Treatment Methods for ADHD: Comparing treatment methods EEG neurofeedback therapy and methylphenidate for mitigating the symptoms of ADHD in children

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental and psychiatric disorders of childhood. It is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. No method can cure ADHD so far, but treatment methods that can mitigate its symptoms exist. To further elaborate on the debate about medication versus non-medication treatments in ADHD and ultimately contribute to establishing more nuanced, personalized treatment approaches, this article aims to compare two treatment methods for mitigating ADHD in children. The first method, electroencephalographic (EEG) neurofeedback therapy, utilizes precise, modern devices to regulate brain behaviour. Contrary, a more well-known and commonly used drug methylphenidate helps by regulating neurotransmission between nerve cells. It was found that neither treatment method is better than another for all children, and that the choice of the method should depend on careful consideration of the circumstances of each particular child.

Introduction

Definition and symptoms of ADHD

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental and psychiatric disorders of childhood (Arns et al., 2013). It is defined as a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development (American Psychiatric Association, 2013). It is estimated that ADHD affects up to around 11% of children between ages of 4 and 18 (American Psychiatric Association, 2013).

Still, children are affected differently depending on their age and gender (Abdoli et al., 2023). The prevalence of ADHD is approximately three times higher in males than in females, though it is not well known why (Visser et al., 2014). The initial signs of ADHD are usually hard to detect until a child reaches the age of four, and they are most notable in elementary school (Abdoli et al., 2023). The symptoms usually continue into early adolescence and seem to reduce in adulthood (Abdoli et al., 2023).

It is nevertheless clear that ADHD is a major public health problem leading to difficulties such as school performance difficulties (as cognitive skills are impaired by inattention and hyperactivity), obesity (as impulsivity often leads to binge eating), and substance use (as drugs may be seen as a way to cope with impulsivity and emotional challenges; Arnold et al., 2020; Schoenfelder & Kollins, 2016). Even though no method so far can cure ADHD, treatment methods that can mitigate its symptoms exist (Mayo Clinic, 2023).

The nature of ADHD

To understand the mechanisms of different treatment methods, it is necessary to understand the nature of ADHD. As with many other psychiatric disorders, ADHD is multifactorial in origin, meaning that there are multiple genetic and environmental factors contributing to its development (Stanford & Sciberras, 2022).

By using family studies, which compared the rates of ADHD between first-degree relatives of those with the disorder and unrelated controls, it was confirmed that ADHD is a highly heritable disorder (Stanford & Sciberras, 2022). Meta-analysis with twin studies estimated the heritability of ADHD to be between 70 and 80% (Nikolas & Burt, 2010). Molecular research identified specific genes such as DAT1, DRD4, and ADRA2A linked to ADHD’s development (Balogh et al., 2022).

A meta-analysis by Hoogman et al. (2017) that analysed numerous neuroimaging studies found abnormal structure of several brain regions in children and adults with ADHD. Overall brain volume and specific brain regions were significantly smaller in participants with ADHD than in those without ADHD. The regions included the nucleus accumbens, which participates in reward processing; caudate nucleus and putamen, which coordinate smooth movement; amygdala, which plays an important role in emotional regulation; and hippocampus, which is involved with emotion and motivation.

According to a meta-analysis by Rubia (2018), differences in brain structure lead to differences in brain functioning. Brain image studies from the analysis indicate that people with ADHD may show abnormalities in several brain networks that manage cognitive control, attention, timing, reward processing, and working memory. More specifically, reduced activation was found in those brain networks. Consequently, individuals with ADHD struggle with tasks requiring sustained attention, organization, impulse control, and effective management of daily activities.

Furthermore, research suggests that the levels of neurotransmitters, chemicals that enable communication between nerve cells, are abnormal in people with ADHD (Cleveland Clinic, 2022a; Hunt, 2006). Low levels of neurotransmitters norepinephrine and dopamine are emphasized as a possible cause of ADHD. Both norepinephrine and dopamine are also hormones, i.e. chemicals that travel in the blood to control the actions of other cells. Norepinephrine is released from the adrenal gland in response to stress and low blood pressure, while dopamine is released from both the adrenal gland and hypothalamus to give one a feeling of pleasure as a part of the brain’s reward system (Cleveland clinic, 2022b; National Cancer Institute, n.d.). Both play essential roles in attention which is especially hindered by ADHD (Hunt, 2006). Some experts believe that lower levels of these neurotransmitters may occur in people with ADHD because they have higher concentrations of proteins known as dopamine and norepinephrine transporters, which reduce dopamine and norepinephrine levels in the brain (Hunt, 2006; Mick & Faraone, 2008).

