ABSTRACT Operant conditioning of the electroencephalographic rhythm (EEG biofeedback) is argued to be an effective method for treating children with ADHD. This study was designed to evaluate whether this method, compared to methylphenidate, achieves an equally effective outcome. Participants were 39 children aged between 7-12 years. Thirteen children with attention-deficit/hyperactivity disorder (ADHD) were trained to enhance the amplitude of the beta1 activity (15-18 Hz) and decrease the amplitude of the theta activity (4-8 Hz), and 13 of which were treated with methylphenidate alone. Thirteen healthy children did not receive intervention. Several behavioral, neuropsychological and experimental tests were administered before and after intervention. While behavioral measures were improved by both types of method, methylphenidate was significantly more effective than EEG biofeedback. Response inhibition was improved only by EEG biofeedback. Both EEG biofeedback and methylphenidate were associated with improvements on the variability and accuracy measures of computerized tests. Intellectual ability increased also by both methods. Although averaged effect size for methylphenidate seems to be greater than for EEG biofeedback, the difference was not significant. In conjunction with other studies, these findings demonstrate that EEG biofeedback can significantly improve several be-havioral and cognitive functions in children with ADHD, and it might be an alternative treatment for non-responders or incomplete responders to medication as well as for those their parents favor a non-pharmacological treatment.
Cite this paper
nullM. Nazari, L. Querne, A. Broca and P. Berquin, "Effectiveness of EEG Biofeedback as Compared with Methylphenidate in the Treatment of Attention-Deficit/Hyperactivity Disorder: A Cinical Out-Come Study," Neuroscience and Medicine, Vol. 2 No. 2, 2011, pp. 78-86. doi: 10.4236/nm.2011.22012.
 R. T. Brown, R. W. Amler, W. S. Freeman, J. M. Perrin, M. T. Stein, H. M. Feldman, et al "Treatment of attention-deficit/hyperactivity disorder: overview of the evidence," Pediatrics, Vol. 115, No. 6, 2005, pp. 749-57.
 W. J. Pelham, B. H. Smith, “Prediction and meas-urement of individual responses to ritalin by children and adolescents with ADHD, “In: L. Greenhill, B. Osman. Eds., Ritalin: Theory and patient management, 2nd ed. Mary Ann Liebert. , New York, 2000.
 J. Elia,” Drug treatment for hyperactive children: Therapeutic guidelines” Drugs, Vol. 46, No. 5, 1993, PP. 863- 71.
 J. K. Nash, “Treatment of attention deficit hyperactivity disorder with neurotherapy,” Clin Electroencephalography, Vol. 31, No. 1, 2000, pp. 30-7.
 T. Spencer, J. Biederman, T. Wilens, “Pharmacotherapy of attention deficit hyperactivity disorder,” Child and Adolescent Psychiatry Clinics of North America,Vol. 9, No. 1, 2000, pp. 77-97.
 D. A. Waschbusch, G. P. Hill, “ Empirically sup-ported, promising, and unsupported treatments for chil-dren with Attention-Deficit/Hyperactivity Disorder,” In :SO. Lilienfield, Lynn. S. Jay, J. M. Lohr. eds. Science and pseudoscience in clinical psychology, Guilford Press, New York , 2003.
 National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effec-tive- ness and growth after the end of treatment. Pediatrics, Vol. 113, No. 4, 2004 ,PP. 762-9.
 J. Biederman, S. V. Faraone, “Attention-deficit hy-peractivity disorder”, Lancet, Vol. 366, No. 9481, 2005, PP. 237-48.
 L. C. Smoot, L. A. Boothby, R. C. Gillett, “Clinical assessment and treatment of ADHD in children,” inter-national journal of clinical practice, 2007, Vol. 61, No. 10, pp. 1730-8.
 W. E. Pelham, “Psychosocial interventions for ADHD”. In: P. S. Jensen, J. R. Cooper. Eds., Attention deficit hyperactivity disorder: State of the science: Best Practices. Kingston, NJ: Civic Research Institute, 2002, pp. 12-13.
