386. Comparative efficacy of EEG-based neurofeedback as an alternative or adjunct to pharmacological treatment in patients with ADHD and psychiatric comorbidities

Abstract

Abstract Background Attention-deficit/hyperactivity disorder (ADHD) is associated with dysfunction of fronto-striatal and fronto-parietal circuits, as well as electroencephalographic abnormalities characterized by an increased theta/beta ratio. Pharmacological treatment primarily modulates dopaminergic and noradrenergic neurotransmission; however, its effectiveness may be limited in the presence of psychiatric comorbidities and by adverse effects. Electroencephalography-based neurofeedback (NF) is a non-invasive neuromodulation technique aimed at the self-regulation of specific cortical oscillations, particularly through the reduction of theta activity and the enhancement of beta or sensorimotor rhythm. Clinical studies have reported heterogeneous outcomes: while some describe sustained improvements in attention and inhibitory control, meta-analyses using blinded assessments do not support its use as a stand-alone treatment. This variability highlights the need to evaluate its comparative effectiveness and its role as an adjunctive intervention in comorbid populations. Aims & Objectives Primary objective To compare the efficacy of electroencephalography-based neurofeedback and standard pharmacological treatment in modulating neurophysiological patterns and clinical outcomes of ADHD in patients with psychiatric comorbidities. Secondary objectives To evaluate the potential of neurofeedback as an adjunctive intervention by analyzing changes in the theta/beta ratio, inhibitory control, and tolerability profile in comparison with pharmacotherapy. Method A comparative review focused on neurophysiological biomarkers was conducted through systematic searches of PubMed, Scopus, and Google Scholar (2014–2024). Randomized controlled trials, meta-analyses, and clinical studies evaluating EEG-based neurofeedback and pharmacological treatment in patients with ADHD and psychiatric comorbidities were included. Primary outcomes comprised modulation of cortical oscillations—particularly the theta/beta ratio and sensorimotor rhythm—while secondary outcomes included validated clinical scales of attention and impulsivity and safety profiles. Studies with blinded assessments and adequate methodological quality were prioritized. Results The included studies showed that both neurofeedback and pharmacological treatment led to improvements in the core symptoms of ADHD. Pharmacotherapy was associated with a more rapid symptomatic reduction, whereas neurofeedback demonstrated sustained effects on the modulation of cortical oscillations, particularly through a decrease in the theta/beta ratio and an increase in sensorimotor rhythm. However, meta-analyses based on blinded assessments did not demonstrate consistent superiority of neurofeedback as a stand-alone treatment. In patients with psychiatric comorbidities, some studies reported additional improvements in attention and inhibitory control, with a lower incidence of adverse effects. Discussion & Conclusions EEG-based neurofeedback demonstrates a modulatory effect on altered neurophysiological patterns in ADHD, particularly on cortical oscillations associated with attentional control. Although pharmacotherapy remains more effective for immediate symptomatic reduction, neurofeedback may serve as an adjunctive intervention in patients with psychiatric comorbidities or limited drug tolerability. Methodological heterogeneity and the lack of standardized protocols limit the interpretation of results. Controlled comparative studies focused on neurophysiological biomarkers are needed to more precisely define its clinical utility within the neurological management of ADHD.