In addition to genetic factors, environmental influences such as unstable family environment, stress, and poor nutrition may be relevant to the development of ADHD. Research shows that genes and the environment often work together through gene-environment correlations. People with ADHD may actively look for environments that facilitate the expression of genes involved with ADHD. They may seek situations or settings that satisfy their need for high stimulation, novelty, or movement. There also seems to be reverse, so-called epigenetic effects, through which the environmental factors either enhance or supress the expression of genetic factors (Stanford & Sciberras, 2022). For example, being exposed to environmental factors such as inadequate pre-natal diet (insufficient delivery of essential nutrients to a child during pregnancy) or toxins (exposure to lead, mercury, pesticides etc.) has been shown to increase the likelihood that genes associated with ADHD will be expressed and that consequently ADHD symptoms will appear (Gervin et al. 2017; Rijlaarsdam et al. 2017).

Treatment

Methylphenidate and EEG neurofeedback therapy

Based on understanding the nature of ADHD, this article presents two treatment methods, electroencephalographic (EEG) neurofeedback therapy and methylphenidate. The comparison between the two methods is interesting because it encapsulates the broader debate about medication versus non-medication treatments in ADHD. It highlights differences in mechanisms (distinct ways in which these two treatment methods work to influence brain function and mitigate ADHD symptoms), short-time side effects, and (potential) long-term impacts, ultimately contributing to establishing more nuanced, personalized approaches to managing ADHD that can suit the diverse needs of patients.

The first method, using a drug methylphenidate, is one of the most common treatment methods for ADHD that has been in use for more than 60 years (Asherson, 2024; Pereira Ribeiro, 2021). Methylphenidate is a central nervous system stimulant that has been shown as one of the most effective treatment methods for reducing the core symptoms of ADHD such as inattention, hyperactivity, and impulsivity (Drechsler et al., 2020; Faraone & Buitelaar, 2010). Furthermore, it significantly improves social behaviour and academic performance in children and adolescents with ADHD (Faraone & Buitelaar, 2010). It works by inhibiting the reuptake of neurotransmitters dopamine and norepinephrine, increasing their levels in the synaptic cleft and thereby improving neurotransmission between nerve cells. Attention and focus, both of which are primarily influenced by dopamine and norepinephrine, are consequently improved in individuals with ADHD (da Silva et al., 2023).

Because of the benefits, it is often used first in children when they get diagnosed with ADHD (Asherson, 2024). Still, clinicians need to consider the presence of co‐occurring conditions, the use of other medications, and potential known side-effects of methylphenidate (such as addiction that may cause substance abuse), therefore methylphenidate is not an appropriate option for all children with ADHD (Storebø et al., 2018). Furthermore, the positive effects of one prescribed dose of methylphenidate usually last between three and 16 hours, and after that, a patient needs a new dose to alleviate ADHD symptoms (Cleveland clinic, 2022c). There has also been criticism pointing to a lack of adequate research on methylphenidate’s potentially harmful side effects including an increased risk for cardiovascular diseases, growth suppression, and mental health issues (Cortese et al., 2018; Verghese & Abdijadid, 2023). Long-term effects of methylphenidate on human health are especially under-researched (Cortese et al., 2018).

Contrary to commonly used, but short-lasting and not yet well researched methylphenidate, there is a more modern, drug-free treatment method, EEG neurofeedback therapy, which was designed to give more long-term improvements in brain function compared to drug medication (Leigh, n.d.; Suruchi, 2021). It is a non-invasive, pain-free approach for treating ADHD that was pioneered in the 1960s (Othmer, 2020; Suruchi, 2021). It aims to optimize brain functioning based on the principles of neuroplasticity (the brain’s ability to change and adapt) and operant conditioning (rewarding and hence reinforcing favourable activity; Coben et al., 2015; Othmer, 2020; Suruchi, 2021).