 S. M. Butnik, “Neurofeedback in adolescents and adults with attention deficit hyperactivity disorder,” Journal of Clinical Psychology, Vol. 61, No. 5, 2005, pp. 621-5.
 J. F. Lubar, M. N. Shouse, “EEG and behavioral changes in a hyperkinetic child concurrent with training of the sensorimotor rhythm (SMR): a preliminary report, ” Biofeedback Self Regulation, Vol. 1, No. 3, 1976, pp. 293- 306.
 M. N. Shouse, J. F. Lubar, “Operant conditioning of EEG rhythms and ritalin in the treatment of hyperkine-sis,” Biofeedback Self Regulation, Vol. 4, No. 4, 1979, pp. 299-312.
 J. O. Lubar, J. F. Lubar, “Electroencephalo-graphic biofeedback of SMR and beta for treatment of attention deficit disorders in a clinical setting”, Biofeedback Self Regulation, Vol. 9, No. 1, 1984, pp. 1-23.
 J .F. Lubar, M .O. Swartwood, J .N. Swartwood, P. H. O’Donnell, “ Evaluation of the effectiveness of EEG neurofeedback training for ADHD in a clinical set-ting as measured by changes in T.O.V.A. scores, behav-ioral ratings, and WISC-R performance,” Biofeedback Self Regulation, Vol. 20, No. 1, 1995, pp. 83-99.
 T. R. Rossiter, T. J, La Vaque, “A comparison of EEG biofeedback and psycho stimulants in treating at-tention deficit/hyperactivity disorders,” Journal of Neu-rotherapy, Vol. 1, 1995, pp. 48-59.
 M. Linden, T. Habib, V. Radojevic, “A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities,” Biofeedback Self Regulation, Vol. 21, No. 1, 1996, pp. 35-49.
 L. Thompson, M. Thompson, “Neurofeedback combined with training in metacognitive strategies: ef-fectiveness in students with ADD,” Applied Psycho-physiology and Biofeedback, Vol. 23, No. 4, 1998, pp. 243-63.
 D. P. Carmody, D. C Radvanski, S. Wadhwani, M. J, Sabo, L. Vergara, “EEG biofeedback training and Attention-Deficit/Hyperactivity Disorder in an elemen-tary school setting, ” Journal of Neurotherapy, Vol. 4, 2001, pp .5-27.
 V. J. Monastra, D. M, Monastra, S. George, “The effects of stimulant therapy, EEG biofeedback, and par-enting style on the primary symptoms of atten-tion-deficit/hy- peractivity disorder, ” Applied Psycho-physiology and Biofeedback, Vol. 27, No. 4, 2002, pp. 231-49.
 T. Fuchs, N, Birbaumer, W. Lutzenberger, J. H, Gruzelier, J. Kaiser, “Neurofeedback treatment for at-tention-deficit/ hyperactivity disorder in children: a com-parison with methylphenidate, ” Applied Psychophysiology and Biofeedback, Vol. 28, No. 1, 2003, pp. 1-12.
 C. Heywood, I. Beale, “EEG biofeedback vs. pla-cebo treatment for attention-deficit/hyperactivity disor-der: a pilot study, ” Journal of Attentional Disordered, Vol. 7, No. 1, 2003, pp .43-55.
 B. H. Cho, S. Kim, D. I. Shin, J. H. Lee, S. M. Lee, I. Y. Kim, et al, “Neurofeedback training with virtual reality for inattention and impulsiveness, ” Cyberpsy-chology Behavior, Vol. 7, No. 5, 2004, pp. 519-26.
 H. Heinrich, H. Gevensleben, F. J. Freisleder, G. H. Moll, A. Rothenberger, “Training of slow cortical po-tentials in attention-deficit/hyperactivity disorder: evi-dence for positive behavioral and neurophysiological effects,” Biological Psychiatry, Vol. 55, No. 7, 2004, pp. 772-5.
 T. Rossiter, “The effectiveness of neurofeedback and sti- mulant drugs in treating AD/HD: part II. Replica-tion,” Applied Psychophysiology and Biofeedback, Vol. 29, No. 4, 2004, pp. 233-43.
