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Saturday, February 25, 2017

Is Divorce Bad for Kids?

IS DIVORCE BAD for kids? I get asked this question almost every week. When I provide marital therapy, my role is to represent the marriage for couples who want to stay married and help them achieve their goal of having a good marriage, however they define "good." It's not my role to moralize with them about why they should stay married "at all costs," or "fight" for their marriage, as some people put it. Deciding to, stay married, work on the marriage, or get divorced is not my choice to make. So, I try to avoid responding to this question when people ask because they may rely more on my answer than what is best for their specific situation.
     So, people decide to stay married or get divorced based at least in part on the answer they find to this question. Your therapist should not answer it like it's a matter of yes or no, and any answer to this question is controversial and a matter of opinion; this is because the meaning of the scientific data on the effects of divorce are unclear and complicated.* I am responding to this question here because I think my ideas about this may be helpful to you, and I think most people are getting biased and limited answers.

     If you are having marital problems, there are therapeutic options:
1. Therapy for yourself to discuss your thoughts, feelings, and options regarding marriage   
     and divorce; this can be especially helpful for people who are not sure what they want;
2. Marital therapy with your spouse if you are sure that you want to stay married;
3. Divorce therapy with your spouse, if you are sure you want to get divorced.

    With divorce counseling, I think it's very important for you to carefully weigh the pros and cons of your options. You should probably avoid relying on generalizations that are usually found in self-help books or from friends and family who often spout trite maxims or give advice that is in accord with their needs, not yours. For example, one married couple might feel threatened by your divorce; or another married person who is staying unhappily married may think you should do the same and for the same reasons. You and your own family's issues of finances, health, and other factors are unique and should be considered on their own. However, this big-picture perspective on divorce can help people make better decisions.
     What's good or bad can be measured with many different criteria. There is no agreed upon criteria for measuring if marriage or divorce are good or bad. Often times, the bad decision was getting married in the first place. It's generally assumed that marriage is good and therefore, divorce must be bad, however, given the very high divorce rate, the idea that marriage is inherently good is questionable. Individuals who develop criteria for what is good or bad, and apply it to marital research often engage in confirmation bias where they basically find the conclusion for which they're looking.
    Another problem with determining the good or bad of divorce is trying to establish cause and effect. For example, if 50 of 100 kids have trouble in school after divorce, it isn't accurate to simply say that it was because of "divorce?" In The Unexpected Legacy of Divorce, A 25 Year Landmark Study, by Judith Wallerstein is a good example of this kind of approach. She clearly was biased in favor of staying married, but the "study" was really not scientific and far from being "landmark." For example, her study did not include a randomized experimental and control group. So, unfortunately, no generalizations can be made from the interviews that she conducted in her limited sample. Grand conclusions require grand evidence, so as popular as this book has become with the Christian audiences, it's not useful for making sound decisions about divorce.
    The fundamental issue with divorce is that it involves many changes in the lives of the individuals of the family. There are many possible aspects that can change: family identity, home, neighborhood, child and family friends, schools, teachers, routines, churches, and others. Many parents work hard to minimize changes, but some are inevitable. In general, there are no changes that are too much for someone to handle. Parents and kids constantly adapt to change. For example, Americans move to "new" homes at very high rates. These moves may impact kids in many of the same ways as does divorce, but, parents might not be sensitive to the impact of the move because it was seen as "good" to be in a "better neighborhood with better schools." 
     Kids also grow up. The years go by fast, and from one grade to the next, they gain and lose friends, schools, teachers, start to have an interest in the opposite sex, their appearance changes, their brains develop tremendously, their relationship with their parents change. So, kids are frequently adapting to change, and change can be more difficult for some kids than others.     
     During and after divorce, many parents display negative behaviors. These negative behaviors of parents are not caused by divorce; they are a choice that one or both parents make and they are 100% responsible for them. What makes divorce bad, and in many cases, really bad, are when parents are behaving badly, and again, divorce doesn't cause people to behave this way. It's very possible that what lead to the divorce were these same kinds of negative behaviors or attitudes throughout the marriage that only became public during or after divorce, or the spouse was unable to contain their negativity to within the privacy of the home. Sometimes one spouse has a personality disorder that becomes exacerbated by divorce, such as Narcissism or Borderline.**

