A Randomized Controlled Trial Investigating the Effects of Neurofeedback, Methylphenidate, and Physical Activity on Event-Related Potentials in Children with Attention-Deficit/Hyperactivity Disorder. Real‐time fMRI neurofeedback in adolescents with attention deficit hyperactivity disorder Neurofeedback and Cognitive Attention Training for Children with Attention-Deficit Hyperactivity Disorder in Schools What future research should bring to help resolving the debate about the efficacy of EEG-neurofeedback in children with ADHD Self-reported efficacy of neurofeedback treatment in a clinical randomized controlled study of ADHD children and adolescents Effects of neurofeedback versus stimulant medication in attention-deficit/hyperactivity disorder: a randomized pilot study. Neurofeedback in ADHD: a single-blind randomized controlled trial Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial. Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports Neurofeedback training in children with ADHD: 6-month follow-up of a randomised controlled trial Multimodal treatment in children and adolescents with attention-deficit/hyperactivity disorder: a 6-month follow-up Slow cortical potential neurofeedback and self-management training in outpatient care for children with ADHD: study protocol and first preliminary results of a randomized controlled trial Computer-Based Attention Training in the Schools for Children With Attention Deficit/Hyperactivity Disorder: A Preliminary Trial fMRI Neurofeedback Training for Increasing Anterior Cingulate Cortex Activation in Adult Attention Deficit Hyperactivity Disorder. An Exploratory Randomized, Single-Blinded Study A randomized controlled trial into the effects of neurofeedback, methylphenidate, and physical activity on EEG power spectra in children with ADHD. Alterations of amygdala-prefrontal connectivity with real-time fMRI neurofeedback in BPD patients. Neurofeedback in children with ADHD: Specific event-related potential findings of a randomized controlled trial Distinct EEG effects related to neurofeedback training in children with ADHD: a randomized controlled trial. The Inclusion of Functional Connectivity Information into fMRI-based Neurofeedback Improves Its Efficacy in the Reduction of Cigarette Cravings A 6-month follow-up of an RCT on behavioral and neurocognitive effects of neurofeedback in children with ADHD Neurofeedback, sham neurofeedback, and cognitive-behavioural group therapy in adults with attention-deficit hyperactivity disorder: a triple-blind, randomised, controlled trial.
OBJECTIVE Electroencephalographic ( EEG ) neurofeedback ( NF ) is considered a nonpharmacological alternative for medication in attention-deficit/hyperactivity disorder ( ADHD ) . Comparisons of the behavioral efficacy of NF and medication have produced inconsistent results . EEG measures can provide insight into treatment mechanisms , but have received little consideration . In this r and omized controlled trial ( RCT ) , effects of NF were compared with methylpheni date ( MPH ) , and physical activity ( PA ) in children with ADHD on event-related potential ( ERP ) indices of response inhibition , which are involved in ADHD psychopathology . METHODS Using a multicenter three way parallel group RCT design , 112 children with a Diagnostic and Statistical Manual of Mental Disorders , 4th ed . ( DSM-IV ) ( American Psychiatric Association 1994 ) diagnosis of ADHD , between 7 and 13 years of age , were initially included .  NF training consisted of 30 sessions of theta/beta training at Cz over a 10 week period . PA training was a semiactive control group , matched in frequency and duration . MPH was titrated using a double-blind placebo controlled procedure in 6 weeks , followed by a stable dose for 4 weeks . ERP measures of response inhibition , N2 and P3 , were available for 81 children at pre- and postintervention ( n = 32 NF , n = 25 MPH , n = 24 PA ) . RESULTS Only the medication group showed a specific increase in P3 amplitude compared with NF ( partial eta-squared [ ηp(2 ) ] = 0.121 ) and PA ( ηp(2 ) = 0.283 ) , which was related to improved response inhibition . Source localization of medication effects on P3 amplitude indicated increased activation primarily in thalamic and striatal nuclei . CONCLUSIONS This is the first study that simultaneously compared NF with stimulant treatment and a semiactive control group . Only stimulant treatment demonstrated specific improvements in brain function related to response inhibition . These results are in line with recent doubts on the efficacy and specificity of NF as treatment for ADHD . CLINICAL TRIALS REGISTRATION Train Your Brain ? Exercise and Neurofeedback Intervention for ADHD , https:// clinical trials.gov/show/NCT01363544 , Ref . No. NCT01363544 Abstract Attention Deficit Hyperactivity Disorder ( ADHD ) is associated with poor self‐control , underpinned by inferior fronto‐striatal deficits . Real‐time functional magnetic resonance neurofeedback ( rtfMRI‐NF ) allows participants to gain self‐control over dysregulated brain regions . Despite evidence for beneficial effects of electrophysiological‐NF on ADHD symptoms , no study has applied the spatially superior rtfMRI‐NF neurotherapy to ADHD . A r and omized controlled trial tested the efficacy of rtfMRI‐NF of right inferior prefrontal cortex ( rIFG ) , a key region that is compromised in ADHD and upregulated with psychostimulants , on improvement of ADHD symptoms , cognition , and inhibitory fMRI activation . To control for region‐specificity , an active control group received rtfMRI‐NF of the left parahippocampal gyrus ( lPHG ) . Thirty‐one ADHD boys were r and omly allocated and had to learn to upregulate their target brain region in an average of 11 rtfMRI‐NF runs over 2 weeks . Feedback was provided through a video‐clip of a rocket that had to be moved up into space . A transfer session without feedback tested learning retention as a proximal measure of transfer to everyday life . Both NF groups showed significant linear activation increases with increasing number of runs in their respective target regions and significant reduction in ADHD symptoms after neurotherapy and at 11‐month follow‐up . Only the group targeting rIFG , however , showed a transfer effect , which correlated with ADHD symptom reductions , improved at trend level in sustained attention , and showed increased IFG activation during an inhibitory fMRI task . This proof‐of‐concept study demonstrates for the first time feasibility , safety , and shorter‐ and longer‐term efficacy  of rtfMRI‐NF of rIFG in adolescents with ADHD . Hum Brain Mapp 38:3190–3209 , 2017 . © 2017 The Authors Human Brain Mapping Published by Wiley Periodicals , Objective : To evaluate the efficacy of 2 computer attention training systems administered in school for children with attention-deficit hyperactivity disorder ( ADHD ) . Method : Children in second and fourth grade with a diagnosis of ADHD ( n = 104 ) were r and omly 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 . Results : 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 methylpheni date 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 ) . Conclusion : 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 In recent years a rising amount of r and omized controlled trials , review s , and meta-analyses relating to the efficacy of electroencephalographic-neurofeedback ( EEG-NF ) in children with attention-deficit/hyperactivity disorder ( ADHD ) have been published . Although clinical reports and open treatment studies suggest EEG-NF to be effective , double blind placebo-controlled studies as well as a rigorous meta- analysis failed to find support for the efficacy of EEG-NF . Since absence of evidence does not equate with evidence of absence , we will outline how future research might overcome the present method ological limitations . To provide conclusive evidence for the presence or absence of the efficacy of EEG-NF  in the treatment of ADHD , there is a need to set up a well- design ed study that ensures optimal implementation and embedding of the training , and possibly incorporates different forms of neurofeedback Background Many non-pharmacological treatments for children and adolescents with attention-deficit/hyperactivity disorder ( ADHD ) have been attempted , but reports indicate that most are ineffective . Although neurofeedback ( NF ) is a treatment approach for children with ADHD that remains promising , a variety of appropriate measures have been used in reporting and evaluating its effect . Objective To report the self-evaluations of NF treatment by children and adolescents with ADHD . Methods R and omized controlled trial in 91 children and adolescents with ADHD , aged less than 18 years ( mean , 11.2 years ) participated in a 30-session program of intensive NF treatment .  Participants were r and omized and allocated by sequentially numbered sealed envelopes into three groups : methylpheni date ( MPH ) as an active control group , and two trial groups NF with MPH , and NF alone .  ADHD core symptoms and school performance were given on a scale of 1 to 10 using a self-reporting question naire , and the changes in these scores after treatment were used as the self-reported evaluation . Basic statistical methods ( descriptive , analyses of variance , exact χ2 test , and paired t-test ) were used to investigate the baseline data . Changes in ADHD core symptoms and treatment effects were investigated using a general linear model for repeated measures . Results Eighty participants completed the treatment study and 73 ( 91 % ) responded sufficiently on the self-reporting question naires . The treatment groups were comparable in age , sex , and cognition as well as in the baseline levels of core ADHD symptoms . All treatments result ed in significant improvements regarding attention and hyperactivity ( P<0.001 ) , and did not differ from each other in effectiveness . However , a significant treatment effect in school performance was observed ( P=0.042 ) , in which only the NF group showed a significant improvement . Conclusion The self-reported improvements in ADHD core symptoms and school performance shortly after treatment indicate NF treatment being promising in comparison with medication , suggesting NF as an alternative