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Neurofeedback For Autism Spectrum Disorder (ASD): An Effective Treatment?

Autism is a neurodevelopmental disorder noticeable in childhood characterized by impaired communication skills and difficulty forming relationships or bonds with others.  Those with autism may lack empathy, dislike physical contact, and may be especially sensitive to loud noises, bright lights, or certain smells.  Currently there is no cure for autism, and many individuals diagnosed with autism spectrum disorder (ASD) respond poorly to pharmaceutical treatments.

An intervention that has shown promise in treating symptoms of autism is EEG neurofeedback.  This is a non-invasive technique that focuses on pinpointing neuroelectrical (brain wave) abnormalities and training an individual to consciously correct them with “feedback.”  It is thought that by correcting neuroelectrical abnormalities, many of the severe symptoms associated with autism could significantly diminish or subside.

Understand that while autism is largely influenced by genetics, various interventions such as neurofeedback to alter brain waves may help improve communication skills, learning abilities, and reduce sensory sensitivities.  Perhaps the greatest benefit derived from neurofeedback is that it can have long-lasting effects.  Once an individual has completed enough training, they are able to normalize their brain wave activity “at will.”

Neurofeedback for Autism Spectrum Disorder (The Research)

Below is a compilation of the research associated with using neurofeedback to treat autism spectrum disorder (ASD).  Understand that while some studies have demonstrated efficacy of neurofeedback for the treatment of autism, others have suggested no significant benefit; the evidence remains mixed.

2014: A pilot study was published in 2014 analyzing the feasibility of neurofeedback as a treatment for individuals diagnosed with autism spectrum disorder (ASD).  A total of 10 children (7 to 12 years old) diagnosed with high-functioning autism spectrum disorder (ASD) participated in the study.  The children were noted as having comorbid attentional difficulties, and were given a neurofeedback training protocol designed to improve attention.

Researchers used a checklist to determine whether it was feasible to administer neurofeedback to those with autism spectrum disorder.  They tracked concentration during exercises, academic tasks, and other behaviors (e.g. vocalizations).  They also utilized positive reinforcement and took breaks whenever necessary to improve adherence to the neurofeedback training.

Results suggested that it was “feasible” to utilize neurofeedback training among children with high functioning autism plus attentional difficulties.  They noted that individuals with motivational deficits had greater challenges and that increased parental support improved feasibility.  This provides small-scale evidence that neurofeedback is a practical intervention for children with high-functioning autism.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/24737038

2014: A journal was published in 2014 suggesting that neurofeedback interventions are helpful for reducing symptoms of those with autism spectrum disorder (ASD).  Researchers discuss that the ability to self-regulate brain waves is associated with symptomatic improvement, but doesn’t address other symptoms.  They believe that many symptoms of autism spectrum disorder are caused by peripheral physiological activity including: heart rate variability.

Researchers suggest possible benefit of a “brain-computer interface” that combines both neurofeedback with biofeedback for the treatment of autism spectrum disorders.  With a brain-computer interface combining the modalities, an individual with autism spectrum disorder could learn to regulate both neuroelectrical activity along with peripheral physiological activity (e.g. heart rate variability).  Researchers devised a game including social interactions to provide both neurological and biological feedback.

This interface may simplify training for individuals who were previously engaging in both neurofeedback and biofeedback separately.  In addition, it should be thought that those who were solely engaging in neurofeedback vs. biofeedback, may derive added benefit from training the peripheral nervous system.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/25071545

2014: It is thought that some of the behavioral, social, and communication deficits among those with autism spectrum disorder (ASD) stem from impaired neural communication.  Researchers suggest that neurofeedback training could help improve neural communication and bolster connectivity between regions.  To test this hypothesis, they administered neurofeedback training to children with autism spectrum disorder and typically developing children.

The neurofeedback protocol specifically trained individuals to regulate “mu rhythms” (9 Hz to 11 Hz).  Since the mu rhythm is thought to influence the mirror neuron system (MNS), and those with autism are believed to have dysfunctional mirror neuron systems, training an individual to modulate “mu rhythms” could normalize activity – potentially leading to functional behavioral, perceptual, and social benefits.

