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The Fallacy of Sham-Controlled Neurofeedback Trials: A Reply to Thibault and Colleagues (2018)

H. edmund pigott.

1 NeuroThrive, LLC, Lutherville, MD, USA

2 Private Practice, Juno Beach, FL, USA

3 Knoxville Neurofeedback Group, TN, USA

Mark Trullinger

Background: Sham-controlled neurofeedback (NFB) trials consistently find no separation on ADHD outcome measures leading many to conclude that NFB’s beneficial effects are due to placebo. Method: We deconstruct the NFB training methodology and findings of six sham-controlled trials that assessed for evidence of learning. Results: All six studies found no evidence NFB subjects learned to self-modulate the targeted electroencephalogram (EEG). Careful analyses revealed these studies’ training methodologies were antithetical to the established science of operant conditioning thereby preventing subjects from learning to self-modulate. These findings are in marked contrast to NFB studies whose methodology mirror the best practices of operant conditioning. Conclusion: The premise that NFB’s beneficial effects are due to placebo phenomenon is unproven as these studies compared two forms of false-feedback, not operant conditioning of the EEG. Because these studies are highly cited and considered the gold standard in scientific rigor, a reappraisal of the evidence is urgently needed.

This is now Thibault, Veissière, Olson, and Raz’s (2018) eighth publication making the same argument based on the consistent finding of no separation on any outcome measure when comparing so-called “genuine” neurofeedback (NFB) and sham feedback in sham-controlled trials (e.g., Thibault & Raz, 2017 ). The authors therefore assert that NFB operates as a placebo, all be it a powerful one, with effects commonly equivalent to optimized versions of established ADHD treatments (e.g., Pigott, 2017 ). In their current effort, the authors provide guidance how clinicians can ethically prescribe NFB “as a form of neurosuggestion therapy” ( Thibault et al., 2018 , p. 2). Our Guest Editorial deconstructs these sham-controlled studies demonstrating the fallacies of the authors’ argument. We also examine the evidence supporting neurosuggestion as a therapeutic intervention as well as that supporting NFB’s specificity, sustainability, and effectiveness when compared with stimulant medication (SM). Finally, we question why prescribe NFB as a placebo when with proper training clinicians can provide operant conditioning of the electroencephalogram (EEG) with proven sustained effects.

Learning Methodology Matters

Table 1 summarizes the methodology and findings from six sham-controlled trials treating ADHD. Although each study acknowledged NFB is based on operant learning, their methodology violated established learning science by using either automated or manually adjusted EEG reward thresholds to maintain an “about 80%” level of reward across sessions and subjects. This procedure is contrary to basic learning principles. First, operant conditioning targets a response followed by a stimulus-event to make the desired response occur more or less frequently and then plots the target response’s occurrence over time to document whether or not learning has occurred. In these studies, the target response was not consistently calculated, monitored, plotted, and presented to NFB subjects. Therefore, it is not known what response (if any) was conditioned. Second, the studies do not reference the effects of practice in the experimental process. Subjects in both groups engaged in the same set of behaviors during sessions (e.g., maintaining stillness and focus, reducing muscle and eye-movement artifacts, relaxation, posture, and breathing). If subjects did not engage in these practiced behaviors, their EEG data were riddled with artifact and worthless. Third, operant conditioning of the EEG requires that these core concepts are strictly adhered to demonstrating the operant behavior has been learned and such documentation of learning should occur before examining outcome measures of interest ( Cannon, 2015 ).

Sham-Controlled NFB Studies.

Note. NFB = neurofeedback; EEG = electroencephalogram; RCT = randomized controlled trials.

In these studies, every reset of the EEG reward threshold delivered operant consequences to subjects’ brains antithetical to the goal of training. As Pigott and colleagues (2017) note

if the targeted EEG was strengthening, reinforcement was withdrawn and reset down to 80% thereby punishing participants for learning to self-modulate. Conversely, if the targeted EEG was decreasing, participants were reinforced up to 80% thereby rewarding them for decreasing its strength. (p. 897)

At every reset of the reward threshold, NFB subjects therefore were either rewarded for not learning to self-modulate the targeted EEG or administered a Type 2 punishment for the beginnings of success.

Given their flawed methodology, it is not surprising that all six studies found:

• No evidence NFB subjects learned to self-modulate the targeted EEG;
• No separation between NFB and sham feedback on any outcome measure; and
• When assessed, the vast majority (71% to 75%) of NFB subjects thought they received sham-feedback—correctly determining the NFB they received was often false.