First, EEG electrodes are placed on the head to record brain activity. This is achieved with a software program that records brain waves, electrical impulses that brain cells use to communicate with each other (Suruchi, 2021). The program analyses obtained recordings and provides a visual (e.g. graphics on a screen) or auditory (e.g. music) feedback to the brain to reinforce desirable patterns of activity. For example, if the goal is to increase attention, the feedback might encourage the upregulation of beta waves (associated with focus) and the downregulation of theta waves (associated with daydreaming). This reinforcement strengthens the neural pathways associated with the desired brain state, promoting neuroplastic changes (Cancer et al., 2021; Suruchi, 2021). EEG neurofeedback therapy has been gaining more attention because of its ability to precisely target neurobiological functioning while considering individual needs, as the therapy sessions specifically address those abnormalities that are found in the individual’s brain (Coben et al., 2015; Suruchi, 2021).

The therapy consists of one-on-one sessions and usually takes place in an office or a clinic, where it is provided by trained staff, such as psychologists, psychiatrists, or social workers (Suruchi, 2021). They choose what sensor placement to use, which brain areas to target and the duration of the therapy. This decision is based on factors such as the patient’s initial EEG assessment and personal and family history (EEG Institute, 2024).

To further elaborate on the debate about medication versus non-medication treatments in ADHD and ultimately contribute to establishing more nuanced, personalized treatment approaches, this article aims to assess the advantages and disadvantages of the two methods in mitigating ADHD symptoms in children and compare them.

Evidence

Although research is, to some extent, limited, there is evidence for both treatment methods. Existing evidence mostly focuses on children aged from 3 to 18 years.

To begin with methylphenidate, there are multiple experiments that have shown the advantages and disadvantages of this treatment method in treating ADHD (Storebø et al., 2023). Two hundred twelve studies included altogether 16,302 children (boys and girls) aged from 3 to 18 years (M = 10). Most studies were small, including around 70 participants, and short, lasting one month on average. The shortest study lasted one day, and the longest 425 days. All participants had to have an ADHD diagnosis based on diagnostic classifications such as the American Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, 11th Edition (ICD-11). Additionally, participants had to be of at least average intelligence to ensure that the effects of methylphenidate on ADHD symptoms were not confounded by cognitive impairments. Each participant was randomly assigned to either an experimental group (that received methylphenidate) or a control group (that received no treatment), or there was an experimental and a placebo group (that received a pill similar in look and taste to methylphenidate but with no active ingredient). The change in expressed ADHD symptoms was recorded mainly using teachers’ ratings that involved various standardized ADHD assessment scales.

Results showed that with administered methylphenidate, the children showed significantly reduced hyperactivity and impulsivity, and an improvement in concentration and general behaviour (i.e. overall behavioural patterns that include compliance with rules, interactions with peers and adults, impulse management, emotional regulation etc.). As some studies lasted for only a day or a few days and still demonstrated such improvements, this means that methylphenidate can mitigate ADHD symptoms quickly, even a few hours after it was administered. Another advantage is that there was no clear evidence of serious short-term side effects, such as cardiovascular issues (like tachycardia), severe mental health problems (e.g. suicidal ideation and psychosis), and issues with the respiratory system (e.g. asthma and bronchitis; Storebø et al., 2023).

On the other hand, even though methylphenidate did not seem to increase the risk of life-threatening unwanted effects when administered for up to six months, studies have shown that it is linked to an increased risk of less severe unwanted effects such as sleeping problems and decreased appetite. Long-term side effects (appearing years after treatment) remain unresearched (Storebø et al., 2023).

Conducted were also experiments that showed the advantages and disadvantages of EEG neurofeedback therapy as treatment for ADHD. Meta-analysis (Lee et al., 2023) included 12 studies with altogether 1059 children (boys and girls) aged between 6 and 18 years (mean age not reported). Participants had to have a medical ADHD diagnosis based on diagnostic classifications. In most studies, an inclusion criterion was that children were either not taking any pharmaceutical medication for ADHD (such as methylphenidate) or kept the administration of these medications constant throughout the study. Each participant was randomly assigned to an experimental or a control group. The studies lasted between 3 to 20 weeks (mean duration 10 weeks), and during that period, the experimental groups received from 15 to 40 EEG neurofeedback treatment sessions, each session lasting between 15 and 180 minutes, while the control groups received no treatment. Attention was assessed with standardized neuropsychological/behavioural tests and parent- or teacher-rating or self-reporting before and after the intervention period.

