellen C. Perrin, MD
The Floating Hospital for Children at Tufts Medical Center,
Department of Pediatrics, Boston, Massachusetts; and
School of Public Health, Boston, Massachusetts
ADHD, neurofeedback, biofeedback, cognitive training, growth
ADHDattention-decit/hyperactivity disorder
BOSSBehavioral Observation of Students in Schools
BRIEFBehavior Rating Inventory of Executive Function
CompATcomputer attention training
Conners 3-PConners 3Parent Assessment Report
CTcognitive training
RAresearch assistant
Dr Steiner conceptualized and designed the study, drafted the
initial manuscript, and approved the nal manuscript as
submitted. Ms Frenette and Ms Rene carried out the initial
analyses, reviewed and revised the manuscript, and approved
the nal manuscript as submitted. Dr Brennan carried out the
growth model analyses, reviewed and revised the manuscript,
and approved the nal manuscript as submitted.
This trial has been registered at
(identier NCT01583829).
Accepted for publication Dec 18, 2013
Address correspondence to Naomi J. Steiner, MD, Floating
Hospital for Children at Tufts Medical Center, 800 Washington St,
Box 334, Boston, MA 02111. E-mail: nsteiner@tuftsmedicalcenter.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
FUNDING: All phases of this study were supported by an
Institute of Education Sciences grant (R305A090100).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conicts of interest to disclose.
PEDIATRICS Volume 133, Number 3, March 2014 483
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Attention-decit/hyperactivity disorder
(ADHD) is a neurodevelopmental dis-
order with core symptoms of inatten-
tion, hyperactivity, and/or impulsivity
and has a prevalence of 9.5% for 4- to 17-
year-olds in the United States.
tive functioning is typically impaired in
children with ADHD, affecting their ac-
ademic achievement.
Medication and
behavior therapy are both viable treat-
ment options for ADHD,
but they both
have limitations. These limitations,
along with the pervasiveness of ADHD
symptoms in school, highlight the im-
portance of researching alternative
treatments that can be implemented in
the classroom setting. Computer atten-
tion training (CompAT) is an umbrella
term used to describe many computer
interventions that appear to be effec-
and that might be possible to im-
plement on a large scale in school.
Based on theories of operant condi-
tioning and brain plasticity, the goal of
CompAT interventions is to decrease
ADHD symptoms and improve executive
functioning skills. CompAT interventions
may provide sustainable benets even
after the intervention is terminated
through its conditioning and general-
ization components. Two typesof CompAT
interventions were evaluated in the cur-
rent study: neurofeedback and cognitive
training (CT).
EEG patterns in children with ADHD have
shown more theta wave activity and
increased theta:beta ratio in the frontal
cortex, compared with children without
Beta Waves in the frontal
cortex are associated with sustaining
attention and thinking, whereas theta
waves are prevalent when drowsy or
daydreaming. However, other studies
have not conrmed the nding that
children with ADHD have elevated
theta:beta ratios when compared with
The authors of these stud-
ies hypothesized that children in control
conditions also have elevated theta:
beta ratios than has been observed in
the past, potentially due to decreased
sleep (among other factors), making
the 2 groups look more alike. When
training attention, neurofeedback pro-
vides children with immediate auditory
and visual feedback regarding their
level of attention during each exercise.
Changes are enabled because of brain
plasticity of the frontal brain, which
continues to develop throughout child-
hood and into early adulthood.
rofeedback therefore trains users to
monitor and change their brainwave
patterns, leading to behavioral changes.
Some studies have found that neuro-
feedback can decrease symptoms of
including improved attention,
and cognitive improvements
up to 6 months postintervention as well
as at 2 years postintervention.
ever, the evidence for its sustainability
remains unclear, because there are
limited studies examining follow-up
data, and those that do have small
sample sizes or no control condition.
In contrast, CT uses specically de-
signed exercises to train attention,
working memory, and impulsivity through
ongoing feedback to reinforce correct
responses. Several studies suggest that
CT improves performance on working
memory tasks and decreases inatten-
tiveness, hyperactivity, and disruptive
The largest such trial
included only 44 children diagnosed
with ADHD, ages 7 to 12 years, and re-
ported results 3 months after com-
pleting a 20-session intervention.
Gevensleben et al
examined neuro-
feedback and CT after 6 months and
found that improvements in the neuro-
feedback condition on parent-reported
behavior scales were signicantly su-
perior and sustained compared with the
CT condition. Unfortunately, signicant
attrition makes this studys generaliz-
ability unclear. A recent meta-analysis
regarding nonpharmacologic inter-
ventions for ADHD concluded that in-
creased evidence is needed for both
neurofeedback and CT interventions
before they can be supported as
treatments for ADHD.
The current study is novel for several
reasons. The research team conducted
the rst in-school translational efcacy
trial comparing neurofeedback, CT, and
control conditions. Previous studies
have mostly been conducted in labo-
ratories or in clinical settings. This ef-
cacy trial targeted a precise age range
of children 7 to 11 years of age, as
opposed to previous studies that in-
cluded diverse developmental age
ranges. Many studies are smaller
without a control group and failed to
nd group differences. Last, very few
studies reported follow-up results.
Pre- to postintervention, we found sig-
nicantly greater improvements in
ADHD symptoms, including attention
and executive functioning, among
neurofeedback participants compared
with the control and CT conditions.
the present article, we report outcomes
6 months after the conclusion of the in-
tervention. We hypothesized that partic-
ipants receiving neurofeedback would
maintain improvements in attention and
executive functioning compared with
control or CT conditions and that med-
ication dosage would remain stable.
Students with ADHD who were attending
1 of 19 public elementary suburban or
urban schools in the Greater Boston
area were eligible to participate in the
randomized trial. Inclusion criteria in-
cluded the following: (1) child in second
or fourth grade, (2) clinical diagnosis of
ADHD made by the childs clinician, and
(3) ability to speak and understand
English well enough to follow the pro-
tocol, although English was not neces-
sarily the participantsrst language.
Exclusion criteria included (1) a coex-
isting diagnosis of conduct disorder,
autism spectrum disorder, or other
484 STEINER et al at Harvard University on February 19, 2014pediatrics.aappublications.orgDownloaded from
serious mental illness (eg, psychosis)
and (2) an IQ measured by the Kaufman
Brief Intelligence Test ,80, to limit
confounding factors and requirements
of extensive amendments to the inter-
vention protocol that could affect stan-
dardized implementation. The study was
located in schools, and investigators
had no clinical responsibility for the
childrens medical care. Therefore,
children were included on the basis of
their clinicians diagnosis of ADHD, and
were included regardless of whether
they were taking medications for ADHD.
