Tuesday, November 10, 2009

Neurofeedback: Seeking the Evidence

Thousands of American families, including my own, have invested thousands of dollars in a promising intervention for AD/HD—neurofeedback. No health insurance plan in America pays for neurofeedback for the treatment of AD/HD as the evidence-based science is not yet there. CHADD’s Professional Advisory Board has published What We Know statements on the evidence-based science on complementary and alternative interventions, including neurofeedback, available on the website of CHADD’s National Resource Center on AD/HD.

CHADD advocates a significant additional financial investment by the National Institute of Mental Health in neurofeedback for AD/HD. During the past year, the CHADD Professional Advisory Board (PAB) has discussed with the International Society for Neurofeedback and Research (ISNR) the published science behind this intervention for AD/HD. At this point in time, we have asked ISNR eight key questions about the research. They are:

1. CHADD has stated that for a neurofeedback intervention to be described as "evidence-based,” we would expect to see randomized studies involving double-blind, sham control of equal intensity and duration. Does ISNR agree with this standard for evaluating the published science? If not, what are ISNR's standards for evaluating the published science?

2. Brainwave patterns profiles: There is ambiguity in the literature about: (a) whether or not there are different “profiles” for brainwave patterns; (b) whether or not these profiles can be categorized; and (c) whether or not these profiles can be reliably identified prior to intervention. What is ISNR’s position on the overall issue of profiles and their standardization?

3. Profile-based intervention: Are there standardized practice guidelines for neurofeedback clinicians to use in order to match profile with intervention? If so, is this done uniformly within the profession? Is there a manual that clinicians use for this purpose? Given that the need to match profile with intervention was emphasized in the letter from ISNR, why is this not made clear in the literature?

4. Generalization: Given that discussion of this is largely absent from the literature, to what extent do members of the organization feel that the effects that are seen generalize to other behaviors and real-life settings? What do clinicians say to patients in this regard?

5. Given the comorbidities present in most research samples of individuals with AD/HD, (a) what is the strength of the evidence that the intervention is specifically addressing AD/HD, and (b) to what extent are the dependent measures AD/HD-specific?

6. Persistence: What evidence is there that any effect seen persists, and does this vary by subtype of brain wave pattern? Should neurofeedback studies routinely include a 12-month follow-up assessment of outcomes? If so, should the dependent variables include real-life measures?

7. To what extent may the experience/expectation of the clinician/coach/trainer affect the outcome (i.e., is there a degree of “facilitation” in this type of intervention)? Given that you emphasize the importance of the trainer having clinical background and tailoring the training to the patient, how can it be clarified which factor—the neurofeedback itself or the intense repeated therapeutic interaction with the clinically trained trainer—is having the effect?

8. Who has access to purchase neurofeedback equipment? For clinicians using this equipment, does ISNR have any published or readily available guidelines concerning the qualifications a clinician must have or the minimal standards a clinician must meet?

As this CHADD PAB-ISNR dialogue continues, CHADD will keep the public informed, when there are advances in the evidence-based science.