By Fernando G. Miranda, M.D.
FAAN, Cognitive and Behavioral Neurology
Medical Director, Bright Minds Institute
The purpose of this paper is to present an objective view, governed by rigor and clarity, of so-called Neurofeedback, EEG Biofeedback, and/or Neurotherapy.
This method of treatment has been used extensively to try to treat children and adults with attention deficit hyperactivity disorder  (ADHD,) traumatic brain injury, schizophrenia, and anxiety disorders.
As a practicing Neurologist, with expertise and certification in electroencephalography and Cognitive-Behavioral Neurology, I have had opportunity to observe objectively the reported advantages of this technique.
I have been able in Los Angeles, to observe closely, two large institutions whose business is to teach, sell equipment, and clinically utilize EEG biofeedback.
I have had the opportunity of observing the clinical skills of their Practitioners as well as the overall expertise of the Program Directors.
SCIENTIFIC RATIONALE FOR NEUROTHERAPY:
In a recent article, appearing in Clinical Electroencephalogram, John K. Nash  states data from 1971, suggesting, “under arousal of frontal cortex might explain ADHD symptoms.” He also cites Niedermeyer and Naidu  showing neuroanatomical possibilities for the variety of behavioral manifestations seen in ADHD. These include poor connectivity, structural differences in brain regions, and problems with attention, planning, shifting, emotional control, and working memory.
Although all of the above appears correct, conclusive data relating these findings to the practice of EEG biofeedback has yet to be produced.
Digitization of EEG signals coupled with normative databases with or without discriminant functions has allowed the development of a “neurometric” approach to the examination of EEG.  (Hughes and John.) In short, the creation of pictorial representations of EEG brain activity has allowed for the development of a more comprehensive diagnostic system via which to recognize particular pathological abnormalities. Currently, clinicians are able to better recognize those abnormal brain activities that appear to correspond to specific pathology.
Neurological literature, documents reliable EEG differences  in different types of attentional problems, in which neurometric techniques appear to be important in the diagnosis of functional disorders of attention.
There exists a wealth of data in medical literature supporting a correlation between slowing in the frontal and temporal regions, with attentional problems. These findings have been interpreted by many qualified observers as evidence of cortical and/or sub cortical functional, and/or organic evidence of deficits. At the very least, these deviations from normal development may be attributed to maturational delay.
Extreme importance has been attributed to the Lubar  and Shouse study, conducted in 1976, as it applied to the use of biofeedback in the treatment of seizure disorders and hyperactivity. In this particular study, behavioral improvements in a child with attentional deficit hyperactivity disorder were eliminated by a reversal of stimulus condition, and then subsequently restored using rewards for specific behavior.
In the past five years, numerous publications have underlined the effectiveness of MRI scanning, MR Spectroscopy, MR Diffusion Tensor Imaging, and PET scanning as further functional/anatomical methods of establishing decreased and/or increased function in different areas of the brain that may contain neural networks that deal with attention.
Chabot  et al makes an important point in calling for routine use of quantifying digital EEG signals in the diagnosis, and follow up of attentional disorders.
In the past literature, SPECT scanning has been involved in the diagnoses of these conditions.
HOW DOES NEUROTHERAPY CONCEPTUALLY WORK, AND CONCEPTUAL PITFALLS:
Neurotherapy  (EEG biofeedback) claims that the individual subjected to this technique is aided in learning to recognize small shifts in states of electrical activity of the brain during the course of the session, as well as during the course of the day. This is understood to be a form of cognitive behavior modification. [2,3,4 6,7,8]
Neurotherapy further claims that cognitive tasks, including reading, listening, visual attentional tasks, should be used concurrently with auditory neurofeedback to promote generalization. Basically, practitioners are encouraged to have children undergoing neurofeedback practice tasks requiring attention as an adjunct to the administration of neurotherapy. The implications of this coupling of modalities is manifest later on in this paper when we explore the difficulties in attributing attentional improvement to neurofeedback alone, when it is frequently coupled with other attention enhancing techniques, like reading or Math practice.
The biggest pitfall of these claims is the lack of consideration for the concept of how separate, neural networks that manage attention, working memory, and judgment truly are from each other.
In addition, the validity of the assertion that neurofeedback is actively responsible for any improvement is difficult to confirm. The influence of neurofeedback cannot be electrically differentiated from any other normal activity in the brain. The ultimate contribution, of neurofeedback to the so called somato-motor rhythm, a rhythm that is present in a specific area of the brain; or any basic rhythm of any area recorded, is quite nebulous.
A principle question is how EEG biofeedback training contributes to the rise or fall of some of these amplitudes and frequencies? In addition, how these changes in amplitude relate to the electrical coherent activity necessary for these discrete and function specific neural networks to be effectually altered? Basically, neurofeedback claims that changes in electrical amplitudes and frequencies in particular areas of the brain are necessary and sufficient.
If the modification of an intrinsic EEG rhythm  is thought of as changing underlying brain function, the gap between the expected results and how change is accomplished becomes mythology, and not neurobiologically guided causality.