     Divorce is a bundle of changes in the life of parents and children. Determining which changes were most likely to lead to a child's problem is very difficult. It's possible divorce had nothing to do with the child's problems, or that the child was already in a decline. For example, peer changes unrelated to divorce can have a substantial impact on a child's attitudes and behaviors. Mental illness often emerge between the ages of 11 and 14, so, to blame the illness on divorce might not be accurate. It's also possible that the reasons for the divorce were the same reasons that lead to the child's problems, such as marital discord, parent-child discord, split-parenting, parental substance abuse or violence. Furthermore, it's possible these children will do better in the longer-term because of divorce. For example, divorced parents may fight less often, be happier more often, and kids might develop better relationships with each individual parent than they would of otherwise with both parents in the home. Kids may also have more valuable life experiences through blended families; if a parent re-marries and finds a more compatible spouse, they might model healthy behaviors to the children. I could go on about potential positive outcomes related to divorce that scientific studies on divorce will often never see.
     Why do many kids do well after divorce? Resiliency is the ability to rebound from stress. What makes kids resilient? We spend a lot of time trying to understand what makes some kids sensitive or sick, but not enough to understand what makes others robust or hardy. How is it that two kids going through the exact same experience can come turn out so different? It's a very important question and there isn't a clear answer. One thing seems very true about human nature, that was written a centuries ago, by John Milton,  in Paradise Lost, "The mind is its own place, and in itself can make a heaven of hell, a hell of heaven," or basically, from Charles Swindoll, from The Grace Awakening, "life is 10% what happens to me and 90% how I react to it."
     Every family member involved in a divorce will have a different experience and they will be affected by the experience based on their own ingredients of risk factors and protective factors. For example, one risk factor might be a shy temperament, but this may be neutralized by a parent who is sensitive to the child's shyness. So, it becomes impossible to predict how a child or adult will be effected by divorce. But, divorce is like any life stress, so, the outcome of divorce has more to do with how individuals react to it.
     What makes divorce problematic for kids are when one or both parents act in negative ways. For example, many parents will triangulate kids into what should just be parent-to-parent communication. Some parents will berate or belittle the other parent. Many parents will air the laundry of the other spouse or vilify the other spouse in front of the children. Many parents will use the legal system or their children as a battleground for their unresolved issues towards their spouse. Many parents will become too permissive of their kids' behaviors out of guilt. Some parents will attempt to split the kids or "alienate" the kids from the other parent. Many parents will not seek therapeutic support for their intense negative emotions about divorce and instead act it out with the former spouse and in front of their kids. Most parents misinterpret are not aware of the harm they can cause their children from their own misbehavior; they are not knowledgeable about many childhood behaviors like the Chameleon effect, idealism, and other issues.
         So, no, I really don't think that divorce, per se, is bad, and if it means that you can move on from a bad relationship that is causing you to be chronically unhappy, then you should probably consider seeking professional support to sort through your feelings and choose a path.
     I think one problem with divorce, in our culture, is that we think of it as an inherently bad thing, sort of like quitting is seen as bad - "no one likes a quitter." This attitude can be self-serving for the spouse who finds it easier to be happy; it's easy to say to an unhappy spouse, things like "what about our vows" or "you made your bed..." and other righteous but unhelpful declarations. We shouldn't think of divorce as inherently bad. Freeing ourselves, from this idea, can take pressure off of each spouse to "be the bad guy," and file for divorce, or feel the need to blame each other. For most divorces, there really is no one to blame; one or the other was just not happy and it's really no one's fault, it's just an outcome of mismatched personalities.
     Another problem are the vows. Our culture may do well to consider more than one option for vows other than "till death." The idea that we should commit ourselves until death was established at a time when most people were excited to reach about 40 years of age, and the degree of uncertainty and anxiety about dying in childbirth from diseases or war was far greater than today. If you married at 15 or 17, then marriage might last 25 years. The Catholic church deemed marriage a "sacrament" in 1563. This validated consensual marriage over arranged marriages. I don't think marriage should be a sacrament but that parenting should be. Children should have never been considered illegitimate, but many marriages are, and many women and men choose to stay married for the kids; parenting children into healthy adults is far more important than staying married.
     There's an appealing idea that, "why should I get married if it's not forever." This black and white way of approaching the world is common to human nature, but it's not realistic or necessary. So, it feels right or good for people to think in all-or-nothing terms, but far too many people struggle with the day-to-day reality of what this means. It's an incredibly romantic notion that you're so great that someone would want to stay with you the rest of their life. Certainly, many people achieve this, but most people do not feel this way about the person they marry. In fact, many people will marry two, three, or even four times before they find someone that they would want to spend the rest of their life with; of course, by the third or fourth marriage, there's probably not much life left to worry about. This is especially true for our sense of time which accelerates as we age.