 M. Beauregard, J. Levesque “Functional magnetic resonance imaging investigation of the effects of neuro- feedback training on the neural bases of selective atten- tion and response inhibition in children with atten-tion- deficit/hyperactivity disorder,” Applied Psycho-physi- ology and Biofeedback, Vol. 31, No. 1, 2006, pp. 3-20.
 J. Levesque, M. Beauregard, B. Mensour, “Effect of neurofeedback training on the neural substrates of selective attention in children with atten-tion-deficit/hyperactivity disorder: a functional magnetic resonance imaging study,” Neuroscience Letter, Vol. 394, No. 3, 2006, pp. 216-21.
 U. Strehl, U. Leins, G. Goth, C. Klinger, T. Hinter-berger, N. Birbaumer, “Self-regulation of slow cortical potentials: a new treatment for children with atten-tion-deficit/hype- ractivity disorder,” Pediatrics, Vol. 118, No. 5, 2006, pp. 1530-40.
 M. Arns, S. de Ridder, U. Strehl, M. Breteler, and A. Coenen, “Efficacy of neurofeedback treatment in ADHD: The effects on inattention, impulsivity and hyperactivity: A meta-analysis,” Clinical EEG and Neuroscience, Vol. 40, No. 3, 2009, pp. 180-189.
 J. P. Kline, C. N. Brann, B. R. Loney, “A ca-cophony in the brainwaves: A critical appraisal of neu-rotherapy for Attention Deficit Disorders, ” The Scien-tific Review of Mental Health Practice,Vol. 1, 2002, pp. 46-56.
 P. M. Ramirez, D. Desantis, L. A. Opler, “EEG biofeedback treatment of ADD. A viable alternative to traditional medical intervention? ” Annals of the New York Academy of Sciences,Vol. 931, 2001, pp. 342-58.
 V. J. Monastra, S. Lynn, M. Linden, J. F. Lubar, J. Gruzelier, T. J. LaVaque, “Electroencephalographic biofeedback in the treatment of atten-tion-deficit/hyperactivity disorder, ” Applied Psycho-physiology and Biofeedback, Vol. 30, No. 2, 2005, pp. 95-114.
 T. J. La Vaque, T. Rossiter, “The ethical use of placebo controls in clinical research: the Declaration of Helsinki,” Applied Psychophysiology and Biofeedback, Vol. 26, No. 1, 2001, pp. 23-37,discussion 61-5.
 D. Vernon, A. Frick, J. Gruzelier, “Neurofeed-back as a treatment for ADHD: A methodological review with implications for future research, ” Journal of Neu-rotherapy, Vol. 8, 2004, pp. 53-82.
 T. M. Achenbach, “Manual for the Child Behavior Checklist/4-18 and 1991 Profile, ” Burlington, VT: University of Vermont Department of Psychiatry, 1991.
 J. M. Swanson, S. B. Wigal, D. Udrea, M. Lerner, D. Agler, D. Flynn, et al, “Evaluation of individual subjects in the analog classroom setting: I. Examples of graphical and statistical procedures for within-subject ranking of responses to different delivery patterns of methylpheni-date, ” Psychopharmacology Bulletin, Vol. 34, No. 4, 1998, pp. 825-32.
 G. J. DuPaul, R. A. Barkley, D. F. Connor, “Stimulants”. In: R.A. Barkley, ed, Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Guilford Press, New York, 1998, pp. 510-551.
 D. Wechsler, “Wechsler Intelligence Scale for Children (WISC-III), San Antonio, ” TXC: Psychological Corporation, 1991.
 J. R. Stroop, “Studies of interference in serial ver-bal reactions, ” Journal of Experimental Psychology, Vol. 18, , 1935, pp. 643-662.
 J. Albaret, M. Migliore, “Manuel du test de Stroop, ” Editions du Centre de Psychologie Appliquée, Paris, 1999.
 Conners, K. Conners’ Continuous Performance Test for Windows (CPT II), Multi-Health Systems Inc, Can-ada, 2002.