treatment for children and adolescents who do not respond to MPH , or who suffer side effects . Further long-term follow-up is needed OBJECTIVE The purpose of this pilot study was to compare the effects of 30 sessions of neurofeedback ( NF ) with stimulant medication on attention-deficit/hyperactivity disorder ( ADHD ) patients . METHODS Thirty-two medication-naïve ADHD patients , ages 7 - 16 , from a neuropsychiatric clinic , were r and omized to NF ( n=16 ) or drug treatment ( n=16 ) . Other actions , such as parent management training , information , or support in school were given as needed , with no differences between the groups . All participants were assessed before treatment on two rating scales , each with parent and teacher forms . In addition , quantitative electroencephalogram ( QEEG ) and event-related potentials ( ERPs ) , which included behavioral data from a go/no go test were administered . NF training took place in the clinic over a period of 7 - 11 months , and was followed by a repeat of the same assessment tools . The mean time interval between pre- and postassesment was not significantly different in the two groups . The 18 symptoms of ADHD ( American Psychiatric Association , Diagnostic and Statistical Manual of Mental Disorders , 4th ed . ( DSM-IV ) ) were used as the primary outcome measure . RESULTS Analysis of covariance revealed a significant difference between the groups at evaluation in favor of medication , with a large effect size . This picture was confirmed by other outcome measures . The QEEG spectral power in the theta and beta b and s did not change in either group . In ERP , the P3 no go component increased significantly in 8 of 12 patients who had a clinical ly relevant medication effect , but did not increase in the medication nonresponders or the NF group . CONCLUSIONS Our study supports effects for stimulants , but not for NF . Effects of NF may require thorough patient selection , frequent training sessions , a system for excluding nonresponders , and active transfer training . The P3 no go ERP component may be a marker for treatment response Neurofeedback treatment has been demonstrated to reduce inattention , impulsivity and hyperactivity in children with attention deficit/hyperactivity disorder ( ADHD ) . However , previous studies did not adequately control confounding variables or did not employ a r and omized reinforcer-controlled design . This study addresses those method ological shortcomings by comparing the effects of the following two matched biofeedback training variants on the primary symptoms of ADHD : EEG neurofeedback ( NF ) aim ing at theta/beta ratio reduction and EMG biofeedback ( BF ) aim ing at forehead muscle relaxation . Thirty-five children with ADHD ( 26 boys , 9 girls ; 6–14 years old ) were r and omly assigned to either the therapy group ( NF ; n = 18 ) or the control group ( BF ; n = 17 ) . Treatment for both groups consisted of 30 sessions . Pre- and post-treatment assessment consisted of psychophysiological measures , behavioural rating scales completed by parents and teachers , as well as psychometric measures . Training effectively reduced theta/beta ratios and EMG levels in the NF and BF groups , respectively . Parents reported significant reductions in primary ADHD symptoms , and inattention improvements in the NF group were higher compared to the control intervention ( BF , dcorr = −.94 ) . NF training also improved attention and reaction times on the psychometric measures . The results indicate that NF effectively reduced inattention symptoms on parent rating scales and reaction time in neuropsychological tests . However , regarding hyperactivity and impulsivity symptoms , the results imply that non-specific factors , such as behavioural contingencies , self-efficacy , structured learning environment and feed-forward processes , may also contribute to the positive behavioural effects induced by neurofeedback training BACKGROUND For children with attention deficit/hyperactivity disorder ( ADHD ) , a reduction of inattention , impulsivity and hyperactivity by neurofeedback ( NF ) has been reported in several studies . But so far , unspecific training effects have not been adequately controlled for and /or studies do not provide sufficient statistical power . To overcome these method ological shortcomings we evaluated the clinical efficacy of neurofeedback in children with ADHD in a multisite r and omised controlled study using a computerised attention skills training as a control condition . METHODS 102 children with ADHD , aged 8 to 12 years , participated in the study . Children performed either 36 sessions of NF training or a computerised attention skills training within two blocks of about four weeks each ( r and omised group assignment ) . The combined NF treatment consisted of one block of theta/beta training and one block of slow cortical potential ( SCP ) training . Pre-training , intermediate and post-training assessment encompassed several behaviour rating scales ( e.g. , the German ADHD rating scale , FBB-HKS ) completed by parents and teachers . Evaluation ( ' placebo ' ) scales were applied to control for