All participants (autism and typically developing) engaged in 30 hours of neurofeedback training.  Following the training, “eyes open” and “eyes closed” EEG recordings were collected along with a mu suppression index.  Degree of improvement was determined by parental behavioral questionnaires given pre-neurofeedback and post-neurofeedback training.

Results from this study suggest that neurofeedback training among individuals with autism spectrum disorder (ASD) reduces symptoms, whereas no benefit is attained for typically developing children.  Authors suggest that “mu rhythm” neurofeedback training may normalize dysfunctional mirror neuron systems via neuroplasticity, contributing to the benefit.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/24778378

2014: A study published in 2014 analyzed the effect of combining EEG neurofeedback with transcranial magnetic stimulation (TMS) for the treatment of autism spectrum disorder.  Researchers suggested that this protocol of combined treatments may be beneficial due to the fact that TMS has been previously associated with positive behavioral and electrophysiological effects among individuals with autism.  EEG neurofeedback is a technique that is thought to correct neuroelectrical abnormalities and ultimately improve functionality among those with autism.

To test this combined treatment of neurofeedback and TMS, researchers gathered 42 participants.  All participants were children that had been formally diagnosed with autism spectrum disorder.  Participants were measured in the form of behavior evaluations and reaction time test with ERP (event-related potential) recordings.  A total of 20 participants were assigned to receive neurofeedback with TMS, while the remaining 22 were put on a “wait list” (serving as the control).

Individuals receiving combined neurofeedback with repetitive TMS (targeting the prefrontal cortex) engaged in a total of 18 therapy sessions.  Following the 18 sessions, behavioral, reaction time, and ERP measures were collected.  Results from the study suggest that the combined effect of neurofeedback plus TMS significantly improves behavioral and functional outcomes among those with autism spectrum disorder (ASD) compared to a control group (those on the waiting list).

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/25267414

2013: Preliminary evidence suggests that targeted neurofeedback is able to decrease symptomatic severity among individuals with autism spectrum disorder (ASD).  Despite preliminary evidence, most studies do not control for nonspecific neurofeedback effects.  In addition, many of the studies failed to differentiate individuals that were successful in self-regulating neuroelectrical activity from those that were unable.

To improve upon past study designs, a newer study analyzed the effect of neurofeedback among individuals with autism spectrum disorder.  The design was considered randomized and controlled with measures recorded both pre-test and post-test.  This newer design also incorporated a 6-month follow-up measure.

A total of 38 participants were assigned to receive either: neurofeedback, biofeedback (skin conductance), or put on a “waiting list.”  The neurofeedback and biofeedback training was considered similar, and participants were unable to distinguish these two training modalities.  Measures were taken prior to the  treatment and analyzed executive function tasks and QEEG activity (based on 19-channel recordings).

Results demonstrated that over 50% of participants were able to reduce delta waves and/or theta waves during the neurofeedback sessions; these individuals were considered successful “self-regulators.”  Among these successful “self-regulators,” no significant symptomatic decreases in autism were noted.  That said, researchers noted significant improvement in cognitive flexibility compared to those receiving the skin-conductance biofeedback.

It was noted that neurofeedback could improve cognitive flexibility among those with autism, but may not significantly reduce symptoms.  The authors highlighted that no “nonspecific” neurofeedback effects were discovered.  This was a well-designed study and found no clear benefit of neurofeedback among those with autism.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/22903518

2011: Researchers conducted a review of evidence analyzing the efficacy of neurofeedback as a treatment for symptoms of autism.  They scoured various scientific databases looking for all studies utilizing EEG neurofeedback among those with autism.  Based on the compilation of studies collected, authors noted that the evidence does not support the efficacy of neurofeedback for the treatment of autism spectrum disorder.