      Preventing divorce seems like a good idea. I don't think there's enough emphasis on prevention. Once you're married, it's too late. So, before you get married, you may want to consider doing some of the following things:

1. Date more people. In your 20's there's intense social pressure to get married and have kids; you'd probably do well to ignore this pressure, especially if your female so that you can build of some career experience because there's about a 50/50 chance you'll end up divorced. Our relationship experiences are very relative to each other, so, dating more people can give you a better perspective on what you like and maybe you have more potential than you realize and don't have to settle.

2. Live with someone for the experience and to learn about yourself. The daily conflicts that arise when people live together and how they communicate about these differences will make or break a marriage. So, there are probably some important lessons to be learned here.

3. Women should be careful about how much they put security above happiness and men should be careful about how much they put appearance above personality.  This is a matter of degree of course. Too many people get married for the wrong reasons. I've known many people who end up having affairs with people who are less wealthy and less attractive than their spouse because they learn that meaningful connection comes through good communication more than anything else. If you're female, and you haven't established your career, then you may find that you'll have a really difficult time divorcing when you're older and may end up resigning to stay with your husband for security. Recently, I saw someone write that "marriage is not an achievement," that's a good perspective to have.

4. Don't be afraid to call off an engagement or a marriage, even at the last minute.

5. Don't get caught-up in mental traps, like family idealism and family perfectionism. You won't, but if you have this expectation, then things will be much worse. Family idealism is the idea of how you want to look as a family, with the stereotypical example being a house, two cars, two kids, a dog and a public persona like a politician or celebrity. You'll be happier if you're trying to please each other rather than your neighbors. Family perfectionism is the expectation and desire to have your family days, dates, events, and so on, happen without a hitch, no arguing, no one is unhappy, everyone cooperative and smiling. Sometimes this is called family utopia. These ideas are displayed on Facebook every day, but their sort of laughable, because these snapshots are a far cry from the real movie going on. I'm not saying people should "air dirty laundry," but readers should recite a disclaimer in their mind while viewing, this is just a happy snapshot.

6. Consider taking different vows, if you're permitted to by your church, or if you're secular. For example, you can choose to take a vow of commitment, but not until death or for the rest of your life. Commitments until death becomes like union contracts for many spouses. People seem to get too comfortable and end up neglecting or taking advantage of each other. The security of the agreement becomes its fatal flaw.

7. Consider not getting married at all, but instead living with someone with whom you feel would be a good companion. I've met many couples over the years who quite happily lived together some with children, some without, for more than a decade; I only had the pleasure to meet them after they got married and one or both ended up wanting a divorce. In Iceland, close to 35% of women never marry and will have children with more than one father. The number is growing. In the United States, marriage rates are at an all-time low, and the divorce rate has been decreasing, probably for several good reasons, such as the growth of a low-wage economy and people being more selective and mature when they do get married.

8. Try pre-marital therapy or couples therapy before or during your engagement. Church-based pre-marital programs can be helpful, but going through some therapy sessions where you're talking about very specific problems and exposing your deeper emotions and private communication skills can be very helpful to each of you in identifying areas you need to work on and if you can really tolerate each other's personalities. You also might learn some techniques or gain some important knowledge that will help you now or down the road.

So, no, divorce is certainly not bad for kids.  There are too many risk and protective factors involved in the changes that come with divorce that makes it impossible to predict how any child will react. If your kids seem to be having trouble adjusting, then consider therapy, but don't wait too long. 
This site provides some good information about Adjustment Disorder which is a non-severe mental health problem that anyone could potentially develop in reaction to any type of life change.

Please send questions or comments to ScottLCostello@gmail.come or feel free to comment below. All comments are moderated in order to filter our spam and inappropriate comments.  