Parents of all participants were in-
formed that they should continue to
adhere to scheduled clinician visits
and standard community treatments
(including counseling and medication
management) independent of study
participation, and medication use was
not suspended for treatments or as-
sessments. The study was approved by
the Tufts Medical Center Institutional
Review Board, and written informed
consent and child assent were obtained.
Enrollment of the rst cohort occurred
from May to September 2009 and from
May to September 2010 for the second
cohort. All preintervention assessments
were conducted in October, and inter-
ventions were initiated in November of
each year. For each cohort, the research
coordinator balanced participants on the
basis of school district, gender, and medi-
cation status, and then assigned them via
a computer random number generator
into 3 conditions (neurofeedback, CT, and
control). Before enrollment, parents were
told their child would be randomly
assigned into 1 of these 3 conditions, and
were informed of their childsgroup
status after assignments were made.
Participants received in-school 45-
minute intervention sessions 3 times
per week, monitored by a trained re-
search assistant (RA), for 40 sessions
over 5 months. The same protocol was
used for both intervention conditions.
RAs received a standardized 2-week
training to administer neurofeedback
and CT, followed by a posttraining test
and direct observation assessments.
RAs lled out a standardized session
checklist for each child at every session
to monitor implementation delity.
The specic neurofeedback system used
(Play Attention, Unique Logic and Tech-
nology, Fletcher, NC) detects 2 frequency
ranges, 1 in the low-frequency theta
brainwave range (48 Hz) and another
in the high-frequency beta brainwave
range (1215 Hz).
The brainwaves are
measured by an EEG sensor embedded
in a standard bicycle helmet centrally
located on the top of the skull, and 2
other EEG sensors one a grounding
sensorand the other a reference, on the
chin straps located bilaterally on the
mastoids. Through practice, partic-
ipants learn to manipulate the gures
on the screen, resulting in suppression
of theta and an increase in beta activity.
As the theta:beta ratio changes, an al-
gorithm is used so that participants
score points on the computer program
and learn how to improve attention on
the 6 different exercises.
The specicCTinterventionused(Cap-
tains Log, BrainTrain, North Chestereld,
VA) comprises exercises that train dif-
ferent areas of cognition, which may be
designed into personalized exercise
protocols. The system is well designed
for large-scale delivery, because there is
automatic level advancement after each
The standardized protocol
developed for this study is composed of
14 auditory and visual exercises tar-
geting areas of attention and working
memory. Each exercise is interactive
and lasts 5 minutes. Both systems are
commercially available.
Primary Outcome Measures
Outcome measures included parent
reports of ADHD symptoms and executive
functioning, medication use, and sys-
tematic classroom observations of
behavior. All outcome measures were
obtained pre- and postintervention, and
6 months later.
The Conners 3Parent Assessment Re-
port (Conners 3-P; Multi-Health Sys-
tems Inc, North Tonawanda, NY) is a
validated and standardized instrument
to assess ADHD symptoms,
9 subscales comprising 2 summary
scales summed together as a Global
Index. The Behavior Rating Inventory of
Executive Function (BRIEF) (PAR Inc,
Lutz, FL) is a validated and standard-
ized instrument that assesses execu-
tive functioning,
including 8 subscales
comprising 2 indices summed together
in the Global Executive Composite. Both
parents, if available, completed the
Conners 3-P and BRIEF.
The Behavioral Observation of Students
in Schools (BOSS; Pearson Education,
Inc, New York, NY)
is a systematic
interval recording observation system
for coding classroom behavior and
reports on engagement (active or pas-
sive) and off-task behaviors (motor,
verbal, and passive). Data output from
observations are objective quantitative
assessments, which can help reduce
observer bias, and consist of raw data
as well as the percentage of intervals
the participant was recorded as en-
gaged or off-task. The BOSS has been
found to be reliable between observ-
to differentiate between children
with ADHD and their typically developing
and to be sensitive to treatment
The BOSS was completed 3
times at each time point (ie, before the
intervention, immediately after the in-
tervention, and 6 months after the in-
tervention) for all study participants by
trained RAs
who were unaware of the
participantsrandomization conditions.
The participants were unaware that
they were being observed.
A Medication Tracking Questionnaire
was completed by the primary parent at
each time point to track medication
type, dosage, and history. No direct
PEDIATRICS Volume 133, Number 3, March 2014 485
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consultation regarding medication was
discussed with parents, who were en-
couraged to continue their regularly
scheduled visits with their clinician.
Stimulant medications were converted
into methylphenidate equivalencies by
the research team to compare dosage
over time. The reliability of parent
reports was assessed by comparing
name and dosages of medication at
each time point. Ambiguous responses
were claried by direct communication
with parents and clinicians.
Data Analysis
Analysis of variance was conducted to
assess baseline differences in de-
mographic data between randomiza-
tion conditions. Missing items within
multiitem scales were resolved by using
expectation maximization imputation,
which is an iterative imputation method
suitable for low-frequency missing data
and/or when SEs are not of primary
When a full questionnaire was
missing, it was dropped from the analy-
sis and addressed directly through the
analytic strategy described below. Be-
cause this study investigated whether
the 2 CompAT interventions are superior
to community treatment alone, and
whether neurofeedback is superior to CT,
this randomized controlled trial is con-
sidered a superiority trial and analyses
are presented with 1-tailed tests.
The central focus of these analyses was
to evaluate whether the observed
changes in core ADHD symptoms be-
tween the start and end of the treatment
period were sustained at the 6-month
follow-up. Changes in parent-reported
and classroom observation measures
were investigated by 3-point growth
models by using a multilevel approach
to assess change over the 3 time points
(preintervention, postintervention, and
6-month follow-up) to compare neuro-
feedback and CT with the control.
Our approach used all available data,
including the reports from 2 parents
when available at all 3 time points.
These models allow for the estimation
of reliability of measurement and
change within the overall estimation,
and can exibly accommodate un-
balanced data, so a participant can be
included at a time point even if only 1
parent questionnaire was available at
any or all of the time points. For the
BOSS, 3 observations at all 3 time
points were used to estimate re-
This linear model estimates
the best-tting line to the 3 time points.
Comparisons between neurofeedback
and CT were undertaken using mul-
tivariate general linear hypothesis
For ease in interpretation and
comparison with other studies, ap-
proximate effects sizes (expressed as
standardized mean differences, Cohensd)
were computed from the neurofeed-
back and CT coefcients from the
growth models; however, to the best of
our knowledge, no other study of Com-
pAT reports growth coefcients and,
furthermore, standard calculations do
not accommodate all of the parameters
estimated in a multilevel model.
growth models were estimated by using
HLM version 7.0.
All other analyses and
data treatment were conducted by us-
ing SYSTAT version 13.0.
Paired ttests were conducted to eval-
uate stimulant medication differences
in methylphenidate equivalencies within
randomization conditions between pre-
intervention and the 6-month follow-up.