parental expectations and satisfaction with the treatment . RESULTS For parent and teacher ratings , improvements in the NF group were superior to those of the control group . For the parent-rated FBB-HKS total score ( primary outcome measure ) , the effect size was .60 . Comparable effects were obtained for the two NF protocol s ( theta/beta training , SCP training ) . Parental attitude towards the treatment did not differ between NF and control group . CONCLUSIONS Superiority of the combined NF training indicates clinical efficacy of NF in children with ADHD . Future studies should further address the specificity of effects and how to optimise the benefit of NF as treatment module for ADHD Background A r and omized and controlled clinical study was performed to evaluate the use of neurofeedback ( NF ) to treat  attention-deficit/hyperactivity disorder ( ADHD ) in children and adolescents . Methods The ADHD population was selected from an outpatient clinic for Child and Adolescent Mental Health in Norway . Ninety-one of the 275 children and adolescents ranging in age from 6 to 18 years ( 10.5 years ) participated in 30 sessions of an intensive NF program . The reinforcement contingency was based on the subjects ’ production of cortical beta1 activity ( 15–18 Hz ) . The ADHD participants were r and omized into three groups , with 30 in the NF group , 31 controls in a group that was given methylpheni date , and 30 in a group that received NF and methylpheni date .  ADHD core symptoms were reported by parents using the parent form of the Clinician ’s Manual for Assessment by Russell A. Barkley . Results Ninety-one children and adolescents were effectively r and omized by age , sex , intelligence and distribution of ADHD core symptoms . The parents reported significant effects of the treatments , but no significant differences between the treatment groups were observed . Conclusions NF was as effective as methylpheni date at treating the attentional and hyperactivity symptoms of ADHD , based on parental reports . Trial registration Current Controlled Trials Neurofeedback ( NF ) could help to improve attentional and self-management capabilities in children with attention-deficit/hyperactivity disorder ( ADHD ) . In a r and omised controlled trial , NF training was found to be superior to a computerised attention skills training ( AST ) ( Gevensleben et al. in J Child Psychol Psychiatry 50(7):780–789 , 2009 ) . In the present paper , treatment effects at 6-month follow-up were studied . 94 children with ADHD , aged 8–12 years , completed either 36 sessions of NF training ( n = 59 ) or a computerised AST ( n = 35 ) . Pre-training , post-training and follow-up assessment encompassed several behaviour rating scales ( e.g. , the German ADHD rating scale , FBB-HKS ) completed by parents . Follow-up information was analysed in 61 children ( ca . 65 % ) on a per- protocol basis . 17 children ( of 33 dropouts ) had started a medication after the end of the training or early in the follow-up period . Improvements in the NF group ( n = 38 ) at follow-up were superior to those of the control group ( n = 23 ) and comparable to the effects at the end of the training . For the FBB-HKS total score ( primary outcome measure ) , a medium effect size of 0.71 was obtained at follow-up . A reduction of at least 25 % in the primary outcome measure ( responder criterion ) was observed in 50 % of the children in the NF group . In conclusion , behavioural improvements induced by NF training in children with ADHD were maintained at a 6-month follow-up . Though treatment effects appear to be limited , the results confirm the notion that NF is a clinical ly efficacious module in the treatment of children with ADHD Abstract Background : Different treatment approaches aim ed at reducing attention-deficit/hyperactivity disorder ( ADHD ) core symptoms are available . However , factors such as intolerance , side-effects , lack of efficacy , high new technology costs , and placebo effect have spurred on an increasing interest in alternative or complementary treatment . Aim : The aim of this study is to explore efficacy of multimodal treatment consisting of st and ard stimulant medication ( methylpheni date ) and neurofeedback ( NF ) in combination , and to compare it with the single treatment in 6-month follow-up in ADHD children and adolescents . Methods : This r and omized controlled trial with 6-month follow-up comprised three treatment arms : multimodal treatment ( NF + MED ) , MED alone , and NF alone .  A total of 130 ADHD children/adolescents participated , and 62 % completed the study .  