Most people will argue that divorce is bad for kids. However, to be fair, we should look at the status and health of each spouse and each child, not just the kids. The argument that, if divorce is bad for kids then we should not get divorced is too simplistic to be useful on a case-by-case basis.
    When looking at the impact of divorce on women, the general impact has been very good in some ways, for example, the suicide rate for women dropped by 20% in States where no-fault divorce was legalized. Furthermore, the rate of domestic violence towards women dropped between 25% to 50% in no-fault States; and, women in no-fault States were 10% less likely to be murdered by their husband. Keep in mind that men who abuse or kill their wives are also likely to have been abusing their children, children often witnessed the abuse and may have also been killed by the abuser. This data is available in the National Bureau of Economic Research and other locations.
   Traditionally, women had greater economic loss from divorce than men, but more recent and fair maintenance rules and child support enforcement have made it easier for women to leave the marriage with more security until they have time to recover financially. Most men do not realize the severe impact on earning ability women suffer from having children in their 20's and 30's. This period of time is crucial to career advancement and for most women, it can never be made up. At the same time, most men are free to advance their careers and their economic stability is ensured through retirement.

** Personality disorders are fairly common, with Borderline at about 6%, affecting both men and women equally, and Narcissism, somewhere between 2% and 16%, affecting far more men. There are other personality disorders, such as Avoidant, Histrionic, Anti-Social, Obsessive Compulsive, and others. The overall prevalence of a personality disorder is probably between 10-20% of the population. It's possible that personality disorders play a role in divorce since chronic relationship problems are primary issues of those who suffer from personality disorders. It's easy for couples to label each other as having personality problems when they do not, and this is probably an effect of chronically poor patterns of communication for both spouses, the tendency to move from complaints to contempt, and the tendency of people to blame and label each other. If your spouse thinks you suffer from a personality disorder, it is definitely something to discuss with and possibly explore with your marital therapist.

Mental Health Advice Disclaimer: The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

Thursday, January 12, 2017

"Medical Marijuana" not so much.

Most marijuana medicinal benefits are inconclusive, wide-ranging study finds

Read it for yourself but here are other posts I've written about marijuana use.

Consumers should be aware of the following regarding "medical marijuana:"

1. The FDA has not approved marijuana for use for anything.

2. Medical Marijuana is not based on science but economics and personal preferences. The medical marijuana lobbying efforts have been lead by long-time marijuana advocates like NORML and a few billionaires like Sean Parker and George Soros. Although these two billionaires have financial interests in marijuana products, at least one billionaire, Peter Lewis, who was arrested for marijuana possession, in New Zealand, in 2000, basically wanted marijuana legal wherever he went. NORML is a bunch of college and former college student pot-heads who have been trying to legalize weed for decades (see Life magazine from 1969). The "movement" wasn't taken seriously until billionaires, with lobbying expertise and unlimited money, started funding legal efforts across the country.

3. Regardless of what your uninformed physician tells you or your teen, marijuana is potentially very dangerous for teenagers. So, yes, I've had numerous teens and parents tell me that their doctor(s) have not shown any concern for teen marijuana use. I find this appalling. Lately, Marijuana has been the number one reason for inpatient drug treatment for teens; it's been responsible for hundreds of thousands of teen ER visits from panic attacks and psychosis to suicidality and paranoia. Many teens have attempted suicide while "high" no weed, and I have known several teens who have caused fatal car accidents while high on weed. Clearly, teens should not be smoking weed - at all. It's also a gateway drug. So, parents who smoke weed, love to hear how it's harmless, and, they have kids who are comfortable with it from a young age. Many of these teens start smoking weed at age 10-14, and by the time their 16 to 18, they're "bored" with weed or have reached maximum tolerance, and start looking for other drugs to use. Unfortunately for them, there aren't any good choices when it comes to drugs.

4. Not one medical organization, association, or society has approved or recommended marijuana for anything - and for good reason!  Here's why - yes, marijuana may show some benefits from a few things, but as soon as you start using higher doses or for longer periods of time, the risks have consistently far outweighed the benefits. For example, the level of impairment from marijuana becomes obvious. It stays in the bloodstream and requires less and less of the drug to cause intoxication. It also causes daily withdrawal symptoms, and it causes memory loss and attention problems (this is related to car accidents). On top of that, the users aren't aware of how impaired they are becoming. 

5. Taxing marijuana will probably not outweigh the health and legal costs from problems associated with marijuana use, from things like loss of worker productivity, increased auto accidents, increased healthcare utilization especially amongst the lower working classes who utilize publically funded health insurance programs, costs associated with drug treatment, and costs related to the use of other drugs from escalated addiction.