An analysis of covariance was con-
ducted to evaluate medication dosage
differences among the randomization
conditions at 6-month follow-up, con-
trolling for preintervention stimulant
medication dosages.
Of the 104 children in the study, 102
completed the intervention. Of these,
only 4 did not complete the 6-month
follow-up assessment (n= 98) (Fig 1).
The mean response rates of the parent
questionnaires for pre- and postinter-
vention data were 94% for the primary
parent and 77% for the secondary par-
ent. At the 6-month follow-up, response
rates were 90% for the primary parent
and 82% for the secondary parent. The
BOSS was completed 3 times for each
participant at preintervention, post-
intervention, and 6-month follow-up for
100% of participants. At baseline, 95% of
participants showed clinically signi-
cant scores $65 on the Diagnostic and
Statistical Manual of Mental Disorders,
Fourth Edition, ADHD Inattention and/or
ADHD Hyperactive-Impulsive subscales.
At baseline, 49% of participants were
taking medication. There were no sta-
tistically signicant differences be-
tween randomization conditions at
baseline with regard to gender, family
income, race, medication use, or base-
line ADHD symptoms (Table 1). There were
no signicant differences between par-
ticipants who completed or who did not
complete the intervention, or between
randomization conditions at 6-month
follow-up regarding gender, family in-
come, or race. There were no adverse
side effects in neurofeedback or CT
interventions reported on the session
Growth Model Analysis
The majority of distributions for the
measures at each time point and the
changes were approximately symmet-
rical and tailed, but normality could not
be assumed for all scales, so we relied
on the robust SEs available in HLM
the assessment of hypotheses in the
Conners 3-P, BRIEF, and BOSS models.
The slopes of the primary scales of
research interest on the Conners 3-P,
BRIEF, and BOSS are displayed to show
change over time by condition.
Parent-Reported Measures
Participants in the neurofeedback con-
dition showed signicant improvements
over time compared with the control
condition on Conners 3-P in the intervention-
targeted areas of inattention, executive
functioning, and hyperactivity/impulsivity
486 STEINER et al at Harvard University on February 19, 2014pediatrics.aappublications.orgDownloaded from
as well as in 4 of 6 general behavior
subscales (Table 2 and Supplemental
Table 4) and on all 3 BRIEF summary in-
(Table 2 and Supplemental Table 5). Par-
ticipants in the CT condition showed
signicant improvements over time
compared with the control on only 1 of
the 5 Conners 3-P subscales (Table 2)
and on 2 of 8 BRIEF subscales (Sup-
plemental Table 5). Furthermore, par-
ticipants in the neurofeedback condition
showed signicant improvements over
time compared with the CT condition
on 6 Conners 3-P subscales (Supple-
mental Table 4) and on 6 BRIEF sub-
scales (Supplemental Table 5). See
Fig 2 for observed participant mean
scores across the 3 study time points
by condition in core ADHD and execu-
tive functioning areas.
Classroom Observation
Results from the linear growth model
did not show sustained change; how-
ever, the linear model was not a good t
for Off-task Motor/Verbal, therefore
a quadratic model was estimated and
signicant improvements were found in
the neurofeedback condition compared
with the control (P= .04). There were no
differences found between neurofeed-
back and CT conditions on classroom
observation measures (Table 3).
CONSORT (Consolidated Standards of Reporting Trials) diagram.
In a small number of cases, parent or teacher data were missing; therefore, sample sizes
may be somewhat smaller than is indicated here.
TABLE 1 Participant Characteristics
NF CT Control
n34 34 36
Age, mean (SD), y 8.4 (1.1) 8.9 (1.0) 8.4 (1.1)
Male gender, n23 22 25
Race, n
White 23 24 29
Black or African American 3 1 3
Asian 7 8 4
Fourth grade
,n21 28 22
Family income #$74 999, n13 12 12
Suburban school district, n24 25 27
IQ, mean (SD)
IQ composite 106.6 (13.9) 108.4 (14.3) 108.9 (15.4)
Verbal IQ 101.3 (16.7) 103.9 (19.4) 105.1 (16.3)
Nonverbal IQ 109.6 (12.5) 110.2 (12.1) 109.7 (17.7)
ADHD medication, n15 14 20
Medication MPH equivalent
, mean (SD) 28.9 (14.4) 24.2 (10.2) 25.1 (15.9)
Counseling (private), n978
School services: IEP/504 Plan, n27 22 21
Conners 3-P Global Index, mean (SD) 75.77 (13.46) 70.89 (10.83) 74.61 (12.08)
BRIEF Global Executive Composite, mean (SD) 66.30 (10.00) 61.75 (6.59) 64.65 (9.02)
BOSS Engaged, mean (SD) 72.16 (12.40) 73.37 (13.30) 78.20 (11.67)
BOSS Off-Task , mean (SD) 30.17 (17.10) 25.87 (15.05) 21.14 (13.87)
IEP, Individualized Education Plan; MPH, methylphenidate; NF, neurofeedback.
Signicant difference between conditions.
Only includes participants who were taking a stimul ant medication.
