Level 5 Efficacy

ADHD Research

Neurofeedback has been ranked as a Level 5 ("Efficacious and Specific") treatment for ADHD!

What “Level 5” Means

This ranking comes from the efficacy rating scale established by the Association for Applied Psychophysiology and Biofeedback (AAPB) and ISNR (International Society for Neuroregulation & Research). In this system:

  • Level 5 indicates that the treatment is:

    • Efficacious and specific

    • Proven in multiple controlled studies

    • Demonstrates clinically meaningful, replicable results

    • Equivalent to or better than traditional treatments

Supporting Research

Arns, M., Heinrich, H., & Strehl, U. (2014).
Evaluation of Neurofeedback in ADHD: The Long-Term Effects and Clinical Significance.
📄 Link to full paper (PDF via NIH)

Summary: This meta-analysis reviewed randomized controlled trials and concluded that standard neurofeedback protocols (like Theta/Beta, SMR, and SCP) meet the criteria for a "well-established" and efficacious treatment for ADHD, with long-term benefits and effect sizes comparable to medication.

Feature / Benefit Neurofeedback Medication Behavioral Therapy
How it Works Trains brainwave patterns to improve focus and self-regulation Stimulates or balances brain chemicals to reduce symptoms Uses reinforcement and routines to shape behavior
Evidence-Based for ADHD ✔ Yes (Level 5 – Efficacious & Specific for ADHD) ✔ Yes, particularly stimulants like methylphenidate ✔ Yes, especially effective in children
Non-Invasive ✔ Yes ✘ No – chemical intervention ✔ Yes
Side Effects Minimal to none Possible (e.g., appetite loss, sleep issues) Minimal
Addresses Root Brain Patterns ✔ Yes – targets dysregulated brain activity ✘ No – manages symptoms, not patterns ✘ No – modifies behavior, not brain function
Duration of Benefits Long-term with consistent training Short-term; requires ongoing use Varies; often needs continuous reinforcement
Custom-Tailored ✔ Yes – guided by brain maps (QEEG) ✘ Dosage adjustments, but generalized ✔ Yes – adjusted to individual behaviors
Works Well with Other Treatments ✔ Yes – complements meds and therapy ✔ Often used with therapy ✔ Often used with meds or neurofeedback
Typical Treatment Duration 30–40 sessions (2–4 months average) Ongoing or long-term use Weekly sessions over several months

Key Neurofeedback Research Articles Supporting ADHD/ADD Treatment

1) Arns, M., et al. (2019). "Neurofeedback as a Treatment Intervention in ADHD: Current Evidence and Practice." Current Psychiatry Reports.

  • Summary: This review evaluates the efficacy of standard neurofeedback protocols (theta/beta ratio [TBR], sensorimotor rhythm [SMR], and slow cortical potential [SCP]) for ADHD. Based on meta-analyses and large multicenter RCTs, the authors conclude that these protocols are "efficacious and specific" for reducing ADHD symptoms, particularly inattention and impulsivity, with long-term benefits and minimal side effects compared to psychostimulants. The study emphasizes neurofeedback as a viable alternative but notes the need for standardized clinical implementation.

  • Access: Available as an open-access article via the National Center for Biotechnology Information (NCBI).

    • Link: PMC Article

    • You can download the full PDF directly from the PMC website.

  • Why It Supports Neurofeedback: The study synthesizes evidence from multiple RCTs and meta-analyses, reporting medium-to-large effect sizes for symptom reduction, particularly with TBR and SCP protocols, and highlights neurofeedback’s non-invasive nature.

2) Van Doren, J., et al. (2018). "Sustained Effects of Neurofeedback in ADHD: A Systematic Review and Meta-Analysis." European Child & Adolescent Psychiatry.

  • Summary: This meta-analysis examines the long-term effects of neurofeedback in children with ADHD, focusing on follow-up (FU) assessments 2–12 months post-treatment. It included 10 RCTs with 506 participants and found sustained reductions in inattention (SMD = 0.80 at FU, compared to 0.64 post-treatment) and hyperactivity/impulsivity, with larger effect sizes at follow-up than immediately after treatment. The study suggests that neurofeedback’s effects are durable, likely due to learning principles underlying the treatment.

  • Access: Open-access article available via PMC.

    • Link: PMC Article

    • The PDF can be downloaded directly from the PMC website.

  • Why It Supports Neurofeedback: The meta-analysis demonstrates statistically significant, sustained symptom improvements, particularly for inattention, with effect sizes comparable to or exceeding those of behavioral therapies, supporting neurofeedback’s long-term efficacy.

3) Moreno-García, I., et al. (2022). "Results of Neurofeedback in Treatment of Children with ADHD: A Systematic Review of Randomized Controlled Trials." Applied Psychophysiology and Biofeedback.

  • Summary: This systematic review analyzed 67 RCTs from 1995–2021, involving 1636 participants, and found that neurofeedback significantly reduced ADHD symptoms long-term, with improvements in school, social, and family environments. Protocols like TBR and SCP were particularly effective for inattention and hyperactivity. The review acknowledges limitations in blinding but highlights consistent positive outcomes across diverse settings.

  • Access: Not fully open-access, but the article is available through Springer. You can access it via:

    • Link: SpringerLink

    • Check if your institution has a Springer subscription, or request the PDF via ResearchGate, where authors often share copies. Alternatively, contact the corresponding author (Inmaculada Moreno-García) for a copy.

  • Why It Supports Neurofeedback: The large number of RCTs reviewed provides robust evidence of neurofeedback’s effectiveness, with documented improvements in functional outcomes beyond symptom reduction.

4) Saif, M. G. M., & Sushkova, L. (2023). "Clinical Efficacy of Neurofeedback Protocols in Treatment of Attention Deficit/Hyperactivity Disorder (ADHD): A Systematic Review." Psychiatry Research Neuroimaging.

  • Summary: This review of studies from 2017–2022 (18 articles, 916 participants) compared neurofeedback protocols (TBR, SMR, SCP) to stimulant medications. It found that neurofeedback’s efficacy was comparable to methylphenidate for reducing ADHD symptoms, particularly inattention and hyperactivity, with effect sizes similar to pharmacological treatments. The study suggests neurofeedback as a complementary or alternative treatment, especially for those experiencing medication side effects.

  • Access: Not open-access, but available via ScienceDirect.

    • Link: ScienceDirect

    • Access through an institutional subscription, or request the PDF via ResearchGate or by contacting the authors.

  • Why It Supports Neurofeedback: The study provides recent evidence that neurofeedback protocols achieve outcomes comparable to standard medications, with fewer side effects, supporting its clinical utility.

5) Cheng, Y.-C., et al. (2022). "Additive Effects of EEG Neurofeedback on Medications for ADHD: A Systematic Review and Meta-Analysis." Scientific Reports.

  • Summary: This meta-analysis of five RCTs (305 participants) investigated the combined effects of EEG neurofeedback and medications (e.g., methylphenidate). It found significant additive benefits of neurofeedback on global ADHD symptoms (Hedges’ g = 0.29, p = 0.0327) and inattention (Hedges’ g = 0.33, p = 0.0210) from parents’ observations, though effects waned at six-month follow-up. The study supports neurofeedback as an adjunctive treatment to enhance medication outcomes.

  • Access: Open-access article available via Nature’s Scientific Reports.

  • Why It Supports Neurofeedback: The meta-analysis demonstrates that neurofeedback enhances the effectiveness of pharmacological treatments, offering a synergistic approach for ADHD management.