ADHD core symptoms were recorded pre-/post-treatment , using parents ’ and teachers ’ forms taken from Barkley ’s Defiant Children : A Clinician ’s Manual for Assessment and Parent Training , and a self-report question naire . Results : Significant ADHD core symptom improvements were reported 6 months after treatment completion by parents , teachers , and participants in all three groups , with marked improvement in inattention in all groups . However , no significant improvements in hyperactivity or academic performance were reported by teachers or self-reported by children/adolescents , respectively , in the three groups . Changes obtained with multimodal treatment at 6-month follow-up were comparable to those with single medication treatment , as reported by all participants . Conclusions : Multimodal treatment using combined stimulant medication and NF showed 6-month efficacy in ADHD treatment . More research is needed to explore whether multimodal treatment is suitable for ADHD children and adolescents who showed a poor response to single medication treatment , and for those who want to reduce the use of stimulant medication Background : Treatment for children with attention deficit/hyperactivity disorder ( ADHD ) today is predominantly pharmacological . While it is the most common treatment , it might not always be the most appropriate one . Moreover , long term effects remain unclear . Behavior therapy ( BT ) and non-pharmacological treatments such as neurofeedback ( NF ) are promising alternatives , though there are no routine outpatient care/effectiveness studies yet that have included children with medication or changes in medication . Methods / design : This paper presents the protocol of a r and omized controlled trial to compare the effectiveness of a Slow Cortical Potential ( SCP ) NF protocol with self-management ( SM ) in a high frequent outpatient care setting . Both groups ( NF/SM ) receive a total of 30 high frequent therapy sessions . Additionally , 6 sessions are reserved for comorbid problems . The primary outcome measure is the reduction of ADHD core symptoms according to parent and teacher ratings . Preliminary Results : Untill now 58 children were included in the study ( 48 males ) , with a mean age of 8.42 ( 1.34 ) years , and a mean IQ of 110 ( 13.37 ) . Conners-3 parent and teacher ratings were used to estimate core symptom change . Since the study is still ongoing , and children are in different study stages , pre-post and follow-up results are not yet available for all children included . Preliminary results suggest overall good pre-post effects , though . For parent and teacher ratings an ANOVA with repeated measures yielded overall satisfying pre-post effects ( η2 0.175–0.513 ) . Differences between groups ( NF vs. SM ) could not yet be established ( p = 0.81 ) . Discussion : This is the first r and omized controlled trial to test the effectiveness of a NF protocol in a high frequent outpatient care setting that does not exclude children on or with changes in medication . First preliminary results show positive effects . The rationale for the trial , the design , and the strengths and limitations of the study are discussed . Trial registration : This trial is registered in www . clinical trials.gov as NCT01879644 Objective . This study examined the efficacy of 2 computer-based training systems to teach children with attention deficit/hyperactivity disorder ( ADHD ) to attend more effectively . Design / methods . A total of 41 children with ADHD from 2 middle schools were r and omly assigned to receive 2 sessions a week at school of either neurofeedback ( NF ) or attention training through a st and ard computer format ( SCF ) , either immediately or after a 6-month wait ( waitlist control group ) . Parents , children , and teachers completed question naires pre- and postintervention . Results . Primary parents in the NF condition reported significant ( P < .05 ) change on Conners ’s Rating Scales — Revised ( CRS-R ) and Behavior Assessment Scales for Children ( BASC ) subscales ; and in the SCF condition , they reported significant ( P < .05 ) change on the CRS-R Inattention scale and ADHD index , the BASC Attention Problems Scale , and on the Behavioral Rating Inventory of Executive Functioning ( BRIEF ) . Conclusion . This r and omized control trial provides preliminary evidence of the effectiveness of computer-based interventions for ADHD and supports the feasibility of offering them in a school setting Attention Deficit Hyperactivity Disorder ( ADHD ) is characterized by poor cognitive control/attention and hypofunctioning of the dorsal anterior cingulate cortex ( dACC ) . In the current study , we investigated for the first time whether real-time fMRI neurofeedback ( rt-fMRI ) training targeted at increasing activation levels within dACC in adults with ADHD leads to a reduction of clinical symptoms and improved cognitive functioning . An exploratory r and omized controlled treatment study with blinding of the participants was conducted . Participants with ADHD ( n = 7 in the neurofeedback group , and n = 6 in the control group ) attended four weekly MRI training sessions ( 60-min training time/session ) , during which they performed a mental calculation task at varying levels of difficulty , in order to learn how to up-regulate dACC activation . Only neurofeedback participants received continuous feedback information on actual brain activation levels within dACC . Before and after the training , ADHD symptoms and relevant cognitive functioning was assessed . Results showed that both groups achieved a significant increase in dACC activation levels over sessions . While there was no significant