6. Any prescription for marijuana for any condition is a shot in the dark. You'll be taking an addictive drug with potentially harmful side effects. How will you measure your progress on marijuana? Will you lose awareness of negative effects like regular users often have. I meet so many people who are quitting marijuana because their spouse gives them an ultimatum because marijuana is causing them significant problems, like social isolation, lack of motivation, memory and attention problems, and other problems. 

Don't rely on major media for good medical information and don't trust that just because you state legalized weed that it's okay - state representatives want your tax revenue to spend on their pet projects or salary increases - they don't seem to care much about your health or well-being - as evidenced by the fact that they would even consider voting to make this drug legal or medicinal, circumventing the normal legal channels of the Food and Drug Administration.

Sunday, December 11, 2016

Neurofeedback for ADHD, An Expensive Placebo Effect

     A while ago, I had written a review of Neurofeedback (biofeedback; NF) for ADHD and other mental health problems, and I recently updated the article to show that the status of NF has not changed, it remains an unproved, experimental therapy for ADHD or other mental health problems.  (my original article here:
   However, after my update, I received seven (7) comments, which to summarize, claimed that my review was incorrect, unfair, and one person even wrote, "dangerous." I cut and pasted the comments below and have responded to each.
     It seems as though the commentators may have perceived my post as a personal attack against NF. I wish that NF was shown to be effective; in fact, I wish NF could cure all people with ADHD; but, one of my roles here is to inform people of the scientific status of mental health treatments. My role is not to support the providers of NF, or NF itself, or any other treatment just because I provide it or like it or for some other non-scientific reason. I'm sorry if my post offends readers who think they have benefited from NF or make a living providing it.  

The first commentator:

Anonymous posted this comment:

This article makes some valid points, but I know many people who have benefited from neurofeedback. I wish
it would consider that results in how a patient feels are just as important as valid scientific data. Perhaps it is 

just too early for studies to have been conducted, that does not in my opinion however discount the merit of 
neurofeedback as an alternative form of treatment. on Neurofeedback and ADHD
My response:  
 A provider of NF may inform patients prior to treatment that "in my clinical experience, NF seems to help many patients, but I cannot predict who will benefit from NF." However, NF providers should not say things like, "this is a proven therapy," or that "it helps most people," and certainly not something like, "85% of people who use NF are cured." Claims like this about NF are not supported by properly designed scientific studies. Provides of NF should also inform patients that NF might not be covered by their insurance company.
     From a scientific standpoint, "the merit" of NF is based only on good scientific data. Someone with a Masters or PhD should know this. Anecdotes from various patients about how well a treatment worked are useless from a scientific standpoint. The sum of anecdotes is not science. That's what sets science apart from things like professional gossip and professional biases.

Anonymous #1, posted this:

There are no sources cited in this "review"; that are of relevance. You simply chose to exclude sources where neurofeedback WAS found to be successful and instead focused on the small sample of tests where it was merely inconclusive. Any psychology training would tell you that there are hundreds of external variables that can influence a study. If you intended to run a "REVIEW"; blog as you have so aptly titled it..try evaluating CURRENT research. on Neurofeedback and ADHD

My response:
     The first source I listed in the article is very relevant. It was a randomly controlled placebo trial conducted by scientists who have no financial interests in NF. The results of the study showed that NF was not any better than a placebo. When you have a published RCT's showing this outcome, then you cannot, in absolute terms, tell patients that NF is "proven."
     A significant problem faced by NF is that most of the studies that have been conducted on its effectiveness have not been good studies, and have been done by people who have direct or indirect financial interests in NF. For example, studies that are not randomized, not placebo controlled, have small sample sizes, or are blinded are not useful for determining effectiveness.

     There are sources listed at the end of this page. The sources included at the bottom of the page are reviews of NF. Keep in mind that most studies completed on NF are not even included in reviews because they weren't good enough to be included, or if they are included, the authors conclude that more methodologically sound studies need to be done.

Anonymous #2, posted this:

you sound like an individual who is unwilling to do his homework. on Neurofeedback and ADHD
My response:  
     Back at you on this one, Anonymous. I have done my homework. I've read every systematic review and meta-analysis on the subject of NF.  BCBS is right to not reimburse NF for lack of evidence that it works; they've done their homework, too.