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TABLE 2 Primary Measures: Parent Results
Observed Data
Growth Model Estimates
Preintervention Postintervention Six-Month
Coefcient 95% CI NF Versus
CT Versus
NF Versus
Effect Size
Conners 3-Pcore ADHD symptoms
Control 76.72 (10.02) 75.16 (10.47) 74.58 (10.03) 21.26 22.56 to 0.05 20.12
NF 80.07 (10.77) 71.43 (10.79) 70.06 (13.17) 23.67 25.81 to 21.52 ** 20.34
CT 74.78 (9.50) 70.21 (10.31) 67.56 (9.05) 21.55 23.75 to 0.64 20.14
DSM-IV-ADHD Inattention
Control 75.45 (11.20) 73.90 (11.91) 73.42 (11.45) 21.25 22.31 to 20.19 20.11
NF 79.20 (11.65) 70.13 (11.76) 68.45 (14.30) 23.45 25.36 to 21.55 ** 20.29
CT 73.48 (10.11) 70.07 (10.51) 66.13 (11.91) 21.88 23.78 to 0.02 20.16
Executive Functioning
Control 69.26 (11.64) 70.36 (12.56) 70.52 (12.38) 20.10 21.14 to 0.94 20.0082
NF 72.23 (12.16) 65.97 (13.16) 65.00(14.65) 23.02 24.88 to 21.16 ** 20.25
CT 67.46 (12.04) 66.00 (12.12) 62.45 (11.28) 22.18 23.91 to 20.45 * 20.18
Control 77.03 (13.77) 75.42 (14.51) 77.16 (13.60) 0.67 20.53 to 1.87 0.05
NF 76.92 (13.54) 72.73 (14.38) 72.36 (16.34) 23.19 25.27 to 21.11 ** 20.23
CT 72.04 (13.69) 73.07 (15.75) 72.19 (12.92) 20.03 21.91 to 1.85 20.01
DSM-IV-ADHD Hyperactive-Impulsive
Control 75.45 (13.61) 74.84 (14.00) 65.16 (14.41) 1.11 20.12 to 2.35 0.08
NF 75.43 (13.76) 71.33 (14.51) 72.14 (15.94) 22.90 24.91 to 20.90 ** ** 20.21
CT 69.00 (13.71) 71.43 (15.73) 71.01 (13.25) 0.34 21.47 to 2.15 20.02
BRIEFsummary indices
Behavior Regulation Index
Control 60.84 (11.62) 61.36 (10.35) 60.39 (11.79) 0.39 20.64 to 1.42 0.04
NF 62.43 (11.52) 59.03 (10.05) 59.82 (11.70) 22.43 24.22 to 20.65 * 20.23
CT 59.29 (8.65) 59.86 (10.28) 59.07 (9.60) 20.50 21.97 to 0.97 20.05
Metacognition Index
Control 65.45 (8.41) 65.48 (9.45) 67.13 (8.07) 0.26 20.56 to 1.08 0.03
NF 66.93 (9.69) 62.77 (9.09) 60.80 (12.37) 22.92 24.50 to 21.35 ** 20.33
CT 62.14 (6.67) 61.33 (8.22) 60.21 (7.87) 20.91 22.20 to 0.39 20.10
Global Executive Composite
Control 64.65 (9.02) 64.81 (9.04) 65.48 (8.36) 0.23 20.65 to 1.10 0.0249
NF 66.30 (10.00) 62.07 (8.86) 61.02 (11.57) 22.75 24.37 to 21.13 ** * 20.31
CT 61.75 (6.59) 61.46 (8.30) 60.29 (7.30) 20.65 21.96 to 0.65 20.07
CI, condence interval; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; NF, neurofeedback.
Data are presented as means (SD).
The growth model coefcient estimates for NF and CT represent the difference in the linear slopes between the intervention conditions and the control condition over the 3 time points. A multivariate general linear hypothesis test was conducted to
determine differences between the NF and CT slopes over the 3 time points.
Approximate effect size estimate for linear growth coefcient.
*P,.05, ** P,.01.
488 STEINER et al at Harvard University on February 19, 2014pediatrics.aappublications.orgDownloaded from
Medication Analysis
Among participants receiving stimulant
medication, the mean dosage change in
the neurofeedback condition from pre-
intervention to 6-month follow-up was
a 0.70-mg methylphenidate-equivalent
increase (P= .44). In both CT and con-
trol conditions, parents reported sig-
nicant increases: 13.08 mg for CT (P=
.02) and 9.14 mg for the control (P,
.001). No between-group dosage differ-
ence was found at 6-month follow-up,
controlling for preintervention (P=.08).
The outcomes of these analyses are
promising. Parents of children in the
neurofeedback condition reported sus-
tained improvements 6 months after
the intervention, compared with those in
the control condition. In the CT condition,
areas of executive functioning that did
not show statistically signicant change
immediately after the intervention
showed a signicant change by the 6-
month follow-up assessment compared
with the control condition. Even after
the intervention had stopped, parents
continued to notice improvements in
response to both interventions. Al-
though similar to the Arns et al
analysis, improvements seen in the
hyperactivity/impulsivity-related scales in
the neurofeedback condition are sur-
prising, because hyperactivity was not
directly targeted in the intervention.
Nevertheless, these ndings suggest that
when childrens focus increases, phys-
ical activity level is reduced.
Clinicians management of medication
was conducted independently of the
study protocol. It is noteworthy that par-
ticipants in the neurofeedback condition
showed maintenance of stimulant med-
ication dosage while presumably ex-
periencing the same physical growth
and increased school demands as CT
and control condition peers, whose med-
ication dosage increased clinically and
statistically (9- to 13-mg methylphenidate-
equivalent units).
This study used multiple sources and
types of data including questionnaires
from parents, systematic classroom
observations of behavior, and medication.
Because children had a different teacher
at pre- and postintervention compared
with the 6-month follow-up, teacher re-
ports were not included in these anal-
yses. The inclusion of the systematic
classroom observations provided a valid
double-blinded representation of the
childrens behavior in the classroom.
Randomization of subjects to treatment
conditions, as applied in this study, is the
gold standard for clinical trials. Even
though stratied by gender, school sys-
tem, and medication status and well
balanced regarding demographic char-
acteristics across all 3 randomized
conditions, the participants in the 3
conditions appeared to differ in the se-
verity of baseline ADHD symptoms. How-
ever, none of these differences reached
signicance, and it is unclear how these
differences in baseline severity might
have affected the results. Furthermore,
we relied on growth models to isolate
change over time, not status at post-
treatment or follow-up; our time coding,
which centered time at posttreatment,
was selected to reduce the correlation of
initial status and change.
Parents were aware of the type of in-
tervention their child received, which
was unavoidable, because 1 of the sys-
tems uses a helmet and the other does
not. Parents were informed that the 2
interventions were both commercially
available and had achieved similarly
encouraging results in previous studies
at the time of enrollment. At postin-
tervention, we found no differences in
Observed participant mean scores across 3 study time points. NF, neurofeedback.
PEDIATRICS Volume 133, Number 3, March 2014 489
at Harvard University on February 19, 2014pediatrics.aappublications.orgDownloaded from
satisfaction with the intervention be-
tween parents with participants in the
neurofeedback condition and parents
with participants in the CT condition, sug-
gesting that parent bias most likely did
not affect their reporting of the measures.
Neurofeedback participants showed
signicant improvements that were
sustained 6 months after the interven-
tion compared with those in the control
and CT conditions, as reported by the
parents consistently on all of the core
ADHD subscales and executive func-
tioning scales. Participants in the CT
condition showed signicant improve-
ment 6 months after the intervention
period on 2 executive functioning sub-
scales. Medication dosage was sustained
among participants in the neurofeed-
back condition, whereas for CT and
control conditions it was increased. The
nding that neurofeedback was supe-
rior to CT on multiple scales further
supports its efcacy as a treatment
of children with ADHD. Effects were
reported earlier in the neurofeedback
condition than in the CT condition and
were also stronger at the 6-month
follow-up period, showing the promise
of neurofeedback as a treatment with
sustained gains for children with ADHD.
This is the rst large randomized con-
trolled trial to evaluate the long-term
efcacy of in-school CompAT. Despite
the paucity of scientic data, both
neurofeedback and CT training systems
are currently being used in school
systems across the United States,
underlining the importance of sys-
tematic studies of their effectiveness.
The direct impact of attention decits
on academic progress makes schools
an ideal setting for such an interven-
tion, because all children with ADHD in
all communities could potentially have
access to these services on an ongoing
basis. A next important step will be to
assess individual participant differ-
ences to evaluate which factors might
be associated with the most progress
on the respective interventions and to
study older developmental age cohorts.
