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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:  https://thementalhealthreview.blogspot.com/2016/09/neurofeedback-and-adhd.html).
   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.

References:

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. ajp.psychiatry.online.org.
     "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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