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Journal Article Reviews

Attention-Deficit Hyperactivity Disorder Cortese S, Ferrin M, Brandeis D, et al. Neurofeedback for Attention-Deficit/Hyperactivity Disorder: meta-analysis of clinical and neuropsychological outcomes from randomized controlled trials. J Am Acad Child Adolesct Psychiatry. 2016;55:444–455. Attention-deficit hyperactivity disorder (ADHD) is a common neurobehavioral disorder. Treatments may include psychostimulant and nonstimulant medications as well as behavioral accommodations and strategies as well as parent training. Neurofeedback has been considered as a possible nonpharmacological treatment of ADHD. Neurofeedback trains the patient self-regulation using electroencephalogram indices to control part of a computer program. Previous meta-analytic reviews performed found some positive effects of neurofeedback; however, issues of blinding and including of studies with weak experimental designs have been noted as limitations. This study was a meta-analysis of randomized controlled trials examining the effects of neurofeedback on ADHD symptoms and neuropsychological deficits. It attempted to address some of the limitations of the previous work and also extend the focus of previous work. This analysis included 13 trials with 520 patients with ADHD. When most proximal assessments to the intervention were considered, significant small-tomoderate effects on ADHD symptoms were noted (standardized mean difference [SMD] for ADHD total symptoms 5 0.35, 95% confidence interval [CI], 0.11– 0.59; SMD for inattention 5 0.36, 95% CI, 0.09–0.63; and hyperactivity/impulsivity 5 0.26, 95% CI, 0.08–0.43). However, when only trials with an active control were considered, the effects declined to nonsignificant levels for total ADHD and inattentive symptoms. For hyperactivity/impulsivity, significant effects were maintained but with small effect size (SMD-0.25, 95% CI, 0.03–0.47). When probably blinded outcomes were assessed, effect sizes for ADHD declined further and were no longer significant. It is noted that a number of groups have developed standard neurofeedback protocols addressing the number of sessions recommended, the parameters, etc., and only 54% of the studies in the analysis met these specifications. When analyzing only that cohort, the results were mixed. Another limitation noted was that the level of blinding was unclear and often insufficient. Overall, this meta-analysis does not support the use of neurofeedback in addressing ADHD symptoms. However, due to limitations in qualities of the studies assessed in the analysis, it is difficult to draw absolute conclusions. Further studies using standardized protocols and blinding procedures are warranted. O.V.B.