We thank Tahnee Sidhu and Katie Tom-
asetti from Tufts Medical Center for
their extensive contributions to this re-
search project. We appreciate the assis-
tance of Dr David Gotthelf, PhD, of the
Newton Public Schools, Principal Simon
Ho and Zhen Su of the Boston Public
Schools, and the administrators and
teachers of both school systems. Dr
R. Chris Sheldrick, PhD, provided wise
advice from the beginning of the pro-
ject. We also acknowledge the following
former RAs afliated with Tufts Medical
Center for their hard work on this study:
Susan Mangan, Minakshi Ratkalkar,
Lauren Rubin, Wendy Si, Melissa Arbar,
Stefanie Moynihan, Neena Schultz, Eliz-
abeta Bourchtein, Kolleen Burbank,
Heather Bentley, Amanda Civiletto, Joyce
Kao, and Jessica Charles, as well as stu-
dents Cathryn Magielnicki and Lisa Ngu
from Tufts University and Jessica Ben-
nett and Jessica Chen from Northeast-
ern University. We also acknowledge
all of the participants and their families.
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TABLE 3 BOSS Results
Observed Data
Growth Model Estimates
Preintervention Postintervention Six-Month Follow-Up Coefcient 95% CI Effect Size
Control 78.20 (11.67) 79.34 (13.58) 81.23 (10.37) 1.49 20.87 to 3.86 0.04
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CT 25.87 (15.05) 20.03 (10.88) 23.96 (5.93) 20.49 24.41 to 3.43 20.01
CI, condence interval; NF, neurofeedback.
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ADULT TASTES: Last week I was at the frozen food section of the supermarket
staring at rows of frozen desserts and practically rendered immobile by in-
decision. I was looking for a special frozen dessert for a friend of mine who likes
dessert and specically chocolate ones. Of course, there were many varieties of
chocolate, chocolate chip, and chocolate fudge ice creams. However, I was drawn
to the gelatos, possibly because of my culinary experiences while traveling in
Italy, but also because of gelatos remarkable avors. I could choose from Ar-
gentine caramel, Belgium milk chocolate, and German Chocolate Cake. I even-
tually settled on a pint of Sea Salt Caramel gelato despite the fact that it cost more
than a half-gallon of ice cream. Evidently, I am not the only adult captivated by the
rich avors found in gelato and willing to pay a bit more for the experience.
As reported in The Wall Street Journal (Life & Culture: November 12, 2013), sales
of gelato in the US jumped almost 90% in 2012 while sales of ice cream and ice
cream products remained at. Gelato and premium ice cream makers have been
attempting to lure adults into buying more for themselves by introducing more
complex and exotic avors. The interest in more obscure avors may be due to
the spread of the food culture through TV shows and social media. Occasionally,
the avors do not work out well. For example, tasters found a peach-champagne
sorbetto (a non-dairy gelato) with mint to be too intense and the line was
dropped. As for me, I am thrilled with all the new avors. Still, I tend to gravitate to
the caramel gelatos which for at least one company have become the top selling
gelatos selling even more than vanilla. As for my friend, she was very pleased
with my selection, as was I.
Noted by WVR, MD
492 STEINER et al at Harvard University on February 19, 2014pediatrics.aappublications.orgDownloaded from
DOI: 10.1542/peds.2013-2059
; originally published online February 17, 2014;Pediatrics Ellen C. Perrin
Naomi J. Steiner, Elizabeth C. Frenette, Kirsten M. Rene, Robert T. Brennan and
Randomized Control Trial
In-School Neurofeedback Training for ADHD: Sustained Improvements From a
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... Similar to tFUS, NFT is another technique which has been well-known for decades but has only recently gained increased attention within cognitive enhancement research due to its ability to provide a safe, non-invasive way to modulate neurocognitive states (Marzbani et al., 2016;Sitaram et al., 2017). Moreover, because it does not apply any direct brain stimulation (i.e., it is truly non-invasive), NFT is more widely-regarded as safe for use in children (Baena et al., 2021;Gevensleben et al., 2009Gevensleben et al., , 2012, making it potentially more applicable to realworld educational environments (Gevensleben et al., 2012;Steiner et al., 2014). NFT encompasses a broad category of techniques that can vary across many different parameters, such as the following: the form of neuroimaging used (e.g., fMRI, EEG, functional near-infrared spectroscopy), the modality of feedback provided to the participant (e.g., visual, auditory, combined), the complexity of the feedback (e.g., binary feedback, such as a sound when a specified threshold is reached, or continuous feedback, such as the dynamic changing of colors based on a percentage of the maximum signal), online versus offline administration (e.g., during or before the cognitive task of interest), frequency of feedback (e.g., continuous or periodic reinforcement), and the length and number of sessions (ranging from a single 30-min session to 8 weeks of daily 1-h sessions) (Marzbani et al., 2016;Sitaram et al., 2017). ...
... Despite the promise of NFT, the technique is limited in the following ways: it is difficult to create a well-matched, fully double-blinded control condition, it is very time-intensive to design and administer, and it requires a neuroimaging setup to conduct (Marzbani et al., 2016;Sitaram et al., 2017). Nonetheless, NFT has perhaps the greatest potential to enhance creative cognition in children given its safety and completely non-invasive methodology, compared to tES, TMS, or tFUS, which may pose risks to a child's brain development (Baena et al., 2021;Gevensleben et al., 2009Gevensleben et al., , 2012Steiner et al., 2014). ...
Full-text available
We review several new and emerging methods of non-invasive neuromodulation and consider their potential to enhance creative cognition. This review covers the following techniques: transcranial electric stimulation (tES) (which includes transcranial direct current stimulation (tDCS), transcranial alternating current stimulation (tACS), and transcranial random noise stimulation (tRNS)), transcranial magnetic stimulation (TMS), transcranial focused ultrasound stimulation (tFUS), and neurofeedback training (NFT). For each technique, we explain the basic mechanism of action, review relevant research demonstrating its ability to enhance creative cognition, consider limitations and advantages, and suggest future research directions. Lastly, we offer broader conclusions and recommendations for the field of creativity neuromodulation.
... Remote NFT for AD/HD has been available since 2004 as tele-neurofeedback from clinics in the Netherlands using a wireless Bluetooth-based neurofeedback system (Brainquiry PET) -this method was also successfully used in a remote NFT study for insomnia using SMR tele-neurofeedback (Cortoos et al., 2010). Steiner et al. (2014) conducted the first RCT to examine the efficacy of remote NFT in children with AD/HD. A 40-session TBR-based NFT was run on in-school computers with EEG sensors mounted on bicycle helmets. ...
