Neurofeedback Therapy For ADHD: Is It An Effective Treatment?

Diagnoses of attention deficit hyperactivity disorder (ADHD) have been on the rise for years, increasing 43% since 2003. As many as 11% of the US population may live with ADHD, although many are not diagnosed until later in life. Standard care includes stimulant medication and behavioral therapy, but these treatments may not provide adequate relief of symptoms such as inattention, lack of motivation, distraction, and difficulty with impulse control.

Neurofeedback therapy is a relatively new treatment that aims to directly train the human brain to improve its natural skill deficits. But is neurofeedback an effective treatment?

Brain differences in people with ADHD

According to the National Institute of Mental Health, attention-deficit/hyperactivity disorder, also known as ADHD, is a neurodevelopmental disorder believed to affect the prefrontal cortex, the front part of the cerebral cortex, which is responsible for our "executive functions." Executive functions include working memory, focus, impulse control, and more, the areas of impairment. This dysregulation can make it difficult for people with ADHD to direct and control their attention and behavior, which can significantly impact their lives.

Stimulant medication works by increasing dopamine and norepinephrine in the prefrontal cortex, thereby increasing the ability of the executive functions, which is why they're so commonly prescribed. However, researchers are looking for new ways to improve the functioning of the brain directly.

Neurofeedback therapy for ADHD

Since the prefrontal cortex is believed to have dysregulation as part of this condition, neurofeedback targets this area for improvement.

Neurofeedback is available to both children and adults. Training takes place over multiple sessions, which are performed once a week. These sessions are required to train the brain gradually over time.

Neurofeedback training is thought to strengthen a person's ability to focus and block out distractions, just like any other skill. Since people often do not have the natural ability to concentrate as neurotypical people might, this may make up for the deficiencies present. In a neurotypical brain, a person can concentrate at will without much effort. This is not so for people with ADHD, who generally must put more effort into focusing and blocking out distractions. The theory is that neurofeedback can raise the brain's baseline ability to focus.

How does a neurofeedback session work?

In a neurofeedback session, electrodes are attached to the patient. The practitioner measures uses these electrodes to measure the flow of different brain waves and sensorimotor rhythm, including slow cortical potentials, with an EEG machine, sometimes in combination with fMRI neurofeedback. EEG biofeedback is typically painless and shouldn't cause any discomfort. 

The brain has five distinct types of brain waves: alpha, beta, gamma, delta, and theta, all directly linked to different activity levels. The sessions are conducted by a doctor or technician who guides the patient and monitors the output of brain waves.

The patient is instructed to perform certain activities on a computer screen, such as a video game. Focused attention is rewarded, usually by an audio or visual signal. The patient will then attempt to redirect their focus. The idea is that with continued practice, the prefrontal cortex will naturally strengthen, and this new growth will carry over after therapy has ended. Multiple strategies may be attempted to achieve the level of focus desired.

Neurofeedback and neuroplasticity

It was once thought that the brain could not grow new neurons or form connections after early childhood. Now, with the help of sophisticated technology, we know that the brain is constantly forming new connections in response to its experiences. For this process to occur, the brain needs to be stimulated, usually through repeated activity. As the saying goes, "Nerves that fire together, wire together."

In theory, neurofeedback works via this process. In training the brain over time, the brain's natural neuroplasticity allows it to form new connections and strengthen the areas that are less developed. Neurofeedback is meant to guide the brain into associating focus with the feeling of reward. This training may create new connections that allow the brain to reorder itself to better support executive functions.

Neuroplasticity can work to establish both positive and negative habits. The brain does not know what is good for us, only what it interprets as rewarding. This can lead to the development of addictive and avoidant behaviors, as well as negative thinking patterns. Treatments like neurofeedback aim to guide the brain back to more beneficial patterns.

Is neurofeedback therapy effective for ADHD symptoms?

Currently, we don't have a definitive answer, although current research is promising. 

While previous research, including a study in the Acad Child Adolesc Psychiatry (American Academy of Child and Adolescent Psychiatry), initially found this to be a controversial treatment with questionable clinical and neuropsychological outcomes, some scientific evidence now supports neurofeedback in many cases. In 2012, the American Academy of Pediatrics gave neurofeedback their highest possible rating for ADHD treatment, at par with medication and behavioral therapy to reduce symptoms.

Benefits are mainly thought to be in the areas of impulsivity and inattention, with only a mild effect on symptoms of hyperactivity. This suggests that those with primarily inattentive and combination types of ADHD would benefit most from neurofeedback. In contrast, some research looking into randomized controlled trials suggests that the benefits of neurofeedback may be nothing more than a placebo effect.

Further research is needed to make a conclusion on the ultimate effectiveness of the treatment. Still, many doctors are recommending it as a complementary therapy, part of an overall treatment plan that includes medication, behavioral skills training, and lifestyle adjustments.

Should I try neurofeedback treatment?

If you've tried medication and therapy and found it to be ineffective at adequately controlling your symptoms, you may consider other treatments, such as neurofeedback. The choice to try neurofeedback can depend on many factors, including the cost, availability, and willingness of the patient.

Speak to your doctor if you're considering neurofeedback. They may be able to provide you with more information about the process and whether it may work for you. To find a provider that offers neurofeedback, you can search online through EEG neurofeedback info and other provider searches. While locations are still limited, more and more places are becoming available throughout the country.

Will my insurance cover neurofeedback?

Neurofeedback treatment can be quite expensive, costing anywhere from $3000-5000 for the entire treatment. This cost can prohibit many people from seeking treatment. There is good news on the horizon: as neurofeedback gains more widespread acceptance, more insurance companies are offering coverage. Companies such as United Health Care, Cigna, and Blue Cross have begun covering neurofeedback for some, including ADHD patients.

The requirements of insurance companies vary. While a doctor's prescription is typically unnecessary to receive neurofeedback, it may help approve your insurance reimbursement claim. Neurofeedback therapy, in particular, may be harder to get accepted than for other problems, such as sleep disorders.

Neurofeedback and stimulant medication

Stimulant medications, such as Adderall and Ritalin, are the most common treatment for childhood and adult ADHD. Of those diagnosed with ADHD, about 50% are currently taking stimulant medication. Up to 70% of adults with ADHD who try medication find relief from their symptoms when they start taking stimulant medication.

However, medication typically does not by itself completely treat the symptoms, and it may lose its effectiveness over time. Additionally, side effects, such as nervousness, loss of appetite, and insomnia, can be strong enough to necessitate discontinuing the medication.

Current research has shown that those taking medication at the same time as EEG neurofeedback treatments were better able to retain the benefits after treatment concluded.

Neurofeedback has not yet proven to be an alternative to stimulant medication; however, it can be a viable alternative if combined with behavior therapy. Since neurofeedback doesn't run a risk of side effects, this can be helpful for those who have not found relief with medication.

Combining neurofeedback with therapy

Neurofeedback appears to work best as part of an overall treatment plan for ADHD, which usually includes psychotherapy. The most common type, cognitive behavioral therapy (CBT), aims to teach people with ADHD strategies to compensate for their neurological differences.

It's possible to take advantage of the benefits of CBT and other therapeutic techniques through resources like online therapy. Even when ADHD symptoms may make it difficult to reach out and pursue regular care, online therapy's ability to connect you with a professional at a time and place that works for you can make things easier. 

A therapist can be a great partner in helping you navigate not only your treatment options but any other concerns you may be having. Research supports the effectiveness of online therapy, too. In fact, one study conducted in 2022 found that online behavioral intervention improved symptoms for both adults and children with ADHD, suggesting that web-based treatment options aren't necessarily less successful when it comes to creating real change.