ORIGINAL CONTRIBUTION
Neurofeedback training in children with ADHD: 6-month
follow-up of a randomised controlled trial
Holger Gevensleben • Birgit Holl • Bjo¨rn Albrecht • Dieter Schlamp • Oliver Kratz •
Petra Studer • Aribert Rothenberger • Gunther H. Moll • Hartmut Heinrich
Received: 8 September 2009 / Accepted: 31 March 2010 / Published online: 25 May 2010
 Springer-Verlag 2010
Abstract Neurofeedback (NF) could help to improve
attentional and self-management capabilities in children
with attention-deficit/hyperactivity disorder (ADHD). In a
randomised controlled trial, NF training was found to be
superior to a computerised attention skills training (AST)
(Gevensleben et al. in J Child Psychol Psychiatry 50(7):
780–789, 2009). In the present paper, treatment effects at
6-month follow-up were studied. 94 children with ADHD,
aged 8–12 years, completed either 36 sessions of NF
training (n = 59) or a computerised AST (n = 35). Pre-
training, post-training and follow-up assessment encom-
passed several behaviour rating scales (e.g., the German
ADHD rating scale, FBB-HKS) completed by parents.
Follow-up information was analysed in 61 children (ca.
65%) on a per-protocol basis. 17 children (of 33 dropouts)
had started a medication after the end of the training or
early in the follow-up period. Improvements in the NF
group (n = 38) at follow-up were superior to those of the
control group (n = 23) and comparable to the effects at the
end of the training. For the FBB-HKS total score (primary
outcome measure), a medium effect size of 0.71 was
obtained at follow-up. A reduction of at least 25% in the
primary outcome measure (responder criterion) was
observed in 50% of the children in the NF group. In con-
clusion, behavioural improvements induced by NF training
in children with ADHD were maintained at a 6-month
follow-up. Though treatment effects appear to be limited,
the results confirm the notion that NF is a clinically effi-
cacious module in the treatment of children with ADHD.
Keywords ADHD  Neurofeedback 
Randomised controlled trial (RCT)  Follow-up 
Children
Introduction
For attention-deficit/hyperactivity disorder (ADHD),
European guidelines recommend a multimodal treatment
tailored to the requirements of the child [29]. Medication
(first-line treatment: methylphenidate), cognitive-behav-
iour therapy and parental training have proven to be
effective [22, 31]. But there is still a need for further
effective treatment strategies in improving attentional and
self-management capabilities in children with ADHD,
especially concerning long-term effects [20, 23]. Recent
neurofeedback (NF) studies obtained encouraging results
and raise the hope of closing the gap in providing children
strategies for better self-regulation and -management [9,
12, 28].
NF aims at acquiring self-control over certain brain
activity patterns, deriving self-regulation strategies, and
implementing these self-regulation skills in daily life.
Trial registry: ISRCTN87071503. Comparison of neurofeedback and
computerised attention skills training in children with attention-deficit/
hyperactivity disorder (ADHD; http://www.controlled-trials.com/
ISRCTN87071503).
H. Gevensleben  B. Albrecht  A. Rothenberger
Child and Adolescent Psychiatry, University of Go¨ttingen,
v.Siebold-Str. 5, 37075 Go¨ttingen, Germany
O. Kratz  P. Studer  G. H. Moll  H. Heinrich
Department of Child and Adolescent Mental Health,
University of Erlangen-Nu¨rnberg, Schwabachanlage 6?10,
91054 Erlangen, Germany
B. Holl  D. Schlamp  H. Heinrich (&)
Heckscher-Klinikum, Deisenhofener Straße 28,
81539 Munich, Germany
e-mail: hheinri@arcor.de
123
Eur Child Adolesc Psychiatry (2010) 19:715–724
DOI 10.1007/s00787-010-0109-5

Two training protocols—theta/beta training and training of
slow cortical potentials (SCPs)—are typically used for
children with ADHD [15].
In theta/beta training, children learn to reduce activity in
the theta band of the EEG (4–8 Hz) and to increase activity
in the beta band (13–20 Hz). In the resting EEG, increased
slow wave (theta) activity and/or reduced relative alpha (8–
13 Hz) and beta activity was reported in several studies on
children with ADHD (for review, see [2, 3]). Thus, theta/
beta training may address an underlying neuronal dys-
function. On the other hand, NF may simply be seen as a
tool for enhancing specific cognitive or attentional states
(an alert and focused but relaxed state in theta/beta train-
ing), irrespective of supposed neurophysiological devia-
tions [15].