... A 40-session TBR-based NFT was run on in-school computers with EEG sensors mounted on bicycle helmets. Compared with a CT condition and a waitlist control, the NFT protocol significantly reduced ADHD symptoms rated by parents, the effect of which was maintained for 6 months after training (Steiner et al., 2014). The efficacy of in-school NFT was further confirmed with SCP and SMR protocols (Minder et al., 2018;Rajabi et al., 2020). ...
Improving neurocognitive functions through remote interventions has been a promising approach to developing new treatments for attention-deficit/hyperactivity disorder (AD/HD). Remote neurocognitive interventions may address the shortcomings of the current prevailing pharmacological therapies for AD/HD, e.g., side effects and access barriers. Here we review the current options for remote neurocognitive interventions to reduce AD/HD symptoms, including cognitive training, EEG neurofeedback training, transcranial electrical stimulation, and external cranial nerve stimulation. We begin with an overview of the neurocognitive deficits in AD/HD to identify the targets for developing interventions. The role of neuroplasticity in each intervention is then highlighted due to its essential role in facilitating neuropsychological adaptations. Following this, each intervention type is discussed in terms of the critical details of the intervention protocols, the role of neuroplasticity, and the available evidence. Finally, we offer suggestions for future directions in terms of optimizing the existing intervention protocols and developing novel protocols.
... In therapeutical practice, a typical neurofeedback intervention includes multiple sessions. Especially in treatment for ADHD (attention-deficit hyperactivity disorder) protocols with up to 40 sessions are not uncommon (Gevensleben et al., 2012;Meisel et al., 2013;Steiner et al., 2014), while other studies focus on effects of a single neurofeedback session. Each session can be further subdivided into different time segments, so-called runs, which allows the participant to rest and to recover. ...
Full-text available
Human brain activity can be subdivided into different frequency bands associated with varying functions. Oscillatory activity of frontal brain regions in the theta range (4-8Hz) has been linked to cognitive processing and recent research suggests that it can be modulated by neurofeedback - a technique where participants receive real-time feedback about their brain activity and learn to modulate it. However, criticism of this technique evolved, and high heterogeneity of study designs complicates a valid evaluation of its effectiveness. This meta-analysis provides the first systematic overview over studies attempting to modulate frontal midline theta with neurofeedback in healthy human participants. Out of 1431 articles screened, 14 studies were eligible for systematic review and 11 studies for quantitative meta-analyses. Studies were evaluated following the DIAD model and the PRISMA guidelines. A significant across-study effect of medium size (Hedges g = .66; 95%-CI = −0.62, 1.73) with substantial between-study heterogeneity (Q(16) = 167.43, p < .0001) was observed. We discuss moderators of effect sizes and provide guidelines for future research in this dynamic field.
... Extending the cognitive training approach, other researchers have looked at the effects of providing participants with direct feedback on their performance and taskrelated brain activation during EF training. Adopting this 'neurofeedback' approach, Steiner et al. (2014) conducted EEG assessments (see Chapter 2) in forty seven-to eleven-year-old children while they completed a computerized training task. ...
The most accessible overview of Executive Function during infancy and early childhood, this book provides an up-to-date account of a universally important topic and illustrates a range of core concepts around psychological assessment of infants and children.
Full-text available
Background Attention-deficit/hyperactivity disorder (ADHD) is relatively common among school-age children. Technology-based interventions, such as computer-assisted training programs, neurofeedback training, and virtual reality, show promise in regulating the behaviors and cognitive functions of children with ADHD. An increasing number of randomized controlled trials have been conducted to evaluate the effectiveness of these technologies in improving the conditions of children with ADHD. Objective This study aims to conduct a systematic review of technological interventions for school-age children with ADHD and perform a meta-analysis of the outcomes of technology-based interventions. Methods A total of 19 randomized controlled studies involving 1843 participants were selected from a pool of 2404 articles across 7 electronic databases spanning from their inception to April 2022. ADHD behaviors, cognitive functions, learning ability, and quality of life were addressed in this study. Results Random effects meta-analyses found that children with ADHD receiving technology-based intervention showed small and significant effect sizes in computer-rated inattention (standardized mean difference [SMD] −0.35; P<.04), parent-rated overall executive function measured by the Behavior Rating Inventory of Executive Function (SMD −0.35; P<.04), parent-rated disruptive behavior disorder measured by the Child Behavior Checklist (SMD −0.50; P<.001) and Disruptive Behavior Disorder Rating Scale (SMD −0.31; P<.02), and computer-rated visual attention measured by the Continuous Performance Test (SMD −0.42; P<.001) and Reaction Time (SMD −0.43; P<.02). Conclusions Technology-based interventions are promising treatments for improving certain ADHD behaviors and cognitive functions among school-age children with ADHD. Trial Registration PROSPERO CRD42023446924;
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The Neurofeedback technique has focused on the modification of brain wave patterns for the treatment of psychological pathologies of various etiologies. This article presents the researchers' experience in the application of this technique in a case of post-traumatic stress disorder in an adult woman. In the selection of the case there was the voluntary participation of the person, the absence of previous treatment and compliance with the necessary diagnostic criteria to configure the psychopathological picture. Researchers worked with the consultant during five intervention sessions and three follow-up sessions, under a pretest - posttest design. Quantitative changes were observed in the Beta and Theta brain wave recordings, as well as qualitative changes in the reduction of symptoms associated with the disorder.
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La técnica del Neurofeedback se ha centrado en la modificación de patrones de ondas cerebrales para el tratamiento de patologías psicológicas de diversas etiologías. Este artículo presenta la experiencia de los investigadores en la aplicación de esta técnica en un caso de Trastorno de estrés postraumático en una mujer adulta. En la selección del caso se tuvieron la participación voluntaria de la persona, inexistencia de tratamiento previo y cumplimiento de criterios diagnósticos necesarios para configurar el cuadro psicopatológico. Se trabajó con la consultante durante de cinco sesiones de intervención y tres de seguimiento, bajo un diseño pretest – postest. Se observaron cambios cuantitativos en los registros de ondas cerebrales Beta y Theta, así como cualitativos en la disminución de la sintomatología asociada al trastorno.