While some studies in this review suggested possible benefit of neurofeedback for autism spectrum disorder, authors theorize that the benefits may stem from attentional improvements.  Since many individuals with autism have comorbid attentional deficits, using neurofeedback for ADHD may offer some benefit.  The fact that neurofeedback can improve attention should not be mistaken as an improvement in the core symptoms of autism spectrum disorder.

Many of the studies incorporated in this review included small sample sizes, were short-term, and had differential diagnostic criteria.  Numerous studies failed to provide an adequate control intervention, making it difficult to interpret results.  Future reviews would be strengthened by larger samples, longer-term studies, similar measures, and sufficient control interventions.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/21752020

2010:  Research published in 2010 suggested that core symptoms of autism spectrum disorder (ASD) may improve with behavior therapy.  In addition, there are other treatments such as pharmaceutical drugs that may improve functionality of those with autism.  However, many treatments are associated with problematic side effects, adverse reactions, and may worsen certain symptoms.

Using neurofeedback is a relatively safe way to potentially improve symptoms of autism by altering neuroelectrical activity.  Authors note that neurofeedback is considered a “Level 2” treatment in that it is “possibly efficacious” for those with autism spectrum disorder.  This review highlights a need for future studies with randomized, double-blind, placebo-controlled designs.

This review determined that some studies found neurofeedback to be an “efficacious” intervention for those with autism.  Authors suggest that it is important to understand the mechanisms by which neurofeedback is changing the brain among those with autism.  They discuss the potential of investigating various other neurotherapeutic modalities such as HEG neurofeedback.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/19856096

2010: It is known that the brains of individuals with autism tend to have anatomical and functional abnormalities.  Some experts believe that those with autism tend to display patterns of hyperconnectivity in certain regions, and hypoconnectivity in others; these have been confirmed by QEEG readings.  It is thought that with EEG neurofeedback training, some of the regional connectivity issues (hyper and/or hypo) can be normalized.

This report analyzed the effects of 2 controlled studies determining the efficacy of neurofeedback among those with autism.  Authors of this report sought to understand whether a symptom-specific approach vs. an assessment/connectivity approach was more effective among those with autism receiving neurofeedback treatment.  Both approaches were noted as providing significant improvement in symptoms.

However, it appeared as though a connectivity-based neurofeedback approach resulted in a greater reduction of symptoms as determined by advanced measures (autism subscales).  When individuals in the two studies were “matched” for symptomatic severity, the amount of change was significantly greater among those receiving connectivity-based neurofeedback.  This report suggests that it may be better to use a QEEG and target abnormal connectivity rather than focus on targeting symptoms.

Despite these findings, it should be noted that only two studies were compared.  In addition, no study has directly compared the efficacy of the two neurofeedback approaches.  It appears as though connectivity-based neurofeedback (as guided by a QEEG) may be superior to symptom-specific neurofeedback for the treatment of autism.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/19649702

2010:  A report published in 2010 highlighted data of neurofeedback training among 150 individuals diagnosed with Asperger’s Syndrome (AS) and 9 individuals diagnosed with Autism Spectrum Disorder (ASD).  The data was collected from clinical research published between 1993 and 2008.  Researchers attempted to determine whether neurofeedback improved functionality among those with Aspberger’s syndrome and autism.

Authors noted that various publications note that neurofeedback along with biofeedback may produce better outcomes than either standalone intervention.  Individuals received between 40 and 60 sessions of neurofeedback along with training aimed at enhancement of metacognition.  Those receiving biofeedback typically targeted respiration, electrodermal responses, and/or hear-rate variability.

The neurofeedback was noted as typically decreasing slow wave activity, usually within the theta range.  In addition, many protocols involved decreasing the spindling of beta waves, associated with activity between 23 Hz and 35 Hz, while increasing SMR (sensorimotor) activity between 12 Hz and 15 Hz.  Metacognitive training was conducted to improve social skills, spatial reasoning, comprehension, and mathematics.