Anonymous #3, posted this:

Dear Scott Costello. Your blog and opinion is outright dangerous and misinformed. Unless you want to promote
the use of amphetamines such as Adderall for children, who's brains are still developing of a drug free
alternative, then please state so. The ONE study you referenced concluded: "Conclusions: The current
study found that optimally titrated methylphenidate is superior to neurofeedback and physical activity in
decreasing ADHD symptoms in children with ADHD." The key word is "superior". However,
that assumes that the drug use is without consequences. If addiction is taken into consideration, then perhaps
neurofeedback is more superior. ADHD is a complex mental problem, and neurofeedback is a well proven
technology. To dismiss a technology irrespective of the quality and training of the practitioner, the quality of the
software analysis, the number of electrodes use, the quality of artifacting and so on, dismisses your opinion. A
better advise for parents strugling with ADHD on Neurofeedback and ADHD

My response:       

     Dear Anonymous #3, calling my blog and opinion "outright dangerous and misinformed," makes you sound like a politician; calling my article dangerous, is hyperbole or dramatic from someone who is behaving in an irrationally defensive manner. 
     You argue that I promote amphetamines when I actually discourage their use (this is called a straw-man argument on your part). The one, randomly controlled trial that I did cite in my post included a literature review which showed that NF is not effective at treating ADHD. So, this was not just one study, but a review of the available studies; this is very significant.
     ADHD meds are considered the most effective treatment for ADHD. However, they probably should no longer be considered the first line of treatment; instead behavioral therapies should probably replace meds as the first treatment. The word "superior" is undefined by scientific authors, and although it is commonly used, it probably should be taken at face value and would mean "above" or simply better than.
     Anonymous states that "neurofeedback is a well proven technology," but  does not provide any studies to support this claim; I'm aware that there are not any that do, but I'm wondering why you think NF is "well proven." Proven is a strong word to use, by the way, but then again, so are "dangerous" and "misinformed."
     I'm sorry Anonymous, but the "quality and training of the practitioner, the quality of the software analysis," etc..., are all irrelevant if the outcome shows that NF does not work better than a placebo. I'm guessing that you're a provider of NF, like the other commentators, and your just defending your practice from scrutiny by resorting to unsound and illogical arguments.

Anonymous #4 commented:

ADHD is a very complex disorder and to simplify the solution down to drugs and therapy as the 'holy
grail' is false too. Brain Maps can be an effective tool to identify brain functions, great tool to help rule
in or out ADHD vs. the over- simplified paper test. Neurofeedback not a cure but can help many imperfect
brain functions work a little better. Give thanks that you don't suffer from something like ADHD, Anxiety
and Depression. on Neurofeedback and ADHD

My response:  

     Another commentator critiquing my article, but failing to offer any real evidence that NF works other than because they say it does. I suspect that this post was written by same person as #3, due to the dramatic style. Anyway, this is an argument from compromise: NF isn't a cure but it can help the brain "work a little better." Sorry, there's no compromise here; at this point, after many studies, NF does not work better than a placebo; and, by the way, how do you know that I don't suffer from ADHD, anxiety or depression?

Anonymous #5 commented:

Neurofeedback is a schedule 1 treatment for ADHD with tons of articles and research supporting the efficacy of the treatment. For you to say it's "experimental" simply is not true. Neurofeedback changes the electrical activity of the central nervous system. Also, the skill you claim that neurofeedback practitioners don't have is ridiculous. Brain function is localized and without knowing where to place electrodes and what frequencies to train you can make people worse. You really need to do some more research on this. on Neurofeedback and ADHD
My response:  
     Yes, NF is a "schedule 1 treatment." Please know that "schedule 1" is the lowest rated type of treatment available. The scale is from 1 to 5, where 5 represents the most safe and effective type of treatment known to science, and 1 representing no scientific support and experimental. So, this is a case where being number 1 is not something to brag about.
     Now that we have the numbers straight, there is not "tons" of research supporting NF. I doubt if we printed and weighed all the NF studies that they would weigh 2000 pounds or more. One sheet of paper is 28 grams, and there are 908,000 grams in one ton. So, that would be 64,857 pages of research, or about 5,416 studies - for one ton, but you wrote, "tons." I'm pretty certain there aren't many more than 100 studies, so we're talking ounces of studies, and most of them lack scientific rigor, but the well-designed studies show that NF does not work better than a placebo. 
     I stand by my comments on skill level of NF providers; I'm not saying it doens't require some skill, my point is that the fees charged for the NF procedures seems high relative to the rigor of the certification process which is open to, what appears to be most human service degrees; I think that is clear in the post.
     Do you inform your patients that NF can, as you write, potentially make them worse? I'll watch for the next systematic review of NF, but until then, NF remains in the realm of experimental and probably not effective as indicated by scientific research.

