Comparing Parent Self-Report and Child Cognitive Task in a
Neurofeedback Clinic for ADHD
Kirsten D. Leaberry, B.A., Kate Nooner, Ph.D., Richard Ogle, Ph.D., Julian Keith, Ph.D.
Abstract
Neurofeedback (NFB) is an alternative treatment for childhood ADHD that relies on
the principles of operant conditioning to retrain brainwave patterns associated with
concentration. Although NFB has been shown to alleviate ADHD symptoms, treatment
outcomes have been assessed inconsistently and have largely relied on self-report
measures. Many randomized controlled trials (RCT’s) have only relied on parent
reports to assess treatment outcomes, which are prone to expectancy effects. While
RCT’s have established that 20-40 sessions of NFB is somewhat efficacious in
research settings, multi-faceted outcome assessment studies are also warranted in real
world clinical settings. In outcome assessment 1, children performed a continuous
performance cognitive task (CPT) pre and post 12 NFB sessions to assess cognitive
outcomes. In outcome assessment 2, 12 parents completed a parent measure of child
ADHD symptoms pre and post 12 NFB sessions to assess behavioral outcomes.
Children made statistically significantly fewer errors on the CPT following 12 NFB
sessions, F (1, 30) = 4.87, p = .035. Parents reported statistically significantly less
ADHD symptoms following 12 NFB sessions in the clinic, F (1, 11) = 16.44, p = .002.
This studies novel use of 12 sessions delivered in just 3-4 weeks demonstrates that
modest exposure to NFB leads to measurable cognitive improvements and behavioral
changes. Children will be followed for 6-months to see if the results of this clinic
based treatment hold over time.
Table 1: Demographic characteristics of outcome assessments
Figure 1: BrainPaint® neurofeedback screenshot
Participants receive 12 sessions of theta/beta and SMR neurofeedback aimed at increasing beta
activity (concentration and focus) and decreasing theta activity (daydream state.) The
neurofeedback screen contains fractal images, the what is/what isn’t feedback bar, a “hold”
clock,” EEG, and verbal feedback. Participants are reinforced (green bar, fractal, music) when
brainwaves approach target threshold levels. If these thresholds are not met, the bar appears red,
and an aversive sound plays.
Results/Discussion
One-way repeated measures Analysis of Variance (ANOVA) was conducted to
examine pre- to post- 12 NFB session differences on cognitive and behavioral
measures of ADHD symptoms. Effect sizes were calculated by from pre- to post12 NFB session difference scores. Children made statistically significantly fewer
errors on the CPT following 12 NFB sessions, F (1, 30) = 4.87, p = .035. Parents
reported statistically significantly less ADHD symptoms following 12 NFB
sessions in the clinic, F (1, 11) = 16.44, p = .002. Figure 2 depicts pre and post- 12
NFB session differences on the CPT and CRS-P. There was a small effect size for
the CPT (Cohen’s d= 0.30) and a large effect size for the CRS-P (Cohen’s d=
1.19). These outcome assessment results suggest that statistically significant
reductions in cognitive and behavioral ADHD symptoms can be detected with
only moderate exposure to NFB delivered in a clinic. The large effect size for the
behavioral measure of ADHD symptoms (CRS-P) and the small effect size for the
cognitive assessment (CPT), is consistent with expectancy effects of parent report
(Sonuga-Barke et al., 2013). Previous studies of NFB have often relied solely on
behavioral measures with strict inclusion criteria (e.g., Meisel et al., 2013).
Multimodal outcome assessment is useful in clinic settings to provide information
on behavioral and cognitive changes following NFB.
Method
The current outcome assessments examined behavioral and cognitive outcomes of NFB delivered in
an ADHD clinic. Children were initially assessed for ADHD according to the DSM-IV-TR and
received 12 sessions of clinic-based NFB; comorbid diagnoses and medication were permitted. In
outcome assessment 1, children performed a cognitive task measuring ADHD symptoms, the
Conner’s Continuous Performance Task (CPT). In outcome assessment 2, 12 parents completed a
behavioral measure of child ADHD symptoms, the Conner’s Rating Scale-Parent Form (CRS-P).
Outcome Assessment 1 Measure: The CPT
Introduction
NFB has received “Level 1 Best Support” as an evidence-based treatment for childhood
ADHD according to the American Academy of Pediatrics (2012). NFB has resulted in
improvements in child performance on cognitive tasks measuring inattention and
impulsivity (Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003), as well as
parent and teacher report of attention and hyperactivity (Leins et al., 2007). NFB studies
commonly employ parent report alone to assess outcomes (e.g., Miesel, Servera, GarciaBanda, Cardo, Moreno, 2013). Only a few studies have employed cognitive assessments
of ADHD symptoms (e.g., Bakhshayesh, Hansch, Wyschkon, Rezai, Esser, 2011; Fuchs
et al., 2003), which is surprising given that these assessments are less subject to
expectancy effects and essential for fully examining NFB treatment outcomes. Another
limitation in establishing the clinical effectiveness of NFB is the lack of outcome
assessment in community practice settings. While work is emerging (e.g., Hillard, ElBaz, Sears, Tasman, & Sokhadaze, 2013), the majority of published research is
randomized controlled trials (RCT’s) utilizing 30+ sessions of NFB with stringent
inclusion criteria. Though RCTs are needed to establish an evidence base, their results
may not generalize to heterogeneous clinic populations where many NFB sessions and
strict inclusion criteria are not realistic.
Outcome Assessment 2 Measure: CRS-P
Procedure
1.Eligibility Assessment
-K-SADS- Semi Structured Diagnostic Clinical Interview
-Exclusion criteria: IQ <70, suicidal ideation, psychotic symptoms, manic symptoms
2. Conner’s Continuous Performance (CPT) and Conner’s Rating Scale-Parent Form (CRS-P)
-CPT: 14 minute task; measures omissions and commissions
-CRS-P: 45-item measure measuring ADHD behavioral symptoms
3. Neurofeedback
-12 sessions of BrainPaint® neurofeedback: theta/beta and SMR (Figure 1)
4. Post 12 NFB sessions: CPT or CPT and CRS-P
Figure 2: Pre- and Post- 12 NFB Session Differences in CPT and CRS-P
Top: Significantly less errors on cognitive CPT task post-12 NFB sessions
Bottom: Significantly less behavioral ADHD symptoms on CRS-P post-12
NFB sessions