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DOCUMENT 5
Research Request – Neurofeedback Therapy
Brief
AAT case – request for a literature review on the efficacy of Neurofeedback
therapy for a 14 year old with Autism Spectrum Disorder.
Date
10 September 2019
Requester
Katrin s22(1)(a)(ii) - irrel & K
ylie s22(1)(a)(ii) - irrel
Researcher
Aanika s22(1)(a)(ii) - irre
Contents
Definition of Neurofeedback Therapy .................................................................................................... 2
Nuerofeedback therapy and ASD............................................................................................................ 2
Published TAT advice in HPRM ............................................................................................................... 2
Literature Review for Neurofeedback .................................................................................................... 2
Review of Current Studies .................................................................................................................. 3
Raising Children Website .................................................................................................................... 3
The National Institute for Health and Care Excellence (NICE) ............................................................ 3
Neurodevelopment Centre (US) ......................................................................................................... 4
The Brain Training Centre ................................................................................................................... 4
ADHD and neurofeedback therapy – clinical trials ............................................................................. 5
International Society for Neurofeedback and Research ..................................................................... 5
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Definition of Neurofeedback Therapy
Neurofeedback therapy is considered an alternative therapy. Based on provider websites it is
commonly used for the treatment of ADD/ADHD, epilepsy, brain injuries, post-traumatic stress
disorder, sleep issues, stroke, and alcoholism and drug abuse, stress and anxiety.
Neurofeedback therapy is a treatment method that uses a sound-based biofeedback technology to
help retrain the brain to self-regulate and function optimal y. The computer-based program uses
sound or visual signals to retrain or reorganize these brain signals. By responding to this process, the
clients then learn to regulate and improve their brain function and to help alleviate the symptoms
related to various neurological and mental health disorders1.
Nuerofeedback therapy and ASD
Neurofeedback refers to training in self-regulation aiming to achieve control over cortical electrical
activity. The aim of neurofeedback training is to teach children with ASD to adapt their
neurophysiological profile so that it matches those of typically developing children, resulting in
subsequent improvement in symptoms. The self-regulation of cortical activity is realized through a
process of operant learning using real-time representation of electroencephalographic (EEG)
parameters2.
Published TAT advice in HPRM
The TAT have published five advices relating to reasonable and necessary support requests for
neurofeedback therapy. These advices were all for participants with Autism Spectrum Disorder
whose ages ranged between 10 to 24 years.
All TAT five advices concluded that:
There is limited evidence currently available that supports the
efficacy of neurofeedback therapy in the treatment of Autism. The request for funding for
Neurofeedback therapy does not meet the criteria for Reasonable and Necessary and should be
declined at this time. Research identified in these advices has been collated below.
Literature Review for Neurofeedback
There is very little quality and reliable evidence to support the use of neurofeedback therapy in the
treatment of Autism. The only sources of information that were in support of neurotherapy as a
practice were active providers (Brain Training Centre and Neurodevelopment Centre) and the
information these providers used to substantiate the treatment were not reliable. This is examined
below.
There was very little research discussing the use of neurofeedback in adults with ASD.
1 Natural Therapy Pages, ‘What is Neurofeedback Therapy?’,
<https://www.naturaltherapypages.com.au/energetic medicine/neurofeedback>, accessed 10 September
2019.
2 Holtmann, M et al, ‘Neurofeedback in autism spectrum disorders’, Developmental Medicine & Child
Neurology, 14 July 2011, vol. 53, no. 11, pp.986-93,
<https://www.researchgate.net/publication/51488393 Neurofeedback in autism spectrum disorder>, accessed 10 September 2019,
p.986.
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Review of Current Studies
The most credible source of information available is a 2011 review of current studies on the
effectiveness of neurofeedback as a method of treatment of the core symptoms of autism spectrum
disorders3. This review found that “the existing evidence does not support the use of neurofeedback
in the treatment of ASD. Studies with outcomes in favour of neurofeedback might be showing an
improvement in comorbid attention-deficit–hyperactivity disorder symptoms rather than a true
improvement in core ASD symptoms4.