difference between the neurofeedback and control group in clinical outcome , neurofeedback participants showed stronger improvement on cognitive functioning . The current study demonstrates the general feasibility of the suggested rt-fMRI neurofeedback training approach as a potential novel treatment option for ADHD patients . Due to the study ’s small sample size , potential clinical benefits need to be further investigated in future studies . Trial Registration : IS RCT BACKGROUND The clinical and neurophysiological effects of neurofeedback ( NF ) as treatment for children with ADHD are still unclear . This r and omized controlled trial ( RCT ) examined electroencephalogram ( EEG ) power spectra before and after NF compared to methylpheni date ( MPH ) treatment and physical activity ( PA ) - as semi-active control group - during resting and active ( effortful ) task conditions to determine whether NF can induce sustained alterations in brain function . METHODS Using a multicentre three-way parallel group RCT design , 112 children with a DSM-IV diagnosis of ADHD , aged between 7 and 13 years , were initially included . NF training consisted of 30 sessions of theta/beta training at Cz over a 10-week period . PA training was a semi-active control group , matched in frequency and duration . Methylpheni date was titrated using a double-blind placebo controlled procedure in 6 weeks , followed by a stable dose for 4 weeks . EEG power spectra measures during eyes open ( EO ) , eyes closed ( EC ) and task ( effortful ) conditions were available for 81 children at pre- and postintervention ( n = 29 NF , n = 25 MPH , n = 27 PA ) . CLINICAL TRIALS REGISTRATION Train Your Brain ? Exercise and Neurofeedback Intervention for ADHD , https:// clinical trials.gov/show/;NCT01363544 , Ref . No. NCT01363544 . RESULTS Both NF and MPH result ed in comparable reductions in theta power from pre- to postintervention during the EO condition compared to PA ( ηp ( 2 ) = .08 and .12 ) . For NF , greater reductions in theta were related to greater reductions in ADHD symptoms . During the task condition , only MPH showed reductions in theta and alpha power compared to PA ( ηp ( 2 ) = .10 and .12 ) . CONCLUSIONS This study provides evidence for specific neurophysiological effects after theta/beta NF and MPH treatment in children with ADHD . However , for NF these effects did not generalize to an active task condition , potentially explaining reduced behavioural effects of NF in the classroom With the use of real-time functional magnetic resonance imaging neurofeedback ( NF ) , amygdala activitiy can be visualized in real time . In this study , continuous amygdala NF was provided to patients with borderline personality disorder ( BPD ) with the instruction to down-regulate . During four sessions of NF training , patients viewed aversive pictures and received feedback from a thermometer display , which showed the amygdala blood oxygenation level-dependent signal . Conditions of regulation and viewing without regulation were presented . Each session started with a resting-state scan and was followed by a transfer run without NF .  Amygdala regulation , task-related and resting-state functional brain connectivity were analyzed . Self-ratings of dissociation and difficulty in emotion regulation were collected . BPD patients  down-regulated right amygdala activation but there were no improvements over time . Task-related amygdala-ventromedial prefrontal cortex connectivity was altered across the four sessions , with an increased connectivity when regulating vs viewing pictures . Resting-state amygdala-lateral prefrontal cortex connectivity was altered and dissociation , as well as scores for ' lack of emotional awareness ' , decreased with training . Results demonstrated that amygdala NF may improve healthy brain connectivity , as well as emotion regulation . A r and omized-controlled trial is needed to investigate whether amygdala NF is instrumental for improving neural regulation and emotion regulation in BPD patients OBJECTIVE In a r and omized controlled trial , we could demonstrate clinical efficacy of neurofeedback ( NF ) training for children with ADHD ( Gevensleben et al. , 2009a ) . The present investigation aim ed at learning more about the neuronal mechanisms of NF training . METHODS Children with ADHD either completed a NF training or a computerized attention skills training ( ratio 3:2 ) . NF training consisted of one block of theta/beta training and one block of slow cortical potential ( SCP ) training , each comprising 18 training units . At three times ( pre-training , between the two training blocks and at post-training ) , event-related potentials ( ERP ) were recorded during the Attention Network Test . ERP analysis focused on the P3 , reflecting inter alia attentional re sources for stimulus evaluation , and the contingent negative variation ( CNV ) , primarily related to cognitive preparation . RESULTS After NF training , an increase of the CNV in cue trials could be observed , which was specific for the SCP training . A larger pre-training CNV was associated with a larger reduction of ADHD symptomatology