Results showed that with EEG neurofeedback therapy, attention of the experimental groups significantly improved. Four studies assessed attention also in the follow-up period of 3 to 20 weeks after the treatment period had finished. Results showed retention of improvements in attention and no significant side effects, which suggests that neurofeedback therapy may also have positive long-term effects. In some studies, the benefits of EEG neurofeedback therapy even increased in the follow-up period compared to post-treatment period. According to researchers, the most reasonable explanation for this is the fact that EEG neurofeedback therapy is based on the principles of learning and neuroplasticity, both of which take time to occur, hence positive results were even more explicit in the follow-up period (Lee et al., 2023).

On the other hand, there is an important requirement that needs to be met for EEG neurofeedback therapy to work. Patients (children) need to be able to focus attention to the feedback (e.g. visual information or an auditory tone) of their own brain activities and sustain their attention throughout the therapy time. This is a disadvantage because it may be a challenge for children with ADHD, who have attention deficits due to their condition, to learn how to focus their attention on the feedback, which can lead to frustration and consequently a negative impact on the treatment efficacy (Lee et al., 2023).

Discussion

After taking the presented meta-analyses on methylphenidate and EEG neurofeedback therapy into consideration, both have been shown as significantly effective in mitigating ADHD symptoms in children. It should be noted, however, that research on not only EEG neurofeedback therapy, but also (long-term effects of) methylphenidate, is limited (Lee et al., 2023; Storebø et al., 2023).

While presented research on EEG neurofeedback therapy focused on assessing improvement in one core ADHD symptom (attention), studies on methylphenidate assessed multiple symptoms (hyperactivity, impulsivity, and poor concentration) as well as general behaviour. Hence, methylphenidate has been shown to be effective more broadly than EEG neurofeedback therapy (Lee et al., 2023; Storebø et al., 2023).

The presented research also highlights the difference in the time that each treatment method requires to start noticeably mitigating ADHD symptoms in children. Methylphenidate can mitigate ADHD symptoms quickly, even only a few hours after it was administered, while EEG neurofeedback therapy seems to show more benefits after a longer period of time, as it is based on the principles of learning and neuroplasticity, neither of which can occur rapidly (Cleveland clinic, 2022c; Lee et al., 2023; Storebø et al., 2023).

On the other hand, EEG neurofeedback therapy showing benefits not only consistently, but also more noticeably after a longer time also suggests that there is potential for long-term positive effects, which has not yet been shown for methylphenidate. Additionally, methylphenidate often caused less severe short-term effects such as sleeping problems and decreased appetite. Still, far long-term effects (multiple years after treatment) remain unknown for both research methods (Lee et al., 2023; Storebø et al., 2023).

The disadvantage of both treatment methods is that both have certain requirements that need to be met before the treatment is administered to a patient. For methylphenidate, it is important to thoroughly assess a patient’s medical situation, as the drug may not be compatible with some other medication that the patient may be taking (Storebø et al., 2018). For EEG neurofeedback therapy to work, patients need to be able to focus attention to the feedback (e.g. visual information or an auditory tone) of their own brain activities and sustain their attention throughout the therapy time. This may be a challenge for children with ADHD, who have attention deficits due to their condition (Storebø et al., 2023).

To conclude, given the fact that both treatment methods have their own advantages and disadvantages, there is no answer to the question which one is better. The choice of a treatment method should depend on careful consideration of the circumstances of each particular child. These could include a child’s current medical situation (which medications is the child already taking), goal of treatment (which ADHD symptoms would be best to mitigate), and even family medical history, which could facilitate assessing the risk of experiencing known short- and long-term side effects of a chosen treatment method (Lee et al., 2023; Storebø et al., 2018; Storebø et al., 2023). For some children, the best option might even be to combine both treatment methods and potentially mitigate ADHD symptoms even more effectively, but this should first be addressed by future research. Hopefully, this article will facilitate children’s, families’ and clinicians’ decision-making, so that each child will ultimately receive treatment most suitable for his/her own needs.

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