What Is Neurofeedback? What We Know and Don't Know About Brainwave Training

What is neurofeedback, how do sessions work and how effective is it for attention problems? Learn what research says and which questions to ask before deciding.

After a note from the teacher saying "He's always daydreaming in class", a mother who starts searching online may soon find herself among pages talking about brainwaves, sensors attached to the head and promises of "medication-free attention training". A centre suggests a programme of thirty or forty sessions; a friend says "It really helped our boy"; the paediatrician speaks cautiously. This confusion is entirely understandable. What is neurofeedback, how does it work, who is it recommended for, and what does research actually say about this method? In this article we try to set out what you need to know before making a decision, without exaggerating or dismissing it.

What Is Neurofeedback?

Neurofeedback is a method in which the brain's electrical activity is measured with sensors placed on the scalp, and information about this activity is presented to the person instantly in the form of visual or auditory feedback. For this reason it is also called "EEG biofeedback" or, in everyday language, "brainwave training".

Its logic can be summarised as follows: our brain constantly produces electrical activity at different frequencies, and this activity changes according to our state of attention, alertness and rest. During neurofeedback the person watches a video or plays a simple game. When brain activity shifts in the targeted direction, the video becomes clearer, the sound gets louder or the car in the game speeds up; when it moves away from the target, the screen darkens or the car slows down. Although the person cannot fully explain how they are doing it consciously, over time they may learn to produce the rewarded pattern of brain activity more often. This is the application to brain activity of learning principles well known in behavioural science.

The difference between biofeedback and neurofeedback

Biofeedback is the name of a general family of methods in which different bodily functions are measured and fed back to the person. Measurements such as heart rate, muscle tension, skin temperature or breathing rhythm can be used. Neurofeedback is the branch of this family that focuses directly on brain activity. Breathing and heart-rhythm feedback used when working with anxiety is a simpler and more widespread practice; neurofeedback requires more complex equipment and a longer process.

How Does a Neurofeedback Session Work?

Although practice varies from centre to centre, the process usually involves the following steps:

1. Initial assessment: The reason for referral, developmental history, school or working life and any previous diagnoses are discussed. Some centres take a comprehensive EEG recording at this stage and state that they are mapping brain activity.
2. Choosing the protocol: Which area of the brain and which frequency ranges will be measured, and what will be rewarded, are selected. Protocols commonly used for attention problems aim to reduce slow waves and increase activity associated with focus.
3. Sessions: A few sensors are placed on the person's scalp; a gel may be used to improve conductivity. The person sits in front of a screen and does a training session lasting roughly between half an hour and an hour.
4. Repetitions: To be able to speak of an effect, a long series of sessions is usually recommended, typically several times a week. This is something the family needs to think about from the outset in terms of both time and cost.

How can the process be explained to a child?

Having sensors attached to the head can spark curiosity in some children and anxiety in others. Giving the child an age-appropriate, unexaggerated explanation makes things easier: "These little buttons will stick to your head and tell the computer how carefully your brain is working. You'll play the game on the screen; it won't hurt at all." Avoid presenting the sessions as a punishment or a "cure for laziness". Pressuring sentences such as "The sessions will stop once you pull your attention together" can also make the child feel defective. It is natural for a child's motivation to dip over a long series of sessions; during this period it is important to appreciate their effort rather than blame them.

No current is delivered to the brain during the session; the sensors only take measurements. This is one of the questions families ask most often and worry about most.

In Which Situations Is Neurofeedback Recommended?

Neurofeedback comes up most often in the context of attention deficit hyperactivity disorder (ADHD). Beyond this, you may hear of it being applied in very different areas such as sleep difficulties, anxiety, learning difficulties, migraine, post-traumatic symptoms and performance enhancement in athletes or musicians. It is also known that in some medical conditions, for example certain types of epilepsy, neurofeedback has been researched as a supportive method under a doctor's supervision.

An important distinction needs to be made here: the fact that a method is applied in a particular area does not mean its effectiveness in that area has been proven. In particular, promotions that give the impression that it "is good for everything" should be a reason for caution. If you are curious about the symptoms through which ADHD shows itself, you can take a look at the article on ADHD symptoms.

Seeking neurofeedback in Turkey

In Turkey, neurofeedback is mostly offered in private centres and clinics. Given the long series of sessions, the total cost can be a serious burden for many families; at times when the cost of living rises, some families cut back on other needs in order to turn to these programmes. That is why openly discussing what neurofeedback is, what it promises and what it cannot promise before making a decision protects the family both financially and emotionally. Turning to this method as a "last resort" as exams such as the LGS or YKS (Turkey's national high-school and university entrance exams) approach is also common; however, because intense exam-period stress can itself increase attention problems, assessments made during this period need to be interpreted with caution.

What Does Research Say? What We Know and What Remains Uncertain

Neurofeedback is a method that has been researched for decades, and the scientific debate is still ongoing. Today's overall picture can be summarised as follows:

• Some studies report positive results. Particularly in children with ADHD, studies based on parents' ratings have reported improvements in attention and impulsivity.
• In controlled studies the picture is more complicated. In studies where the person doing the rating does not know whether the child received real neurofeedback or a similar-looking sham procedure, the effects tend to come out smaller. This suggests that part of the observed improvement may be linked to general factors such as regular attention, a structured routine, expectations and the family's hope.
• There is great variation between protocols. Because the frequencies, brain areas and number of sessions targeted vary from study to study, comparing the results with one another is difficult.
• It is not among the first-line treatments in international guidelines. The core approaches recommended for ADHD include parent training, collaboration with the school, behavioural and cognitive behavioural interventions and, where necessary, medical treatment planned following a psychiatrist's assessment. Neurofeedback is mostly regarded as an option still under investigation or as a complementary one.