The review recommends that significant further research is required to determine the link between
ASD and neurofeedback therapy, stating that: “A multitude of methodological limitations will have
to be addressed in future studies on neurofeedback in ASD. The use of criterion standard diagnostic
instruments and blinded multiple informants using standardized instruments for parents, teachers,
and specialists is warranted. The comorbidity of ASD and ADHD needs to be carefully addressed”5.
Raising Children Website
The Australian parenting website Raising Children Network has established a therapies guide related
to Autism. The guide identified neurotherapy as unrateable – (not yet reviewed by our research
sources) using the rating system based on National Standards Project- National Autism Center 2009
and the Cochrane Col ection6.
The Raising Children website also states “More high-quality research is needed to determine
whether neurofeedback works for people with autism spectrum disorder (ASD) [and] Some research
suggests that positive results in treating ASD might be because neurofeedback improves ADHD
symptoms – which many people with ASD have – rather than ASD symptoms. But well-designed and
control ed research is also needed to determine whether neurofeedback is effective for people with
ADHD”7.
The National Institute for Health and Care Excel ence (NICE)
The National Institute for Health and Care Excellence (NICE) guidelines make evidence - based
recommendations on a wide range of topics for use by public health and social care practitioners in
England.
These guidelines are made public8. The PTSD, anxiety, depression, adult ADHD NICE guidelines do
not list Neurofeedback as an evidence based treatment. Any other specific condition can be
searched on the NICE website to determine if Neurofeedback is an evidence based treatment for
that specific condition. In fact the NICE Guideline for autism spectrum disorder in under 19s: support
3 Holtmann, loc cit.
4 Ibid.
5 Holtmann et al., p.992.
6 Raising Children, ‘Parent Guide to Therapies for ASD: FAQs’,
<https://raisingchildren.net.au/autism/therapies-guide/guide-to-therapies-for-asd>, accessed 10 September
2019.
7 Raising Children, ‘Neurofeedback: Therapy at a glance’, <https://raisingchildren.net.au/autism/therapies-
guide/neurofeedback>, accessed 10 September 2019.
8 The National Institute for Health and Care Excel ence, 2019, <https://www.nice.org.uk/About/What-we-
do/Our-Programmes/NICE-guidance/NICE-guidelines>, accessed 10 September 2019.
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and management says ‘do not use neurofeedback to manage speech and language problems in
children and young people with autism’9.
Neurodevelopment Centre (US)
The Neurodevelopment centre is a progressive neurotherapy provider in the US. The approach to
therapy at this centre is as follows:
“At the NeuroDevelopment Center, we closely fol ow the research on these promising
approaches. We recognize the need for scientific evidence, and carefully evaluate the
research on new therapy methods
. But we also realize that it takes decades to compile
conclusive scientific proof. You may not want to wait until the research is conclusive. So
we offer neurofeedback and Cogmed working memory training and even our Preschool
ADHD LEAP program – research supported treatments that harness the brain’s capacity for
change through brain exercise and training”10.
The Neurodevelopment Centre states that “Early studies have provided research support for
neurofeedback as a treatment of the symptoms of autism spectrum disorders (ASD) including
Autism, Asperger’s Disorder, and Pervasive Developmental Disorder (PDD). As of 2011, nine studies
have been completed, showing significant improvements in social, emotional, and behavioral
functioning with neurofeedback.
However, the Neurodevelopment centre also acknowledges that “More research needs to be done,
particularly more studies employing random assignment of subjects to a neurofeedback and to a
good comparison or control group”11.
The Brain Training Centre
The Brain Training Centre is a provider of neurotherapy based in ACT, Australia.
The website states that:
Autism is a neurodevelopmental disorder. Symptoms include lack of social interaction,
challenged communication, lack of appropriate eye contact and expression, and a narrow
range of repetitive behaviours. The sufferer’s brain is not operating as it should in a number
of different regions. Some areas are ‘talking to each other’ too much while other brain
regions aren’t interacting at all. Neurofeedback is all about working with the brain. It makes
sense therefore, that it can help with reducing symptoms in a brain chal enged with ASD.