SCPs are changes of cortical electrical activity lasting
from several hundred milliseconds to several seconds.
They are thought to represent task-dependent short-term
mobilisations of cortical processing resources. While neg-
ative SCPs reflect increased excitation (e.g., during states
of behavioural or cognitive preparation), positive SCPs
indicate reduction of cortical excitation of the underlying
neural networks (e.g., during behavioural inhibition) [4].
The contingent negative variation (CNV) is an SCP that
reflects anticipation and/or preparation [18]. It is, for
example, elicited in cue trials of a continuous performance
test. In event-related potential studies, the CNV was found
to be reduced in children with ADHD (for review, see [2]).
Training of SCPs leads to an increase of the CNV [14].
Thus, SCP training, in which surface-negative and surface-
positive SCPs have to be generated over the sensorimotor
cortex, could help children with ADHD to improve their
assumed dysfunctional regulation of energetical resources
[26].
In the last decade, several NF studies in children with
ADHD have been published which manage to overcome
the methodological shortcomings of earlier studies [9, 10,
14, 21, 28]. In all of these studies, positive behavioural,
cognitive and/or neurophysiological effects were descri-
bed. Our group conducted a randomised controlled trial
encompassing 102 children with ADHD. In this trial,
behavioural and neurophysiological effects of NF, which
included one training block of theta/beta training and one
block of SCP training, were analysed in comparison to a
computerised attention skills training (AST) [12, 13, 32].
According to parent and teacher ratings, children of the
NF group showed larger behavioural improvements than
those of the control group (medium effect size of 0.6 for
the primary outcome measure, total score of the German
ADHD rating scale, FBB-HKS [7]). Due to comparable
settings and demands for NF and the control training,
superiority of NF was first and foremost ascribed to
specific factors. A tendency for larger improvements was
observed if theta/beta training preceded SCP training
[12].
At the neurophysiological level (resting EEG, event-
related potentials), specific associations with behavioural
improvements could be revealed for theta/beta and SCP
training (e.g., association between decrease of theta activ-
ity and reduction of ADHD symptomatology) [13, 32].
These neurophysiological effects contribute to a better
understanding of the mechanisms underlying a successful
training and indicate specificity of NF training effects.
Both behavioural and neurophysiological findings of our
trial indicate that NF may be considered as a clinically
efficacious module in the treatment of children with
ADHD.
One of the questions which has not been studied under
controlled conditions is whether NF training effects remain
stable after completing the training. Leins et al. [17]
reported that children with ADHD, who had participated in
either a theta/beta training or an SCP training, were able to
learn cortical self-regulation accompanied by significant
improvements in behaviour and cognition. These effects
remained constant after 6 months. For a subgroup of 23
(from initially 47) children, 2-year follow-up data could
also be assessed [11]. Neuroregulation skills were still
preserved. Behavioural and cognitive effects were reported
to be stable or even further enhanced. However, due to the
lack of a control group, the effects cannot be differentiated
from the natural course.
This paper reports follow-up behavioural data assessed
6 months after completion of the training (either NF
training or AST) for the children with ADHD of our pre-
vious paper [12]. We hypothesised that behavioural
improvements in the NF group remain stable and superior
to those of the control group.
Materials and methods
Subjects
102 children with ADHD (8–12 years) participated in a NF
training or an AST. Subjects were randomly assigned to
one of the two study groups (ratio NF, control train-
ing = 3:2; see also Fig. 2). Eight children (NF, n = 5;
AST, n = 3) discontinued the study due to immediate need
for medical treatment (n = 3), organisational problems of
the parents (n = 2), loss of motivation (n = 1) or protocol
violation (n = 2). Sample size had been estimated a priori
to be large enough to detect a medium effect size of about
0.5 with a power of 0.8 (one-sided, 0.05-level test).
Table 1 summarises inter alia demographic, psycho-
logical and clinical variables of the children completing
their training. Concerning these variables, there were no
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