This does not mean neurofeedback does not work; but it does mean that, with the knowledge we have today, it is not right to present it as a proven main treatment for attention problems.

When evaluating a method, the question to ask is not "Whom did it help?" but "How many children in similar circumstances did it help, compared with what, and for how long?"

What Is Neurofeedback, and What Is It Not? Common Mistaken Expectations

The answers given online to the question of what neurofeedback is often go beyond the truth. That is also why families and adults approach this method with high hopes. Placing these hopes on realistic ground prevents disappointment and unnecessary spending.

• "Electricity is given to the brain." No. In classic neurofeedback the sensors only take measurements. Methods that deliver current to the brain are entirely different practices and should not be confused with neurofeedback.
• "A brain map makes a diagnosis." EEG recordings can provide some information; but conditions such as ADHD, learning difficulties or anxiety are not diagnosed by looking at a single brain recording. Diagnosis is made together with a clinical interview, developmental history, observations at home and school and, where needed, other assessments.
• "It's an alternative to medication." This decision should be made between the family and the doctor, with the child's situation assessed as a whole. Do not use neurofeedback as a reason to stop medical treatment on your own or not to start it.
• "You'll see a difference in a few sessions." By the nature of the method, a long process is recommended. Changes seen in the first sessions may often be the effect of a new routine and of the attention received.
• "It helps everyone in the same way." Individual differences are large. Some people say they have benefited, while others experience no noticeable change.

Side effects are generally described as mild: tiredness after a session, headache or short-lived changes in sleep. Even so, it is important to share any such symptoms with the practitioner.

Questions to Ask Before Deciding

If you are considering neurofeedback, looking for answers to the following questions before approaching a centre will make things easier:

• Who will carry out the procedure, what is their core profession and what training do they have in this field?
• Will a comprehensive clinical assessment be carried out before the procedure, or will sessions begin straight away?
• Which protocol will be used, and why was this protocol chosen?
• How will progress be measured? Only through the family's observations, or also with teacher forms and standardised scales?
• What will be done if no benefit is seen after a certain number of sessions?
• Are the total cost and payment terms stated clearly from the outset?
• What other support is planned for the child's school, family and emotional needs?

If you come across an approach that promises definite results, makes all other treatments seem unnecessary or pressures you to decide quickly, it is wise to pause for a while and get a second opinion.

When Should You Seek Professional Support?

Attention and focus problems can stem from different causes. Factors such as lack of sleep, anxiety, low mood, learning difficulties, hearing or vision problems, stress in the family and screen use can create a picture resembling distractibility. For this reason, it is important that a comprehensive assessment is carried out before starting any method. You may consider seeking support from a child mental health specialist or a psychiatrist in the following situations:

• If problems with attention and activity are seen both at home and at school and have been going on for months,
• If your child's school performance, friendships or self-esteem are markedly affected by these problems,
• If, as an adult, disorganisation, procrastination and forgetfulness are straining your work and relationships. The article on adult ADHD may give you some ideas on this.

You can find information about assessment and therapy work with children on the child and play therapy page.

How Are Attention Problems Addressed in Therapy?

Working with attention problems in psychotherapy aims not so much to train a single brain function on its own as to make the person's daily life more manageable alongside this difficulty. When working with children, parent training plays an important part: the focus is on skills such as giving clear, short instructions, breaking large tasks into small steps, noticing and reinforcing positive behaviour and establishing a predictable routine at home. There is collaboration with the school, and simple adjustments the teacher can make in the classroom are discussed.

Let's imagine a middle-school child whose homework time ends in tears every evening. The assessment reveals that the child watches videos on a tablet until midnight, gets up early to catch the school minibus, and experiences intense anxiety before starting lessons because they have fallen behind in maths. In this picture the first step is not training brainwaves; it is restoring the sleep routine, dividing homework into short sections with breaks, addressing the maths anxiety and rebuilding the family's evening routine. If attention problems persist after these steps, other options can be discussed on a healthier footing.

Cognitive behavioural therapy can be helpful, especially for adolescents and adults, in terms of planning, time management, coping with procrastination and working on negative beliefs that have taken root over the years, such as "I'm useless anyway". Many people with attention difficulties also struggle with the marks left by constant criticism; addressing this emotional burden is an important part of treatment.

If a family has decided to try neurofeedback, the healthiest path is for this decision too to be made within this holistic plan, keeping expectations realistic and tracking progress in concrete terms.

Frequently Asked Questions

How many neurofeedback sessions are needed?

This varies according to the protocol used and the individual; however, a programme of dozens of sessions is usually recommended. Before starting, it is advisable to clarify after how many sessions an interim review will be held and how you will proceed if no benefit is seen.

Does the effect continue after the sessions end?

Research does not yet give a definite answer on this. While some studies report that effects continue for a time, more research is needed on long-term outcomes. For this reason it is more sensible to think of neurofeedback together with other forms of support that strengthen skills in daily life.

Can adults have neurofeedback too?

Yes, it is also applied to adults. However, in adults too, a comprehensive assessment should first be carried out to understand the causes behind attention problems, and the method should be considered together with other evidence-based approaches.

• #attention deficit
• #ADHD
• #brainwaves
• #assessment

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Eda Erkan Alapala

Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.

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