Medication vs Neurofeedback in Children with ADHD

Medication, particularly psychostimulants such as methylphenidate (Ritalin), have become a first-line treatment option for ADHD. While medication has demonstrated high efficacy in reducing behavioural symptoms, adverse side-effects (sleep issues, anxiety, decreased appetite, and headaches in a high percentage of children) as well as very little long-term research have driven research into other non-medication areas. One of the most common of these alternate treatments is neurofeedback, a form of self-regulation training which influences brain functioning without using direct stimulatory input, and thus circumvents many of the problems associated with medication. Nonetheless, the question of how neurofeedback compares to methylphenidate in mitigating ADHD symptoms remains; this was investigated in 2018 by Sudnawa and colleagues.

Children with ADHD were randomly assigned to receive either neurofeedback or methylphenidate for a 12-week period. The authors designed their study to use a fixed neurofeedback protocol (rather than individualised), compared to a  high level of individualised medication titration, looking at results at both home and school. The neurofeedback group for this study all received the same protocol of decreasing the theta/beta ratio, rather than personalising the training according to specific brainwaves issues on an EEG (ie. they assumed this was the issue creating the ADHD symptoms).

The authors found that children from both groups had significant reductions in ADHD symptoms following their treatment block, across both parent and teacher ratings. There were equal levels of improvement on parents ratings for both children who received neurofeedback and children who received methylphenidate. Improvements in behavioural and academic performance were also rated similarly by teachers of the methylphenidate and neurofeedback groups.  However, teacher’s ratings for those who received methylphenidate rated them as having greater improvement than those who received neurofeedback in ADHD symptoms, showing that medication was more helpful in classroom environments. They also noted that the improvements in their study for the methylphenidate group were greater than in previous research studies which did not use titration, and this may have widened the disparity between teacher ratings for methylphenidate and neurofeedback groups – particularly as some of the side-effects of methylphenidate that were avoided by titration can actually worsen ADHD symptoms.

Nonetheless, the authors concluded that neurofeedback was a promising stand-alone treatment for ADHD in children who are unable to take medication, or as a treatment to be used in conjunction with medication. Further research should however look at titrating both the medication and the neurofeedback, given that the results were likely to have been stronger for the neurofeedback group if patients with poor theta-beta ratios were given theta-beta training, but patients with other brainwave issues (eg. frontal slow-wave, fast-wave variants) were given training protocols more specific to their dysregulation. It would be expected by doing this (in the same way the medication was titrated) would yield even better results for the neurofeedback.

Sudnawa, K. K., Chirdkiatgumchai, V., Ruangdaraganon, N., Khongkhatithum, C., Udomsubpayakul, U., Jirayuchiaroensak, S., & Israsena, P. (2018). Effectiveness of Neurofeedback Versus Medication for Attention-Deficit/Hyperactivity Disorder. Pediatrics International, 60(9), 828-834. doi: 10.1111/ped.13641