Z-Score Neurofeedback and Heart Rate Variability Training for Adults and Children with Symptoms of Attention-Deficit/Hyperactivity Disorder: A Retrospective Study

Appl Psychophysiol Biofeedback. 2019 Dec;44(4):291-308. doi: 10.1007/s10484-019-09439-x.


ADHD is a common condition that causes suffering for those affected and economic loss for society at large. The current standard treatment for ADHD includes stimulant medications, which are not effective for all patients, may include side effects, and can be non-medically misused. Z-score neurofeedback (NFB) and heart rate variability (HRV) biofeedback are alternative treatment strategies that have been associated with Attention-Deficit/Hyperactivity Disorder (ADHD) symptom improvement. We utilized a retrospective pre-post study design to quantify the change in clients' ADHD symptoms after combined NFB + HRV treatment (which included simultaneous z-score training at four sites). We also assessed whether relevant physiological measures changed in accordance with the protocol, which would be consistent with effective NFB + HRV training. Adults (n = 39) and children (n = 100) with Borderline or Clinical ADHD classifications by the Achenbach System of Empirically Based Assessment (ASEBA) received 30 sessions of NFB + HRV training. Measures were compared before and after treatment for the ASEBA, the Integrated Visual and Auditory Continuous Performance Test (IVA), ADHD medication use, HRV and breathing parameters, and quantitative electroencephalogram (QEEG) parameters. Average ASEBA Attention-Deficit/Hyperactive Problems score improved after treatment for adults and children (p < 0.0001), with Cohen effect sizes (dz) of -1.21 and -1.17, respectively. 87.2% of adults and 80.0% of children experienced improvements of a magnitude greater than or equal to the Minimal Clinically Important Difference. After treatment, 70.8% of adults and 52.8% of children who began in the ASEBA Clinical range, and 80.0% of adults and 63.8% of children who began in the ASEBA Borderline range, were classified in the Normal range. IVA scores also improved after treatment. Changes in HRV and breathing pattern after treatment were consistent with the protocol. QEEG parameters after treatment were closer to the age-based normative mean, which is consistent with effective z-score NFB training.

Keywords: ADHD; Attention-deficit/hyperactivity disorder; Heart rate variability biofeedback; QEEG; Z-score neurofeedback.

MeSH terms

  • Adolescent
  • Adult
  • Attention Deficit Disorder with Hyperactivity / therapy*
  • Auditory Perception / physiology
  • Child
  • Electroencephalography*
  • Female
  • Heart Rate* / physiology
  • Humans
  • Male
  • Middle Aged
  • Neurofeedback / methods*
  • Outcome Assessment, Health Care*
  • Psychomotor Performance / physiology
  • Retrospective Studies
  • Severity of Illness Index
  • Visual Perception / physiology
  • Young Adult