Real-time fMRI Neurofeedback as a novel neurotherapy for children with ADHD

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The study aims to test a novel, non-pharmacological, brain-based therapy for ADHD. Attention Deficit/ Hyperactivity Disorder (ADHD) is one of the most prevalent childhood disorders, typified by poor attention and poor self-control. The last 2 decades of brain imaging have shown that ADHD children have problems with engaging the right inferior frontal cortex (rIFC), which is a key region for self-control and attention. ADHD children are treated typically with stimulant medication which we have shown enhances the activation of this normally underactivated region, bringing it to normal functioning levels. However, stimulants seem to have no longer-term effects, are associated with side effects and not tolerated by all patients. Non-pharmacological treatments are preferred by parents, patients and clinicians, but are not very efficient. In this study we want to test a new treatment that targets a key deficient brain activity in ADHD by teaching ADHD children to self-up-regulate the activity of the rIFC. We hypothesise that this treatment will be efficient because it targets the key brain abnormality that is causing the behavioural problems. We plan to achieve this by using functional magnetic resonance imaging Neurofeedback (fMRI-NF). In fMRI-NF the brain activity of the participant is connected to a videogame. Every time the child increases or decreases brain activity in the target region of the brain (i.e. rIFC) this will drive the gameplay in the videogame. This way the child learns to enhance the activity of certain brain regions by trial and error in a playful way by playing the videogame with their own brain activity. fMRI-NF therefore trains patients to achieve volitional self-control over brain activation. NF using a cheaper method, using electrophysiology (EEG-NF), has been shown to have moderate but relatively long-term efficiency in improving ADHD symptoms of up to 2 years. However, it has been shown that fMRI-NF effects are significantly faster and can target deep cortical regions that are affected in ADHD such as rIFC that cannot be targeted with EEG-NF. rtfMRI-NF studies have been promising in other disorders in remediating key neurofunctional deficit and associated behaviours. Our own pilot feasibility rt-fMRI-NF study showed that 31 ADHD children learned to progressively enhance the activity of their rIFC within 11 sessions of 8 min of fMRI-NF. Furthermore, they managed to do this even without the feedback at the end of the training which shows that the learning effect can be sustained without the scanner. The self-upregulation of rIFC was furthermore associated with reduced severity of their ADHD problems, with better performance on cognitive tests of attention and self-control and with better brain activity in rIFC during tests of self-control. We also showed that the improvement of their behavioural symptoms were maintained 11 months after the treatment. The findings of this first pilot study to test fMRI-NF in ADHD children were therefore very promising. However, we did not include a control condition and hence cannot rule out a placebo effect. We therefore plan a larger and more definite study to prove the concept that children with ADHD can learn to self-upregulate brain activity in the rIFC in 14 sessions of 8.5 minutes of rtfMRI-NF. For this purpose, we will recruit 100 children with ADHD and randomise them between an experimental group (NF of rIFC) and a "sham" (placebo) control group (they will receive "non-real" feedback from another participant), to test whether this new brain treatment will improve ADHD behaviour, as well as brain activity and performance on tests of attention and self-control. The aim is to develop a novel, side-effect free, non-pharmacological, and longer-lasting treatment for ADHD that is based on neuroscience evidence remediating the key brain abnormality of ADHD children that is underlying their poor self-control and poor attention.