Neurofeedback in ADHD: A qualitative study of strategy use in slow cortical potential training

Neurofeedback (NF) as a treatment for children and adolescents with attention deficit hyperactivity disorder (ADHD) has gained growing interest in recent years. Most research has been quantitative, focusing on treatment outcomes, while qualitative approaches exploring the treatment process and participants’ experiences are scarce. The objective of this study was to examine NF participants’ use of cognitive and other strategies for approaching and solving NF tasks, their development over the course of the training and the influence of participants’ compliance. METHOD: We collected 130 short semi-structured interviews following treatment sessions from 30 participants with ADHD receiving NF using slow cortical potential training (SCP). The interviews were transcribed verbatim and analyzed using thematic analysis. Themes where evaluated for changes over-time and between participants with high/low treatment compliance. Interviews from 14 participants who had undergone at least five completed interviews were examined in more depths, aiming to establish typical strategy/training profiles. RESULTS: We identified 16 strategies covering four domains: cognitive, physiological, emotional and unspecified. Typical of most strategies were that they served as a vehicle to regulate mental arousal. Overall, no clear patterns of changes over time were found. Highly compliant participants reported to use the strategies from the emotional domain and the strategy focus more frequently than neutral compliant participants did, while neutral compliant participants reported the use of the strategies muscular activity and passivity more often than participants did with high compliance. Across participants, three strategy profiles were derived, those who handled the task by manipulating their state of mind in relation to the NF task, those who were mainly manifest and concrete towards the task, and those who were mostly unaware of what they were doing. These profiles differed in self-regulatory performance, and only participants showing the state of mind profile experienced a decrease of ADHD symptoms accompanied by objectively measured improvements in self-regulation. In addition, compliance affected both how and what strategies were used. CONCLUSION/DISCUSSION: A heterogeneous array of cognitive and other strategies is used at varying levels of training compliance by participants with ADHD during SCP that could be condensed to three prototypical profiles. Future research should take compliance and strategy/training profiles into account when evaluating NF. The latter may help to clarify which and how brain activity regulating mechanisms drive training, individual response to NF, and how they are influenced by motivational factors. Our findings might also help to facilitate more effective instructions in how to approach SCP in clinical practice.