The Evidence-Base for Neurofeedback as a Reimbursable Healthcare Service to Treat Attention Deficit/Hyperactivity Disorder

The Evidence-Base for Neurofeedback as a Reimbursable Healthcare Service to Treat Attention Deficit/Hyperactivity Disorder

ADHD is the most frequently diagnosed pediatric behavioral health disorder with 11% of American school-aged children (and nearly 20% of all high school boys) having been medically diagnosed with ADHD according to the latest report from the Centers for Disease Control and Prevention. Stimulant medication and behavior therapy (BT) are the two most widely accepted treatments for ADHD and these treatments are commonly reimbursed by healthcare insurers. While both are considered to meet the highest standards for the ‘evidence-based treatment’ of ADHD, and been recognized as such by the American Academy of Child and Adolescent Psychiatry and CHADD, the leading ADHD advocacy group, the actual evidence is that these treatments fail to result in sustained benefit for the vast majority of children who receive them as demonstrated in the NIMH-funded MTA Cooperative study, the gold standard study in ADHD treatment effectiveness research.

As documented by the eight-year long NIMH-funded MTA Cooperative study, optimal versions of stimulant medication and BT failed to result in sustained benefit for the majority of children. Surprisingly, in this study’s 22-month follow-up assessment of the currently recognized best treatments for ADHD, no sustained benefit was evident for any of these treatments as compared to those ADHD children who had simply been referred to community-based professionals and may or may not have actually followed through with treatment from them. Even after 14 months of free intensive multi-component behavior therapy combined with systematic medication management followed by referral to community-based treatment professionals for continuing care, ADHD was found to be an ongoing debilitating illness and the societal costs that are associated with it included 10.4% of such ‘optimally-treated’ children requiring psychiatric hospitalization one or more times during follow-up. The psychiatric hospitalization rate for those receiving intensive multi-component behavior therapy without medication was even higher at 12.3% compared to only 8.3% of those who had simply been referred to community-based professionals. The MTA study results dramatically demonstrate that more effective treatments for ADHD are desperately needed and as such treatments are identified, they warrant reimbursement by healthcare insurers to improve outcomes for ADHD children and their families.

ADHD is widely viewed as being associated with neuronal dysregulation resulting in high rates of inattentiveness, impulsivity, and often hyperactive behaviors in the children and adolescents diagnosed with this disorder. NFB is a form of behavior therapy with over 40 years of basic and applied research combining real-time measurement of neuronal electrical activity with the scientifically 4 established principles of operant conditioning to teach trainees how to better self-regulate brain functioning. As such, NFB is uniquely suited to treat the neuronal dysregulation that is common in children and youth diagnosed with ADHD.

Beginning in the early-1960s, neuroscientists demonstrated that decreases in the motor activity of cats was associated with increased 12-16hz neuronal electrical activity in the sensorimotor cortex, an activity pattern that Professor Maurice Sterman from UCLA named the sensorimotor rhythm (SMR). Professor Sterman found that when hungry cats were fed contingent upon the increase in SMR activity, the cats “became very alert” and displayed “an almost intense cessation of movement;” behaviors seldom seen in children with ADHD. Building on Dr. Sterman’s findings, in the mid-1970s using a scientifically rigorous research design in which both the child subjects and raters of ADHD behaviors were blind to the experimental condition and the children acted as their own experimental controls, Professor Joel Lubar and colleagues demonstrated both 1) the functional relationship between SMR and the manifestation of the core behaviors associated with ADHD, and 2) that through real-time feedback of SMR activity levels paired with operant conditioning, ADHD children learned to selfregulate SMR with the resulting improvements or worsening in their core ADHD symptoms based on whether they were being reinforced to increase or decrease their level of SMR neuronal activity.

Building on the neuroscience research foundation provided by Professors Maurice Sterman and Joel Lubar, NFB’s evidence-base continues to grow with over 50 peer-reviewed journal articles published to date documenting its effectiveness in treating ADHD’s core symptoms. This paper reviews in detail the controlled studies published during the past decade evaluating NFB’s effectiveness in treating children and adolescents with ADHD. Our review documents that not only has NFB been found to be superior to a variety of experimental control group conditions, but also in three studies NFB was found to be equivalent to stimulant medication in treating the core symptoms of ADHD. Furthermore, we found five studies that assessed whether or not NFB resulted in sustained benefits after treatment ended, including two studies with two-year follow-up assessments. In each of these follow-up assessments, the gains from NFB were maintained after treatment had ended and in one study had increased further during the two-year follow-up such that half of the children no longer met the diagnostic criteria for ADHD. In contrast, stimulant medications’ beneficial effects commonly cease when the medication is stopped, and as found in the MTA Cooperative study, the authors concluded that there was no evidence to support the “long-term advantage of (continued) medication treatment beyond 2 years for the majority of children.”

Discouragingly, the just published 6 year follow-up results from the NIMH-funded Preschool AttentionDeficit/Hyperactivity Disorder Treatment Study (PATS) found results virtually identical to those of the MTA study. These researchers found that “medication status during follow-up, on versus off, did not predict symptom severity” with 89% still exhibiting moderate to severe symptoms of ADHD. Even more troubling, the PATS researchers found that by year 3 of follow-up, an antipsychotic had been added to the medication regimen for 8.3% of the preschoolers’ and by year 6, 12.9% were taking an antipsychotic. This increased pairing of ADHD medications with antipsychotics is documented in a 2012 article published in Archives of General Psychiatry finding that over the past decade the rate of antipsychotics prescribed to children increased by over 750% (from 0.24 to 1.83% of all outpatient visits to general practitioners and psychiatrists). Their analysis found that disruptive behavior 5 disorders (primarily ADHD) were the most common diagnoses in children that were prescribed an antipsychotic accounting for 63% of such cases, and that in 54.1% of the outpatient visits, whenever an antipsychotic was prescribed there was also an ADHD medication prescribed to the same child.

So while the initial reports of both the MTA and PATS study findings, along with 50 years of research and clinical practice, clearly document the short-term effectiveness of stimulant medications in treating ADHD’s core symptoms, these large taxpayer-funded studies have each failed to find any evidence of sustained benefits from continuing to take these medications during follow-up care and the long-term risks from taking them are still not fully known. The increased pairing of ADHD medications with antipsychotics provides collaborating evidence of stimulant medications’ all-toooften loss of efficacy overtime and is particularly troublesome from a public health perspective given the increased weight gain and risk of diabetes in youth that are associated with taking antipsychotics. Furthermore even during initial treatment, one-third or more of children do not respond adequately to ADHD medications and/or have significant adverse side-effects from them heightening further the need for effective treatment alternatives.

Besides the findings from our review, independent evaluations of NFB’s evidence-base are increasingly validating NFB’s effectiveness in treating the core symptoms of ADHD. A recent meta-analysis found NFB to be more than twice as effective as the six other non-pharmacological ADHD treatments that were analyzed, and in October 2012, the company that maintains the American Academy of Pediatrics’ ranking of research support for psychosocial treatments awarded NFB the highest level of evidencebased support for the treatment of ADHD. Given the generally poor long-term outcomes for the most commonly reimbursed ADHD treatments, and NFB’s substantial and growing evidence-base, NFB clearly warrants reimbursement by insurers for the treatment of ADHD thereby facilitating its widespread adoption.

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