Comparing Parent Self-Report and Child Cognitive Task in a Neurofeedback Clinic for ADHD Kirsten D. Leaberry, B.A., Kate Nooner, Ph.D., Richard Ogle, Ph.D., Julian Keith, Ph.D. Abstract Neurofeedback (NFB) is an alternative treatment for childhood ADHD that relies on the principles of operant conditioning to retrain brainwave patterns associated with concentration. Although NFB has been shown to alleviate ADHD symptoms, treatment outcomes have been assessed inconsistently and have largely relied on self-report measures. Many randomized controlled trials (RCT’s) have only relied on parent reports to assess treatment outcomes, which are prone to expectancy effects. While RCT’s have established that sessions of NFB is somewhat efficacious in research settings, multi-faceted outcome assessment studies are also warranted in real world clinical settings. In outcome assessment 1, children performed a continuous performance cognitive task (CPT) pre and post 12 NFB sessions to assess cognitive outcomes. In outcome assessment 2, 12 parents completed a parent measure of child ADHD symptoms pre and post 12 NFB sessions to assess behavioral outcomes. Children made statistically significantly fewer errors on the CPT following 12 NFB sessions, F (1, 30) = 4.87, p =.035. Parents reported statistically significantly less ADHD symptoms following 12 NFB sessions in the clinic, F (1, 11) = 16.44, p =.002. This studies novel use of 12 sessions delivered in just 3-4 weeks demonstrates that modest exposure to NFB leads to measurable cognitive improvements and behavioral changes. Children will be followed for 6-months to see if the results of this clinic based treatment hold over time. Introduction NFB has received “Level 1 Best Support” as an evidence-based treatment for childhood ADHD according to the American Academy of Pediatrics (2012). NFB has resulted in improvements in child performance on cognitive tasks measuring inattention and impulsivity (Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003), as well as parent and teacher report of attention and hyperactivity (Leins et al., 2007). NFB studies commonly employ parent report alone to assess outcomes (e.g., Miesel, Servera, Garcia- Banda, Cardo, Moreno, 2013). Only a few studies have employed cognitive assessments of ADHD symptoms (e.g., Bakhshayesh, Hansch, Wyschkon, Rezai, Esser, 2011; Fuchs et al., 2003), which is surprising given that these assessments are less subject to expectancy effects and essential for fully examining NFB treatment outcomes. Another limitation in establishing the clinical effectiveness of NFB is the lack of outcome assessment in community practice settings. While work is emerging (e.g., Hillard, El- Baz, Sears, Tasman, & Sokhadaze, 2013), the majority of published research is randomized controlled trials (RCT’s) utilizing 30+ sessions of NFB with stringent inclusion criteria. Though RCTs are needed to establish an evidence base, their results may not generalize to heterogeneous clinic populations where many NFB sessions and strict inclusion criteria are not realistic. Method The current outcome assessments examined behavioral and cognitive outcomes of NFB delivered in an ADHD clinic. Children were initially assessed for ADHD according to the DSM-IV-TR and received 12 sessions of clinic-based NFB; comorbid diagnoses and medication were permitted. In outcome assessment 1, children performed a cognitive task measuring ADHD symptoms, the Conner’s Continuous Performance Task (CPT). In outcome assessment 2, 12 parents completed a behavioral measure of child ADHD symptoms, the Conner’s Rating Scale-Parent Form (CRS-P). Outcome Assessment 1 Measure: The CPT Outcome Assessment 2 Measure: CRS-P Procedure 1.Eligibility Assessment -K-SADS- Semi Structured Diagnostic Clinical Interview -Exclusion criteria: IQ <70, suicidal ideation, psychotic symptoms, manic symptoms 2. Conner’s Continuous Performance (CPT) and Conner’s Rating Scale-Parent Form (CRS-P) -CPT: 14 minute task; measures omissions and commissions -CRS-P: 45-item measure measuring ADHD behavioral symptoms 3. Neurofeedback -12 sessions of BrainPaint® neurofeedback: theta/beta and SMR (Figure 1) 4. Post 12 NFB sessions: CPT or CPT and CRS-P Results/Discussion One-way repeated measures Analysis of Variance (ANOVA) was conducted to examine pre- to post- 12 NFB session differences on cognitive and behavioral measures of ADHD symptoms. Effect sizes were calculated by from pre- to post- 12 NFB session difference scores. Children made statistically significantly fewer errors on the CPT following 12 NFB sessions, F (1, 30) = 4.87, p =.035. Parents reported statistically significantly less ADHD symptoms following 12 NFB sessions in the clinic, F (1, 11) = 16.44, p =.002. Figure 2 depicts pre and post- 12 NFB session differences on the CPT and CRS-P. There was a small effect size for the CPT (Cohen’s d= 0.30) and a large effect size for the CRS-P (Cohen’s d= 1.19). These outcome assessment results suggest that statistically significant reductions in cognitive and behavioral ADHD symptoms can be detected with only moderate exposure to NFB delivered in a clinic. The large effect size for the behavioral measure of ADHD symptoms (CRS-P) and the small effect size for the cognitive assessment (CPT), is consistent with expectancy effects of parent report (Sonuga-Barke et al., 2013). Previous studies of NFB have often relied solely on behavioral measures with strict inclusion criteria (e.g., Meisel et al., 2013). Multimodal outcome assessment is useful in clinic settings to provide information on behavioral and cognitive changes following NFB. Figure 1: BrainPaint® neurofeedback screenshot Participants receive 12 sessions of theta/beta and SMR neurofeedback aimed at increasing beta activity (concentration and focus) and decreasing theta activity (daydream state.) The neurofeedback screen contains fractal images, the what is/what isn’t feedback bar, a “hold” clock,” EEG, and verbal feedback. Participants are reinforced (green bar, fractal, music) when brainwaves approach target threshold levels. If these thresholds are not met, the bar appears red, and an aversive sound plays. Table 1: Demographic characteristics of outcome assessments Figure 2: Pre- and Post- 12 NFB Session Differences in CPT and CRS-P Top: Significantly less errors on cognitive CPT task post-12 NFB sessions Bottom: Significantly less behavioral ADHD symptoms on CRS-P post-12 NFB sessions