 L. Deltour, M. Barathon, V. Quaglino, M. P Vernier, P. Despretz, M. Boucart, et al, “Children with benign epilepsy with centrotemporal spikes (BECTS) show im- paired attentional control: evidence from an attentional capture paradigm, ” Epileptic Disorder, Vol. 9, No. 1, 2007, pp. 32-8.
 L. Querne, P. Berquin, “Distinct response time dis-tribu- tions in Attention Deficit Hyperactivity Disorder subtypes, ” Journal of Attentional Disorders, Vol. 13, No. 1, 2009, pp. 66-77
 A. Scheres, J. Oosterlaan, S J. wanson, S. Morein-Zamir, N. Meiran, H. Schut, et al, “The effect of methylphenidate on three forms of response inhibition in boys with AD/HD, “ Journal of Abnormal Child Psychology, Vol. 31, No. 1, 2003, pp. 105-20.
 M. M. Lansbergen, J. L. Kenemans, H. van Enge-land, “Stroop interference and atten-tion-deficit/hyperactivity disorder: a review and meta-analysis, ” Neuropsychology, Vol. 21, No. 2, 2007, pp. 251-62.
 G. J. DuPaul, A. D. Anastopoulos, T. L. Shelton, et al, “Multimethod assessment of attention deficit hyper-acti- vity disorder: the diagnostic utility of clinic-based tests, ” Journal of Clinical Child Psychology, Vol. 21, 1992, pp. 394-402.
 H. H. Jasper, “The ten–twenty electrode system of the International Federation, ” Electroencephalogr. Clinical Neurophysiology, Vol. 10, 1958, pp. 367-380.
 J. Cohen, “Statistical Power Analysis for the Be-havioral Sciences, ”2nd ed, NJ: Lawrence Erlbaum Associates Inc; Hillsdale, 1998.
 H. S. Leff, D. A. Wieman, B. H. McFarland, J. P. Morrissey, A. Rothbard, D. L. Shern, et al, “Assessment of Medicaid managed behavioral health care for persons with serious mental illness, ” Psychiat-ric Services, Vol. 56, No. 10, 2005, pp. 1245-53.
 J. L. Rogers, K. I. Howard, J. T. Vessey, “Using significance tests to evaluate equivalence between two experimental groups, ” Psychological Bulletin, Vol. 113, No. 3, 1993, pp. 553-65.
 J. P. Hatch, “Using statistical equivalence testing in clinical biofeedback research, ” Biofeedback Self Regulation, Vol. 21, No. 2, 1996, pp. 105-19.
 D. D. Langleben, J. Monterosso, I. Elman, B. Ash, G. Krikorian, G. Austin, “Effect of methylphenidate on Stroop Color-Word task performance in children with attention deficit hyperactivity disorder, ” Psychiatry Research, Vol. 141, No. 3, 2006, pp. 315-20.
 A. C. Bedard, A. Ickowicz, R. Tannock, “Meth-ylphe- nidate improves Stroop naming speed, but not re-sponse interference, in children with attention deficit hyperactivity disorder, ” Journal of Child and Adoles-cent Psychopharmacology, Vol. 12, No. 4, 2002, pp. 301-9.
 G. Bush, J. A Frazier, S. L. Rauch, L. J. Seidman, P. J. Whalen, M. A. Jenike, et al, “Anterior cingulate cortex dysfunction in atten-tion-deficit/hyperactivity disorder revealed by fMRI and the Counting Stroop,” Biological Psychiatry, Vol. 45, No. 12, 1999, pp. 1542-52.
 T. Shallice, G. M. Marzocchi, S. Coser, M. Del Savio, R. F. Meuter, R. I. Rumiati, “Executive function profile of children with attention deficit hyper-activity disorder,” Developmental Neuropsychology, Vol. 21, No. 1, 2002, pp. 43-71.s
 R. M. Wielkiewicz, “Interpreting low scores on the WISC-R Third Factor: It’s more than distractibil-ity. Psychological Assessment,” A Journal of Consulting and Clinical Psychology, Vol. 2, 1990, pp. 91-97.