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Meta-Analysis
. 2025 Feb 1;82(2):118-129.
doi: 10.1001/jamapsychiatry.2024.3702.

Neurofeedback for Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

Samuel J Westwood  1 , Pascal-M Aggensteiner  2 , Anna Kaiser  2 , Peter Nagy  3 , Federica Donno  4   5 , Dóra Merkl  3 , Carla Balia  4   5 , Allison Goujon  6 , Elisa Bousquet  6 , Agata Maria Capodiferro  4   5 , Laura Derks  7 , Diane Purper-Ouakil  6   8   9 , Sara Carucci  4   5 , Martin Holtmann  7 , Daniel Brandeis  2   8   10 , Samuele Cortese  11   12   13   14   15 , Edmund J S Sonuga-Barke  16 ; European ADHD Guidelines Group (EAGG)
Collaborators, Affiliations
Meta-Analysis

Neurofeedback for Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

Samuel J Westwood et al. JAMA Psychiatry. .

Abstract

Importance: Neurofeedback has been proposed for the treatment of attention-deficit/hyperactivity disorder (ADHD) but the efficacy of this intervention remains unclear.

Objective: To conduct a meta-analysis of randomized clinical trials (RCTs) using probably blinded (ie, rated by individuals probably or certainly unaware of treatment allocation) or neuropsychological outcomes to test the efficacy of neurofeedback as a treatment for ADHD in terms of core symptom reduction and improved neuropsychological outcomes.

Data sources: PubMed (MEDLINE), Ovid (PsycInfo, MEDLINE, Embase + Embase Classic), and Web of Science, as well as the reference lists of eligible records and relevant systematic reviews, were searched until July 25, 2023, with no language limits.

Study selection: Parallel-arm RCTs investigating neurofeedback in participants of any age with a clinical ADHD or hyperkinetic syndrome diagnosis were included.

Data extraction and synthesis: Standardized mean differences (SMDs) with Hedges g correction were pooled in random effects meta-analyses for all eligible outcomes.

Main outcomes and measures: The primary outcome was ADHD total symptom severity assessed at the first postintervention time point, focusing on reports by individuals judged probably or certainly unaware of treatment allocation (probably blinded). Secondary outcomes were inattention and/or hyperactivity-impulsivity symptoms and neuropsychological outcomes postintervention and at a longer-term follow-up (ie, after the last follow-up time point). RCTs were assessed with the Cochrane risk of bias tool version 2.0.

Results: A total of 38 RCTs (2472 participants aged 5 to 40 years) were included. Probably blinded reports of ADHD total symptoms showed no significant improvement with neurofeedback (k = 20; n = 1214; SMD, 0.04; 95% CI, -0.10 to 0.18). A small significant improvement was seen when analyses were restricted to RCTs using established standard protocols (k = 9; n = 681; SMD, 0.21; 95% CI, 0.02 to 0.40). Results remained similar with adults excluded or when analyses were restricted to RCTs where cortical learning or self-regulation was established. Of the 5 neuropsychological outcomes analyzed, a significant but small improvement was observed only for processing speed (k = 15; n = 909; SMD, 0.35; 95% CI, 0.01 to 0.69). Heterogeneity was generally low to moderate.

Conclusions and relevance: Overall, neurofeedback did not appear to meaningfully benefit individuals with ADHD, clinically or neuropsychologically, at the group level. Future studies seeking to identify individuals with ADHD who may benefit from neurofeedback could focus on using standard neurofeedback protocols, measuring processing speed, and leveraging advances in precision medicine, including neuroimaging technology.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Nagy reported personal fees from Medice and Egis Pharmaceuticals and conference participation support from Medice outside the submitted work. Dr Donno reported serving as a subinvestigator in clinical trials sponsored by Lundbeck and as an independent rater in clinical trials sponsored by Servier, Acadia, and Bioproject. Dr Balia reported travel fees from Medice and collaboration on projects from the EU Seventh Framework Program and on clinical trials sponsored by Lundbeck, Otsuka, Janssen-Cilag, Angelini, Bioproject, and Acadia. Dr Purper-Ouakil reported nonfinancial support from HAC Pharma and personal fees from Medice outside the submitted work. Dr Carucci reported personal fees from Medice and Ecupharma and collaboration on projects from the EU Seventh Framework Programme, Era-Net Neuron, and connect4children and on clinical trials sponsored by Lundbeck, Otsuka, Janssen-Cilag, Angelini, Acadia, and Bioproject. Dr Holtmann reported personal fees from Medice, Hogrefe Publishers, Takeda, and Infectopharm outside the submitted work. Dr Brandies reported having served as an unpaid scientific advisor of an EU-funded neurofeedback study. Dr Cortese reported personal fees from Medice, Association for Child and Adolescent Mental Health, personal fees from British Association of Psychopharmacology, and Canadian ADHD Resource Alliance outside the submitted work. Dr Sonuga-Barke reported speaker fees from Takeda and Medice and in-kind support from ObTech outside the submitted work as well as personal fees from Journal of Child Psychology and Psychiatry (editor in chief), Aarhus University (visiting professor), and Hong Kong University (visiting professor) outside the submitted work and was involved in the development of parent training interventions. No other disclosures were reported.

References

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    1. National Institute for Health and Care Excellence . Attention deficit hyperactivity disorder: diagnosis and management. Accessed October 15, 2024. https://www.nice.org.uk/guidance/ng87 - PubMed
    1. Gevensleben H, Moll GH, Rothenberger A, Heinrich H. Neurofeedback in attention-deficit/hyperactivity disorder—different models, different ways of application. Front Hum Neurosci. 2014;8:846. doi:10.3389/fnhum.2014.00846 - DOI - PMC - PubMed

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