Currently, classrooms are experiencing an increase in the number of schoolchildren with a diagnosis of attention deficit hyperactivity disorder (ADHD). Numerous studies propose, as an alternative to medication, the implementation of different neurotechnology in the classroom to improve the symptomatology and enhance the cognitive abilities of children with this diagnosis. This umbrella review aims to compile the scientific evidence that exists on the application of these techniques, as well as their implementation, in schools. A systematic review was carried out, following accepted recommendations (PRISMA), which included systematic reviews in English or Spanish, published in scientific journals, which deal with ADHD, apply some neurotechnology used in this population such as neurofeedback, transcranial stimulation (tDCS) or hyper scanning, and which refer to education or school. Fourteen systematic reviews were retained, which show that neurofeedback is the most widely used neurotechnology, although its actual implementation in school has been scarcely treated or only aimed to evaluate its efficacy. In second place, tDCS appears with a more clinical approach, while hyper scanning does not appear. Despite the promising experimental results, ecological studies proposing the effective implementation of these techniques in educational centers are necessary; on the other hand, the commitment to neuroeducation would entail the emergence of new professional figures. En la actualidad, las aulas experimentan un incremento del número de menores escolarizados con un diagnóstico de trastorno por déficit de atención e hiperactividad (TDA-H). Numerosos estudios proponen, como alternativa a la medicación, la implementación de diferentes neurotecnologías en el aula para mejorar la sintomatología y favorecer las capacidades cognitivas de los escolares con dicho diagnóstico. La presente revisión sistemática persigue recopilar la evidencia científica que existe sobre la aplicación de estas técnicas, así como su implementación en el aula. Se realizó una revisión sistemática, siguiendo los estándares de rigor aceptados (PRISMA), incluyendo las revisiones sistemáticas en inglés o español, publicadas en revistas científicas, que aborden el TDA-H, apliquen alguna neurotecnología utilizada en esta población (neurofeedback, estimulación transcraneal (tDCS) o hiperescaneo) y que hagan referencia a la educación o a las aulas. Se retuvieron 14 revisiones sistemáticas, poniendo de manifiesto que el neurofeedback es la neurotecnología más utilizada, aunque su implementación real en el aula ha sido escasamente tratada o sólo lo ha sido con fines de evaluación de eficacia. En segundo lugar, aparece la tDCS con un enfoque más clínico, mientras que el hiperescaneo no aparece. A pesar de encontrar resultados experimentales prometedores, son necesarios estudios ecológicos que propongan la implantación efectiva de estas técnicas en los centros educativos; por otra parte, la apuesta por la neuroeducación conllevaría la aparición de nuevas figuras profesionales.
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Background: Non-pharmacologic interventions can potentially improve cognitive function, sleep, and/or mood in patients with attention-deficit/hyperactive disorder (ADHD), post-concussion syndrome (PCS), or memory loss. Objective: We evaluated the benefits of a brain rehabilitation program in an outpatient neurology practice that consists of targeted cognitive training, lifestyle coaching, and electroencephalography (EEG)-based neurofeedback, twice weekly (90 minutes each), for 12 weeks. Methods: 223 child and adult patients were included: 71 patients with ADHD, 88 with PCS, and 64 with memory loss (mild cognitive impairment or subjective cognitive decline). Patients underwent a complete neurocognitive evaluation, including tests for Verbal Memory, Complex Attention, Processing Speed, Executive Functioning, and Neurocognition Index. They completed questionnaires about sleep, mood, diet, exercise, anxiety levels, and depression-as well as underwent quantitative EEG-at the beginning and the end of the program. Results: Pre-post test score comparison demonstrated that all patient subgroups experienced statistically significant improvements on most measures, especially the PCS subgroup, which experienced significant score improvement on all measures tested (p≤0.0011; dz≥0.36). After completing the program, 60% to 90% of patients scored higher on cognitive tests and reported having fewer cognitive and emotional symptoms. The largest effect size for pre-post score change was improved executive functioning in all subgroups (ADHD dz= 0.86; PCS dz= 0.83; memory dz= 1.09). Conclusion: This study demonstrates that a multimodal brain rehabilitation program can have benefits for patients with ADHD, PCS, or memory loss and supports further clinical trials in this field.
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Background: Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that commonly occurs in childhood. The aim of this meta-analysis was to summarize the available evidence for the efficacy of digital therapeutics in children and adolescents with ADHD. Methods: We searched the MEDLINE, EMBASE, Cochrane Library (Cochrane Database of Systematic Reviews), and Web of Science (science and social science citation index) databases for relevant studies and used Stata 15.0 software to carry out the meta-analysis. Results: A total of 31 studies involving 2169 participants (1665 boys and 504 girls) aged 4-17 years old were included in the final analysis. The meta-analysis results showed that digital interventions improved the symptoms of inattention with an effect value of -0.20 (95% confidence interval [CI] -0.36, -0.04) and decreased the continuous performance task (CPT) reaction time (effect, -0.40, 95% CI -0.73, -0.07) in ADHD patients. The score for impulsive hyperactivity was slightly decreased (effect, -0.07, 95% CI -0.23, 0.09). Moreover, executive function was improved (effect, 0.71, 95% CI 0.37, 1.04). The capability of working memory appeared to be increased (effect, 0.48, 95% CI 0.21, 0.76) between the two groups. Visual appraisal of the sensitivity analysis suggested the absence of heterogeneity, and no obvious publication bias was detected. Discussion: Based on the existing literature evidence, we conclude that digital therapy can be a promising therapeutic strategy for ADHD patients.
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This article illustrates new statistical methods for the study of psychological change in married couples. The design involves time-series data on each partner. The analysis combines longitudinal methods for studies of individual change with cross-sectional methods for the study of matched pairs. Each person is viewed as changing over time as a function of an individual growth curve or change function. As in previous studies of individual change, a person's trajectory depends on time-invariant personal background characteristics and time-varying changes in the environment. However, unlike typical studies of individual change, a person's changing psychological profile depends, in part, on the influence of that person's partner. These methods apply directly to other types of longitudinal studies on families (e.g., studies that use teacher and parent reports of a child's social behavior). The methodology is flexible in allowing randomly missing data, varying spacing of time points, unbalanced designs, and time-varying and time-invariant covariates.
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To evaluate the efficacy of 2 computer attention training systems administered in school for children with attention-deficit hyperactivity disorder (ADHD). Children in second and fourth grade with a diagnosis of ADHD (n = 104) were randomly assigned to neurofeedback (NF) (n = 34), cognitive training (CT) (n = 34), or control (n = 36) conditions. A 2-point growth model assessed change from pre-post intervention on parent reports (Conners 3-Parent [Conners 3-P]; Behavior Rating Inventory of Executive Function [BRIEF] rating scale), teacher reports (Swanson, Kotkin, Agler, M-Flynn and Pelham scale [SKAMP]; Conners 3-Teacher [Conners 3-T]), and systematic classroom observations (Behavioral Observation of Students in Schools [BOSS]). Paired t tests and an analysis of covariance assessed change in medication. Children who received NF showed significant improvement compared with those in the control condition on the Conners 3-P Attention, Executive Functioning and Global Index, on all BRIEF summary indices, and on BOSS motor/verbal off-task behavior. Children who received CT showed no improvement compared to the control condition. Children in the NF condition showed significant improvements compared to those in the CT condition on Conners 3-P Executive Functioning, all BRIEF summary indices, SKAMP Attention, and Conners 3-T Inattention subscales. Stimulant medication dosage in methylphenidate equivalencies significantly increased for children in the CT (8.54 mg) and control (7.05 mg) conditions but not for those in the NF condition (0.29 mg). Neurofeedback made greater improvements in ADHD symptoms compared to both the control and CT conditions. Thus, NF is a promising attention training treatment intervention for children with ADHD.