Results indicated that individuals improved significantly in attentional abilities (as measured by the TOVA and IVA).  In addition, core symptoms (as measured by the Australian Scale for Asperger’s Syndrome and the DSM-IV), achievement (Wide Range Achievement Test), and intelligence (Wechsler Intelligence Scales) all improved.  It was revealed that average increase in IQ was 9 points; this is a substantial change.

Evidence highlighted in this report suggests that neurofeedback may be an effective intervention for treating symptoms of Asperger’s syndrome (AS) and ADHD.  Since Asperger’s syndrome is related to autism spectrum disorder, there may be similar benefit of neurofeedback training derived from individuals with autism.  This report documented the potential of improvement in numerous symptomatic domains.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/19908142

Does the research suggest neurofeedback is effective and safe for autism spectrum disorder?

Most of the research analyzing the effect of neurofeedback for the treatment of autism spectrum disorder (ASD) has suggested some benefit.  That said, a majority of study designs are questionable and the degree of improvement in core symptoms is subject to significant variation.  At this time, it is impossible to conclude whether neurofeedback is effective for those with autism spectrum disorder.

Most experts classify neurofeedback as a “Level 2” intervention, suggesting that it’s “possibly efficacious.”  No studies have reported significant neurofeedback side effects, suggesting that it is likely a safe intervention.  There is evidence suggesting that neurofeedback is efficacious for those with comorbid attentional deficits (common among those with autism).

It should be noted that since many individuals with autism spectrum disorder have abnormalities of neural connectivity (hypo or hyper), dysfunctional mirror neuron networks, and excess slow brain waves – neurofeedback is likely to provide some benefit.  The degree of benefit may be subject to individual variation based on the type of neurofeedback training, number of sessions, and whether it was utilized in synergy with another intervention (e.g. biofeedback or behavioral therapy).

Benefits of Neurofeedback for Autism Spectrum Disorder (ASD)

Listed below are some potential benefits associated with using neurofeedback for the treatment of autism spectrum disorder.  Keep in mind that the potential benefits are subject to significant individual variation and may be a reflection of the specific neurofeedback protocol or modality utilized.

  • Brain wave regulation: Those that are trained with neurofeedback are able to self-regulate electrical activity within the brain. Regulating brain wave activity can help reduce symptoms associated with autism spectrum disorder and comorbid conditions.  This ability to consciously modulate brain wave activity is a skill that can be maintained long after neurofeedback training is complete.
  • Concentration improvement: Many individuals diagnosed with autism spectrum disorders struggle with attention deficits. These attention deficits can often be corrected or mitigated via neurofeedback.  Training a person to consciously increase beta waves, while simultaneously decreasing slow theta waves is often very helpful for improving attention.
  • Connectivity normalization: Among individuals with autism spectrum disorders, there is a hypothesized overconnectivity (hyper) and underconnectivity (hypo) of certain regions. Some evidence suggests that connectivity can be altered with neurofeedback training.  In fact, targeting abnormal connectivity may yield the best results for individuals with autism.
  • Less reliant on medications: Many individuals with autism spectrum disorder are taking medications to treat various symptoms. For example, individuals may be taking SSRIs to target mood problems and/or psychostimulants to target attentional deficits.  With proper neurofeedback training, a person may be able to reduce the need for pharmaceutical interventions.
  • Long term effect: The ability to consciously normalize brain wave activity is often maintained long after neurofeedback training is complete. Just like it takes many sessions of trial and error to ride a bike, it can take many sessions of neurofeedback before a person learns how to regulate their brain waves.  Some believe that the skill of normalizing electrical activity is maintained for months (or years) after neurofeedback training.
  • Low risk: Using neurofeedback for any condition (including autism) should be considered low risk. There haven’t been any reported significant side effects nor adverse reactions.  The only major risk associated with the practice is using a suboptimal or poor training protocol.  A poor training protocol has potential to worsen symptoms rather than improve them.
  • Mood improvement: There is some evidence to suggest that neurofeedback may improve mood as a result of correcting brain waves. (Read: Neurofeedback for depression). Since it is known that many individuals with autism struggle with comorbid depression and anxiety, neurofeedback may target these comorbid symptoms.
  • Neurotransmission: The fact that neurofeedback is associated with brain wave changes means that it could influence production of neurotransmitters and hormones. Faster brain waves are associated with heightened physiological arousal and production of different neurotransmitters than slow waves.  It should be thought that neurofeedback may indirectly influence an individual’s neurochemistry.
  • Non-invasive: Another advantage associated with neurofeedback for autism is that it’s non-invasive. The technique involves placing electrodes on the outside of a person’s scalp, thereby measuring brain wave activity.  No incisions are required to get an accurate reading of neuroelectrical activity throughout the cortex.
  • Targets neuroelectrical abnormalities: Many therapies engineered for autism spectrum disorder do not address possible neuroelectrical problems. Despite the fact that a person may ingest pharmaceuticals or supplements designed to alter neurochemistry, these interventions do not target neuroelectrical activity.  With neurofeedback, the neuroelectrical component of autism can be isolated and targeted during treatment.