In addition, Sterman’s  article that reported the accidental discovery in animals of a central somato motor rhythm (SMR) of 11-15 Hz that was capable of being reinforced. Animals so reinforced subsequently demonstrated increased receptivity to seizures.
This amplification of the seizure threshold has been proposed as a mechanism by which conditioning of a particular rhythm changes brain functional state. The problem with these findings is that they have yet to be retested with human subjects. The process of extrapolating from a test performed on a dog to claiming that the same, or similar results will manifest in a human subject is pure speculation. This claim is far from scientific.
EBT Neurotherapy (EEG biofeedback) as sponsored by the EEG and Clinical Neuroscience Society, underscores that it was crucial for “maintenance of interest and cooperation” that there be ongoing secondary activity, since most children would not voluntarily complete the 40, twice a week sessions (each 20-60 minutes long,) considered necessary for permanent results.
From an objective standpoint of view, this raises the possibility that any positive effect may be attributable equally to “peripheral activities” as to the biofeedback itself. It was furthermore emphasized at the meeting that considerable “skill” must be exercised in maintaining an appropriate environment. This implies that a practitioner of neurofeedback is not simply a technician performing neurofeedback, but is in fact acting as a educational therapist of sorts at the same time. This again calls into question the same point raised at the beginning of this paper. How can neurofeedback claim credit for attentional improvements when it is in fact not practiced in isolation, but as an adjunctive modality to tried and true educational techniques documented as aiding in improvement of attention?
If true, then the therapy sessions would be seen as moving from straightforward operant conditioning sessions to a modified form of psychotherapy. This also raises the question of the specific training of the therapist in charge of the process. Psychotherapy is not a modality meant to be performed by someone lacking in the requisite education to be competent in such a role. One should be quite careful who is fulfilling such a role for their children.
Since there are no published recommendations as to standard procedures to help lay people and motivated parents to look into this expensive technology, the following advice from the neurological standpoint of view emerges:
A. Who is the therapist, how is the individual trained, and what expertise or licensure does the individual have that will allow him/her to administer neurofeedback to my child?
B. For which clinical conditions and under what circumstances should biofeedback be employed?
C. How should the initial diagnosis be determined: Patient report, Detailed Neuropsychological Testing, Neurology/Psychology evaluations? 
D. What will be the electric montage used for each condition?
E. Should all subjects have before and after neurometrics?
F. How does the clinician in charge go about determining which EEG signals to use for feedback purposes? 
G. Should one train for a prescribed number of sessions or should one train to a criterion?
It is my opinion that it is unclear if EEG biofeedback is better and more cost effective than existing therapies. It appears that the technique suffers from a significant disparity in the quality of clinical practice due to a lack of established standards, stemming from poor understanding of its theoretical underpinnings, as well as the many types of clearly different underlying neurological conditions that this technique appears to help.
If one submits that something appears to be too good to be true, perhaps one should follow the wisdom that it probably is too good to be true.
- Thatcher RW. EEG operant conditioning (biofeedback) and traumatic brain injury. Clinical Electroencephalogr. 2000
- Nash, JK. Treatment of attention deficit hyperactivity disorder with neuropathy, Clinical Electroencephalogr. 2000.
- Lubar JF, Shouse MN. Use of biofeedback in the treatment of seizure disorders and hyperactivity. Clinical Electroencephalogr. 2000;
- Moore NC. A review of EEG biofeedback treatment for anxiety disorders. Clinical Electroencephalogr. 2000.
- Sterman MB. Basic concepts and clinical findings in the treatment of seizure disorders with EEG operant conditioning. Clinical Electroencephalogr. 2000
- Rosenfeld, JP. An EEG biofeedback protocols for affective disorders. Clinical Electroencephalogr. 2000.
- Trudeau, DL. The treatment of addictive disorders by brain wave biofeedback: A review and suggestions for future research. Clinical Electroencephalogr. 2000.
- Gruzelier J. Self-regulation of electrocortical activity in schizophrenia and schizotypy: A review. Clinical Electroencephalogr. 2000.
- Lehtonen JB, Lehtinen I. Alpha rhythm and uniform visual field in man. Clinical Electroencephalogr. 2000.
- Hughes, JR, John ER. Conventional and quantitative electroencephalography in psychiatry. J Neuropsychiatry 1999; J Clin Neuropsychiatry Clin Neurosci 11: 190-208
- Niedermeyer E, Naidu SB. Attention-deficit hyperactivity disorder (ADHD) and frontal-motor cortex disconnection. Clin. Electroencephalogr. 1997; 28: 130-136
- Chabot RJ. Serfontein G. Quantitative electroencephalographic profiles of children with attention deficit disorder. Biol Psychiatry 1996; 40: 951-963
- Chabot RJ, Merkin H, Wood LM, Davenport, TL, Serfontein G, Sensitivity and specificity of QEEG in children with attention deficit or specific developmental learning disorders. Clin Electroencephalography 1996; 27: 26-34.
- Duffy F, The State of EEG Biofeedback Therapy (EEG Operant Conditioning) in 2000: An Editor’s Opinion.
This piece was originally published by the CNS Foundation in 2005.