Anonymous #6 commented:

I have used a type of neurofeedback called NeurOptimal® in clinical practice for a decade and based on what
clients tell me, neurofeedback works. People feel less anxiety and more capable of dealing with life. Children
suddenly function better and can better self regulate. People are more resilient and have better focus. And they
 tell their family and friends about us. I stopped paying attention to research long ago, especially given that the
work of Dr. Barry Streman proved that neurofeedback works. This was in the 1960s. What I now listen to is what
 clients tell me about how they are feeling. on Neurofeedback and ADHD
My response:  
     This is similar to the first comment, that because your clients say it works, then that's good enough, but unfortunately, if you want to have the support of the scientific community, then that's not good enough. The sum of anecdotes is not science, it's gossip. NF practitioners seem to be similar to pharmaceutical companies, always expanding the mental health problems that can allegedly be treated with NF - from ADHD, to depression, to anxiety, and so on, and producing poorly designed studies with small sample sizes. 
     Sorry to hear that you "stopped paying attention to research long ago." Nothing was "proven" in the 1960's, that's sounds absurd. The scientific process has changed substantially since then. I think it's completely irresponsible to use NF and pretend that it's supported by scientific research. Patients rightfully assume that you'll be using interventions that are based on sound science. So, by not keeping up with scientific studies, you're being irresponsible. The level-system used by researchers is to be used by providers when giving informed consent to their patients. So, the status of NF as a level 1, possibly level 2 treatment should be known to patients before they consent to treatment. I suspect that people would not be willing to pay as much for NF if they knew that it was not better than a placebo.


Sibley, Margaret, et al. (2014). Clinical Psychology Review. Pharmacological and psychosocial treatments for adolescents with ADHD: An updated systematic review of the literature. Elsevier, ltd. 
     "Review of past 13 years of research on treatment of ADHD in adolescence" (218). "There was no evidence that... neurofeedback improved the functioning of adolescents with ADHD" (218). Authors do not recommend stimulants as the preferred treatment for ADHD.

Loaiza, Juana Gaviria, et al. (2014)Psychology Journal (Revista CES Psicologia)Is Neurofeedback training an efficacious treatment for ADHD? Results from a systematic review.  University of Deleware. 
     "The results point to a level of efficacy located between level two (potential effectiveness) and level three (probable effectiveness), therefore, it is necessary to conduct a research with a higher level of variables and larger samples." CES Psicologia, 7(1), 16-34.

Liew, Ashley. (2014)Journal of Neurology, Neurosurgery, and Psychiatry. EEG Biofeedback Therapy for ADHD: A Systematic Review.  J Neurol Neurosurg Psychiatry 85:e3 doi:10.1136/jnnp-2014-308883.34.
     "There is growing evidence for neurofeedback as a non-pharmacological alternative in the treatment of ADHD, but the existing literature displays a range of methodological weaknesses. Further and more convincing research is required." (Abstract).

Vollebregt, Madelon A., et al. (2014). The Journal of Child Psychology and Psychiatry. Does EEG-neurofeedback improve neurocognition function in children with attention-deficit/hyperactivity disorder? A systematic review and a double-blind placebo-controlled study. Volume 55, Issue 5, May 2014, pages 460-472. Errata.
     "No significant treatment effect on any of the neurocognitive variables  was found. A systematic review of the current literature also did not find any systematic beneficial effect of EEG-neurofeedback on neurocognitive functioning.... Overall, the existing literature and this study fail to support any benefit of neurofeedback on neurocognitive functioning in ADHD, possibly due to small sample sizes and other study limitations."

Sonuga-Barke, Edmund J.S., PhD, et al. (2013). American Journal of Psychiatry. Nonpharmacological Interventions for ADHD: Systematic Review and Meta-Analyses of Randomized Controlled Trials of Dietary and Psychological Treatments. March 2013, 170;275-289.
     "Better evidence for efficacy from blinded assessments is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms."

Willis, Grant, et al. (2011)Journal of Applied School Psychology. Neurofeedback as a Treatment for Attention-Deficit/Hyperactivity Disorder: A Systematic Review of Evidence for Practice.  July 2011, 27(3):201-227.
     "Commonly used guidelines regarding empirically supported treatment approaches show that, at present, neurofeedback is not well supported as a treatment for ADHD."

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