Limitations of Research: Neurofeedback for Autism Spectrum Disorder

There are numerous limitations associated with research of neurofeedback for autism.  The most notable limitation is the fact that most studies analyzing the efficacy of neurofeedback for autism are small scale.  Furthermore, most studies are not well-designed and aren’t personalized based on QEEG readings.

  • Evaluation (Measures): The evaluation of autism spectrum disorder is often subject to variation between studies. Different scales, subscales, and measures for comorbidities are used, making it difficult to compare the outcomes from one study to those of another.  In the future, it would be recommended to utilize the same evaluation scales to determine degree of symptomatic improvement among those with autism.
  • Individual differences: Most studies fail to account for specific individual differences, which may skew the results. It would be helpful to know whether participants are high-functioning, normal-functioning, or low-functioning, whether they are taking medications, and specific individual differences associated with QEEG recordings.
  • Modality of neurofeedback: There are many different types of neurofeedback including: EEG, HEG, and even rtfMRI neurofeedback. While this article focused solely on understanding the efficacy of EEG neurofeedback for autism, it is important for researchers to determine differences in efficacy between various neurofeedback modalities.  They may discover that EEG neurofeedback is more or less effective than other specific types.
  • Participants: Many studies involve different age groups of those with autism spectrum disorder. It is unclear as to whether individuals of certain ages are more or less likely to derive benefit from neurofeedback training.  Some would speculate that younger ages may have a tougher time understanding how to engage in the neurofeedback, while others may believe that results may be less significant among older individuals.
  • Protocol variation: Due to the significant variation in protocols, it is difficult to determine the efficacy of neurofeedback for autism. Certain protocols may be more or less effective than others.  For example, some research has investigated the effects of downtraining (decreasing) slow wave activity in the theta and delta ranges, while other research focused on training individuals to modulate the “mu rhythm.”  The differences in brain waves being trained and the neural locations (“sites”) of training may significantly influence outcomes.
  • Sample sizes: Most sample sizes are relatively small-scale, making it difficult to determine whether results are accurate. Evidence for the use of neurofeedback in treating autism symptoms is mixed and will remain difficult to interpret until larger-scale trials are conducted.  Studies with hundreds of participants would be preferred over those with double-digit numbers.
  • Study designs: Due to the fact that most study designs are not randomized, double-blind, and placebo-controlled, it is unclear whether neurofeedback is effective for treating core symptoms of autism. It is difficult to suggest that neurofeedback is clinically effective in poorer designed studies, despite favorable outcomes.  In addition, many poorly designed studies have small samples, further complicating the interpretation of results.
  • Synergistic effects: Some studies involve using neurofeedback plus biofeedback, metacognitive training, and/or transcranial magnetic stimulation. In these studies, it is unknown whether the neurofeedback is capable of significantly reducing symptoms compared to the paired treatment.  It is possible that: both interventions produce significant results as standalone treatments, neither intervention produces substantial results as a standalone treatment, and/or the synergistic effect of multiple treatments are more substantial than either standalone intervention.