for SCP training . CONCLUSIONS CNV effects reflect neuronal circuits underlying re source allocation during cognitive preparation . These distinct ERP effects are closely related to a successful NF training in children with ADHD . In future studies , neurophysiological recordings could help to optimize and individualize NF training . SIGNIFICANCE The findings contribute to a better underst and ing of the mechanisms underlying NF training in children with ADHD In a r and omized controlled trial , neurofeedback ( NF ) training was found to be superior to a computerised attention skills training concerning the reduction of ADHD symptomatology ( Gevensleben et al. , 2009 ) . The aims of this investigation were to assess the impact of different NF protocol s ( theta/beta training and training of slow cortical potentials , SCPs ) on the resting EEG and the association between distinct EEG measures and behavioral improvements . In 72 ( of initially 102 ) children with ADHD , aged 8 - 12 , EEG changes after either a NF training ( n=46 ) or the control training ( n=26 ) could be studied . The combined NF training consisted of one block of theta/beta training and one block of SCP training , each block comprising 18 units of 50 minutes ( balanced order ) .  Spontaneous EEG  was recorded in a two-minute resting condition before the start of the training , between the two training blocks and after the end of the training . Activity in the different EEG frequency b and s was analyzed . In contrast to the control condition , the combined NF training was accompanied by a reduction of theta activity . Protocol -specific EEG changes ( theta/beta training : decrease of posterior-midline theta activity ; SCP training : increase of central -midline alpha activity ) were associated with improvements in the German ADHD rating scale . Related EEG-based predictors were obtained . Thus , differential EEG patterns for theta/beta and SCP training provide further evidence that distinct neuronal mechanisms may contribute to similar behavioral improvements in children with ADHD Real-time fMRI ( rtfMRI ) neurofeedback ( NF ) facilitates volitional control over brain activity and the modulation of associated mental functions . The NF signals of traditional rtfMRI-NF studies predominantly reflect neuronal activity within ROIs . In this study , we describe a novel rtfMRI-NF approach that includes a functional connectivity ( FC ) component in the NF signal ( FC-added rtfMRI-NF ) . We estimated the efficacy of the FC-added rtfMRI-NF method by applying it to nicotine-dependent heavy smokers in an effort to reduce cigarette craving . ACC and medial pFC as well as the posterior cingulate cortex and precuneus are associated with cigarette craving and were chosen as ROIs . Fourteen heavy smokers were r and omly assigned to receive one of two types of NF : traditional activity-based rtfMRI-NF or FC-added rtfMRI-NF . Participants received rtfMRI-NF training during two separate visits after overnight smoking cessation , and cigarette craving score was assessed . The FC-added rtfMRI-NF result ed in greater neuronal activity and increased FC between the targeted ROIs than the traditional activity-based rtfMRI-NF and result ed in lower craving score . In the FC-added rtfMRI-NF condition , the average of neuronal activity and FC was tightly associated with craving score ( Bonferroni-corrected p = .028 ) . However , in the activity-based rtfMRI-NF condition , no association was detected ( uncorrected p > .081 ) . Non-rtfMRI data analysis also showed enhanced neuronal activity and FC with FC-added NF than with activity-based NF . These results demonstrate that FC-added rtfMRI-NF facilitates greater volitional control over brain activity and connectivity and greater modulation of mental function than activity-based rtfMRI-NF Abstract To assess the long-term effects of neurofeedback ( NFB ) in children with attention deficit hyperactivity disorder ( ADHD ) , we compared behavioral and neurocognitive outcomes at a 6-month naturalistic follow-up of a r and omized controlled trial on NFB , methylpheni date ( MPH ) , and physical activity ( PA ) .  Ninety-two children with a DSM-IV-TR ADHD diagnosis , aged 7–13 , receiving NFB ( n = 33 ) , MPH ( n = 28 ) , or PA ( n = 31 ) , were re-assessed 6-months after the interventions . NFB comprised theta/beta training on the vertex ( cortical zero ) . PA comprised moderate to vigorous intensity exercises . Outcome measures included parent and teacher behavioral reports , and neurocognitive measures ( auditory oddball , stop-signal , and visual spatial working memory tasks ) . At follow-up , longitudinal hierarchical multilevel model analyses revealed no significant group differences for parent reports and neurocognitive measures ( p = .058–.997 ) , except for improved inhibition in MPH compared to NFB ( p = .040 ) and faster response speed in NFB compared to PA ( p = .012 ) during the stop-signal task . These effects , however , disappeared after controlling for medication use at follow-up . Interestingly , teacher reports showed less inattention and hyperactivity/impulsivity at follow-up for NFB than PA ( p = .004–.010 ) , even after controlling for medication use ( p = .013–.036 ) . Our findings indicate that the superior results previously found for parent reports and neurocognitive outcome measures obtained with MPH compared to NFB and PA post intervention became smaller or non-significant at follow-up . Teacher reports suggested superior effects of NFB over PA ; however , some children had different teachers at follow-up . Therefore , this finding should be interpreted with caution . Clinical trial registration Train your brain and exercise your heart ? Advancing the treatment for Attention Deficit Hyperactivity Disorder ( ADHD ) , Ref . no. NCT01363544 , https:// clinical trials.gov/show/NCT01363544 BACKGROUND Many studies suggest that electroencephalographic ( EEG ) neurofeedback might be beneficial in the treatment of attention-deficit hyperactivity disorder ( ADHD ) . However , numbers of well controlled studies are low and neurofeedback techniques are regarded as highly controversial . The present trial examined the efficacy ( compared with sham neurofeedback ) and efficiency ( compared with meta-cognitive therapy ) of a st and ard EEG neurofeedback protocol in adults with ADHD . METHODS We did a concurrent , triple-blind , r and omised , controlled trial using authorised deception in adults with ADHD from one centre ( University of Tübingen ) in Tübingen , Germany . Participants were eligible if they fulfilled the DSM-IV-TR criteria for ADHD , were aged between 18 years and 60 years , and had no or stable use of medication for at least 2 months with no intention to change . We excluded participants who had comorbid schizophrenia or schizoaffective disorder , bipolar disorder , borderline personality disorder , epilepsy , or traumatic brain injury ; substance abuse or dependence ; or current or planned other psychological treatment . Those eligible were r and omly assigned to three groups : a neurofeedback group which received 30 verum θ-to-β neurofeedback sessions over 15 weeks , a sham neurofeedback group which received 15 sham followed by 15 verum θ-to-β neurofeedback sessions over 15 weeks , or a meta-cognitive group therapy group which received 12 sessions over 12 weeks . Participants were assigned equally to one of the three interventions through a computerised minimisation r and omisation procedure stratified by sex , age , and baseline symptom severity of ADHD . Participants were masked as to whether they were receiving neurofeedback or sham neurofeedback , but those receiving meta-cognitive therapy were aware of their treatment . Clinical assessors ( ie , those assessing outcomes ) and research staff who did the neurofeedback training were masked to participants ' r and omisation status only for neurofeedback and sham neurofeedback . The primary outcome was symptom score on the Conners ' adult ADHD rating scale , assessed before treatment , at midtreatment ( after 8 weeks ) , after treatment ( after 16 weeks ) , and 6 months later . All individuals with at least one observation after r and omisation were included in the analyses . This trial is registered with Clinical Trials.gov , number NCT01883765 . FINDINGS Between Feb 1 , 2013 , and Dec 1 , 2015 , 761 people were assessed for eligibility . 656 ( 86 % ) were excluded and 118 ( 15 % ) were eligible for participation in this study . Eligible participants were r and omly assigned to neurofeedback ( 38 [ 32 % ] ) , sham neurofeedback ( 39 [ 33 % ] ) , or meta-cognitive therapy ( 41 [ 35 % ] ) . 37 ( 97 % ) individuals for neurofeedback , 38 ( 97 % ) for sham neurofeedback , and 38 ( 93 % ) for meta-cognitive therapy were included in analyses . Self-reported ADHD symptoms decreased substantially for all treatment groups ( B=-2·58 [ 95 % CI -3·48 to -1·68 ] ; p<0·0001 ) between pretreatment and the end of 6 month follow-up , independent of treatment condition ( neurofeedback vs sham neurofeedback B=-0·89 [ 95 % CI -2·14 to 0·37 ] , p=0·168 ; neurofeedback vs meta-cognitive therapy -0·30 [ -1·55 to 0·95 ] , p=0·639 ) . No treatment-related or trial-related serious adverse events were reported . INTERPRETATION Our findings suggest that neurofeedback training is not superior to a sham condition or group psychotherapy . All three treatments were equivalently effective in reducing ADHD symptoms . This first r and omised , sham-controlled trial did not show any specific effects  of neurofeedback  on ADHD symptoms in adults . FUNDING German Research Foundation
Further data on specificity comes from electrophysiological studies reporting that  NF effectively changes brain activity patterns .
No safety issues have emerged from clinical trials and NF seems to be well tolerated and accepted .
Follow-up studies support long-term effects of NF .
In conclusion , NF is a valid option for the treatment for ADHD , but further evidence is required to guide its use
Summary Neurofeedback ( NF ) is a training to enhance self-regulatory capacity over brain activity patterns and consequently over brain mental states .
Recent findings suggest that NF is a promising alternative for the treatment of  attention-deficit/hyperactivity disorder ( ADHD ) .