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A variety of coding schemes are available for direct observational as- sessment of student classroom behavior. These instruments have been used for a number of assessment tasks including screening children in need of further evalu- ation for emotional and behavior problems, diagnostic assessment of emotional and behavior problems, assessment of classroom ecology in the formulation of academic interventions, and monitoring the progress of medical, psychosocial, and academic interventions. Although this method of behavioral assessment has a high degree of face validity, it is essential to consider the psychometric properties of available coding schemes to select the appropriate instrument for a given as- sessment. This article reviews the structure, content, training requirements, and available psychometric properties of seven available direct observation codes. Rec- ommendations for the use of each code and future directions for research in obser- vational assessment are provided.
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Objective: To assess, in hyperactive children: 1) relative efficacy of behavior therapy, methylphenidate, and their combination; 2) effects of methylphenidate withdrawal after combined treatment; and 3) normalization effects of the combination. Method: Eighty-nine children were randomly assigned to treatment for eight weeks. Children on the combined treatments were switched to a placebo, double-blind. Ratings from parents, teachers and clinicians, and school observations were obtained. Results: Parents and teachers viewed children on behavior therapy as improved, but objective observations did not document behavioral change. In contrast, methylphenidate and the combined treatment induced significant improvement in all measures of outcome. Methylphenidate and the combination treatments were significantly superior to behavior therapy. In a few instances, the combination, which normalized behavior, was superior to methylphenidate. Children switched to placebo deteriorated significantly. Discussion: Behavior therapy delivered in school and home is not nearly as effective as methylphenidate for ADHD, but may be a useful adjunct to methylphenidate.
This chapter reveals a methodology of assessing basic academic skills focused on problem solving that has been designed to evaluate a student's skills and performance that is linked to intervention development and that can be used dynamically to show responsiveness to instructional intervention. It introduces the reader to the concepts of curriculum-based assessment (CBA) and describes how these strategies are being used in the assessment of basic skill development of elementary students. CBA has increasingly become a staple of the assessment process for students referred in schools for academic skills problems. The methodology draws on the foundations of behavioral assessment methodology and emphasizes measures that are frequent, repeatable, direct, and focused on the development and evaluation of instructional intervention. Use of graphic analysis is critical to interpretation. The data are useful for multiple purposes of assessment, including screening, eligibility determination, instructional development, and program evaluation. Although the measures are not designed to replace the use of published, norm-referenced achievement tests, the purposes of CBA meet the important philosophical function of being closely linked to intervention.
Introduction: Neurofeedback is an alternative treatment for Attention Deficit Hyperactivity Disorder (ADHD), but its efficacy is unknown. This narrative review examines rigorous studies conducted utilizing neurofeedback as a treatment for ADHD. Methods: Studies were located by searching the Web of Science and PsycINFO databases with the keywords ADHD or attention deficit hyperactivity disorder AND neurofeedback or EEG biofeedback or electroencephalogram biofeedback. Located studies were chosen for initial review if they met the following criteria: (a) randomized controlled trial or quasi-experiment, (b) ADHD diagnosis based on DSM criteria, (c) published at any time prior to March 2010, (d) English language, and (e) published in a peer-reviewed journal. Participants included children, adolescents, and adults diagnosed with ADHD. Results: Twelve articles reporting 9 different studies met the eligibility criteria and were included in the review. All 9 studies produced results that indicated significant improvements on either tests scores or behavioral conduct for individuals who were treated with neurofeed-back for ADHD. Alternative treatments also demonstrated effectiveness. Conclusion: Neurofeedback may be an effective treatment for ADHD. Future research is needed with larger sample sizes, comparing the efficacy of neurofeedback with the efficacy of other ADHD treatments and comparing different neurofeedback protocols.
The CONSORT (Consolidated Standards of Reporting Trials) Statement, which includes a checklist and a flow diagram, is a guideline developed to help authors improve the reporting of the findings from randomized controlled trials. It was updated most recently in 2010. Its primary focus is on individually randomized trials with 2 parallel groups that assess the possible superiority of one treatment compared with another. The CONSORT Statement has been extended to other trial designs such as cluster randomization, and recommendations for noninferiority and equivalence trials were made in 2006. In this article, we present an updated extension of the CONSORT checklist for reporting noninferiority and equivalence trials, based on the 2010 version of the CONSORT Statement and the 2008 CONSORT Statement for the reporting of abstracts, and provide illustrative examples and explanations for those items that differ from the main 2010 CONSORT checklist. The intent is to improve reporting of noninferiority and equivalence trials, enabling readers to assess the reliability of their results and conclusions. JAMA. 2012;308(24).2594-2604
The factor structure and validity of a 10-item teacher rating scale designed to measure impairment of classroom functioning related to Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms were evaluated with 109 children at a public elementary school. Items were derived from classroom target behaviors used in behavior modification programs for children with ADHD. A principal components analysis resulted in two unambiguous dimensions, which logically fit names of Attention and Deportment. Using external criteria derived from multiple methods and sources, strong divergent validity was found for the subscales. Results suggest the Attention scale measures impairment of task-appropriate behavior and academic under-productivity associated with DSM-IV Inattention, whereas the Deportment scale measures impairment of rule-appropriate behavior and difficulty with classroom social interactions associated with DSM-IV Hyperactivity-Impulsivity. Despite these preliminary theoretical conclusions, additional data from larger, more diverse samples are needed before normative application of the scale can be justified.
The transition to parenthood is a time of stress for many couples. Most research on the transition to parenthood has been conducted with middle-class, heterosexual couples. The current study uses multilevel modeling to examine predictors of change in relationship quality (love and conflict) during the transition to parenthood in 29 lesbian couples. Predictors included personality variables, work context variables, social context variables, and couple characteristics. Results suggest that personality and couple characteristics were important predictors of change in love, whereas personality and expected social support were salient predictors of change in conflict. The importance of research on this key life transition for lesbian couples is discussed.
A computer-assisted cognitive training program was used to treat a 13-year-old Caucasian male with attention deficit hyperactivity disorder. The subject was administered a cognitive training computer program, Captain's Log, for 35 sessions. Pre/post differences on the Conners Parent Rating Scale revealed a decrease on all subscales. The scores on the Conners Teacher Rating Scale were less conclusive. Electrophysiological testing on the A620 EEG/Neurofeedback revealed a reduction in EMG, theta, and beta wave amplitudes. However, the theta/beta ratio increased. A 7-month follow-up revealed that most of the acquired gains were maintained, but at a slightly lower level.