Will neurofeedback cure your autism spectrum disorder?

It is highly unlikely that neurofeedback will “cure” anyone of their autism spectrum disorder.  That said, there is some reason to believe that a properly engineered neurofeedback protocol may result in significant functional improvements and a reduction in core symptoms of autism.  Many individuals with autism have neuroelectrical and connectivity abnormalities within the brain; neurofeedback trains an individual to consciously correct these.

Understand that EEG solely targets a person’s electrical activity – it doesn’t directly target neurochemistry, anatomy, or genetics influencing the manifestation of autism spectrum disorder.  Autism is largely thought to be influenced by genetic polymorphisms and abnormal brain waves is just one of numerous resulting effects from these genetics.  That said, the potential benefit associated with attempting to normalize brain waves shouldn’t be discounted.

Many individuals will likely find that neurofeedback improves specific core symptoms of autism and various comorbidities.  In addition, there is reason to believe that synergistic benefits may be derived from a combination of neurofeedback with metacognitive training, transcranial magnetic stimulation, and/or biofeedback targeting the peripheral nervous system.  Due to possible synergistic effects, brain-computer interfaces have been devised to train EEG neurofeedback with biofeedback (e.g. heart rate variability) simultaneously.

Are all neurofeedback protocols for autism the same?

No, not all neurofeedback protocols for autism are the same.  At this time it is unclear whether certain protocols offer advantages in terms of efficacy over others.  Based on the research, it is apparent that personalizing treatment based on individual QEEG connectivity may produce superior outcomes to approaches that simply target symptoms or specific brain waves.

Most experts would agree that a pre-treatment QEEG is necessary to determine individual abnormalities.  Not everyone with autism spectrum disorders are likely to have the exact same abnormalities.  Therefore personalizing neurofeedback treatment based on individualized QEEG readings should be optimal; without a pre-treatment QEEG, a suboptimal training protocol may be utilized and could theoretically worsen symptoms.

  • Connectivity targeting: This approach involves pinpointing hypoconnectivity and/or hyperconnectivity within the brain based on QEEG readings. Abnormally slow or fast brain waves in certain regions may signify that a region isn’t communicating well (or is communicating excessively) with neighboring regions.  Some practitioners have devised training protocols based off of individual connectivity abnormalities as highlighted by QEEG readings.
  • Mu rhythm modulation: Training individuals to modulate “mu rhythms” (9 Hz to 11 Hz) may improve certain symptoms of autism. Mu rhythms are thought to be connected to the mirror neuron systems within the brain.  Since individuals with autism display abnormal activation of the mirror neuron system, modulation of the mu rhythm may improve various core symptoms of the disease.
  • Beta waves: Some protocols have involved increasing SMR beta, while decreasing beta spindles. Training of SMR is considered relatively safe and is thought to improve various aspects of cognition and concentration.
  • Theta waves: Many individuals with autism spectrum disorder are thought to have excess theta waves on the EEG. Too many theta waves are associated with ADHD and may result in significant brain fog.  In fact, they may also contribute to depressive moods and emotional instability.  Therefore downtraining (decreasing) these waves could be helpful for those with autism.

Have you used neurofeedback for autism spectrum disorder (ASD)?

If you (or someone you know) has used neurofeedback for autism spectrum disorder, feel free to discuss the experience in the comments section below.  Mention the number of sessions conducted, duration of the sessions, and whether any substantial improvement was noted.  If improvement was noted, how was it measured (e.g. what scales were used)?

To help others get a better understanding of the experience, discuss the specific type of neurofeedback training (e.g. mu rhythm modulation) and note whether other interventions were simultaneously utilized (e.g. medications, therapy, biofeedback).  Realize that differences in efficacy of neurofeedback may be subject to significant individual variation and are likely influenced by the specific protocol devised by a neurofeedback practitioner.

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