During brain training you receive real time feedback on the training activity in your brain.
The activity is measured with electrodes placed on your scalp. Don’t worry, you don’t feel a
thing! These electrodes provide feedback to the stimuli of a video or game on a television
screen. If the brain activity changes in the desired direction, you receive a positive ‘reward’.
If it doesn’t change or changes in an undesired direction, you receive no feedback or
negative response. When we are talking about rewards etc. we are referring to a change of
9 The National Institute for Health and Care Excellence, Autism spectrum disorder in under 19s: support and
management, August 2013, https://www.nice.org.uk/guidance/cg170/chapter/1-
Recommendations#interventions-for-autism-that-should-not-be-used
10 The Neurodevelopment Centre, 2019, <https://neurodevelopmentcenter.com/> accessed 10 September
2019.
11The Neurodevelopment Centre, 2019, <https://neurodevelopmentcenter.com/psychological-
disorders/autism-spectrum-disorder/neurofeedback-for-autism/>, accessed 10 September 2019.
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pitch in the sounds through the earphones, or a light snowing/blurring/lightening of the
image on the screen12.
The Brain Training Centre website provides an extensive list of evidence based research for the
effectiveness of neurotherapy for ADD/ADHD, learning and developmental disabilities, and academic
cognitive enhancement to back up the use of neurotherapy as a treatment. However, this reference
list is misleading as the majority of these references relate to ADHD and
none of them are clearly
linked to ASD studies, which is in line with the 2011 review findings (Holtmann et al.).
ADHD and neurofeedback therapy – clinical trials
In 2017 a group of medical experts published a journal article on a concurrent, triple-blind,
randomised, controlled trial using authorised deception in adults with ADHD to determine the
effectiveness of neurofeedback as a therapy, compared to sham neurofeedback, and cognitive-
behavioural group therapy in adults.
Contrary to the Brain Training Centre claims that neurofeedback is effective for the treatment of
ADHD, the control ed trial suggested that:”neurofeedback training is not superior to a sham
condition or group psychotherapy. Al three treatments were equivalently effective in reducing
ADHD symptoms. This first randomised, sham-controlled trial did not show any specific effects of
neurofeedback on ADHD symptoms in adults”13.
In 2016, a meta-analyses of randomized controlled trials to examine the effects of neurofeedback on
attention-deficit/hyperactivity disorder (ADHD) symptoms and neuropsychological deficits in
children and adolescents with ADHD. This publication concluded that “Evidence from well-controlled
trials with probably blinded outcomes currently fails to support neurofeedback as an effective
treatment for ADHD. Future efforts should focus on implementing standard neurofeedback
protocols, ensuring learning, and optimizing clinically relevant transfer”14.
International Society for Neurofeedback and Research
The International Society for Neurofeedback & Research (ISNR) is a membership organization
comprised of people from many countries and various professional disciplines doing neurotherapy,
neurofeedback training and research.
The ISRN provides information on guidelines for neurofeedback therapy and training and credentials
required by the website also states that these “are voluntary and help demonstrate to the public
that a neurofeedback provider is able to provide ethical and competent training [and] Regulations
regarding licensure and scope of practice are determined and enforced by various governmental
agencies, depending on state, country, or province. Consumers should ascertain that the practitioner
has appropriate credentials, training, experience, and licensure to treat their problem, or is
supervised by someone who does”15.
12 The Brain Training Centre, ‘Autism Spectrum Disorder’, 2014,
<https://www.braintrainingcentre.com.au/autism-spectrum-disordern> accessed 10 September 2019.
13 https://www.sciencedirect.com/science/article/pi /S2215036617302912
14 Cortese, S, et al, ‘Neurofeedback for Attention-Deficit/Hyperactivity Disorder: Meta-Analysis of Clinical and
Neuropsychological Outcomes From Randomized Control ed Trials’,
Journal of the American Academy of Child
and Adolescent Psychiatry, 2016, vol.55, no.6, 444-55, <https://www.ncbi.nlm.nih.gov/pubmed/27238063>,
accessed 10 September 2019.
15 https://www.isnr.org/guidelines-for-practice
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