Intriguingly, four of the studies also found significant improvement in both groups, leading Thibault and colleagues among many others to argue that these beneficial effects are due to placebo phenomena versus any specific effects from NFB. Two points in response below:

First, flawed methodology prevented NFB subjects from learning to self-modulate the targeted EEG and therefore no specific effects should be expected since each study compared two forms of false-feedback. Second, both groups participated in an active intervention. Ninaus and colleagues (2013) found multiple cortical regions of the brain are activated when blinded subjects were told to focus and try to control randomly moving bars during five 20-s rounds. In contrast, no such changes occurred when subjects were instructed to merely watch the moving bars. Subjects in sham-controlled trials are commonly instructed to sit still, focus, and use their brains to increase positive feedback. Similar cortical regions therefore likely underwent a vigorous workout during subjects’ 30+ sessions sitting still and trying to control that which was uncontrollable. This is hardly a “placebo” intervention as traditionally understood and likely only had positive effects because subjects were deceived into believing they had a 50% chance of receiving accurate EEG feedback. Transparency eliminated the brain activation found by Ninaus et al. as it likely would in all false-feedback trials.

Thibault and colleagues’ (2018) claim that NFB is a placebo is not supported by the referenced data. Their referenced studies compared two forms of false-feedback— not operant conditioning of the EEG . NFB has a 75+ year history of scientific inquiry documenting operant conditioning of the EEG in cats (e.g., Wyrwicka & Sterman, 1968 ), primates (e.g., Schafer & Moore, 2011 ), and people (e.g., Jasper & Shagass, 1941 ), including a 40-year history of research treating ADHD children ( Lubar & Shouse, 1976 ; Shouse & Lubar, 1979 ). The authors though dismiss this extensive research history asserting that “Following the results from recent double-blind studies, we can now add EEG-nf for ADHD to this list of placebo therapies that masquerade under other biomedical labels” (p. 2). In contrast, it is our assessment that it is these double-blind studies themselves that are the masquerade since they did not compare operant conditioning of the EEG with a sham-control but rather two forms of false-feedback.

Bad Science Begets More Bad Science

In their introductions, each of these sham-controlled studies states something similar to “neurofeedback is based on the assumption that deviant brain activity patterns can be voluntarily modulated by operant learning strategies” ( Schönenberg et al., 2017a , p. 674) and yet then used a methodology antithetical to operant learning. When we challenged Schönenberg and colleagues to either “acknowledge that their neurofeedback methodology violates the very essence of operant conditioning or explain the errors in our analysis” ( Pigott et al., 2017 , p. 897), these authors stated that they used a “previously established protocol” ( Schönenberg et al., 2017b , p. 897) and then made additional points unrelated to our analysis.

This is the problem. Bad science begets more bad science until it is corrected. Each of these studies cited one or more of their predecessors and appears more focused on single/double/triple blinding and empirical rigor than ensuring competence in administering the independent variable, in this case operant conditioning of the EEG. True scientific rigor demands a higher level of adherence to learning principles when evaluating treatments based on operant conditioning.

Unfortunately, the impact factors of the journals publishing these six studies ranged from 2.5 to 11.6 placing them in the mid-to-top tier of behavioral health journals. These studies therefore have had a nefarious impact on the scientific literature as they are highly cited in research and review articles, meta-analyses, editorials, and authoritative practice guidelines (e.g., AACAP, 2011 ) as well as by insurance companies when denying coverage since these studies are presumed to demonstrate that NFB has no specific effects when rigorously evaluated and therefore does not meet evidence-based treatment standards. This contaminated scientific literature has harmed the public by limiting access to a treatment with a long history of using operant conditioning to improve lives by teaching children and adults how to self-modulate targeted neuronal activity.

Neurosuggestion, Specificity, and Comparative Effectiveness

Thibault and colleagues (2018) argue it is the efficacy of suggestion and the placebo effect that drives behavioral change from NFB— nothing specific to NFB itself —and if transparent, clinicians can ethically prescribe NFB as a placebo treatment “with an eye for amplifying the psychosocial mechanisms of suggestion rather than grasping at the elusive neural signatures many practitioners speciously assign as the cause of ADHD” (p. 709). To buttress their argument, the authors cite an unpublished, uncontrolled, open-label feasibility study they presented at a hypnosis conference ( Veissière, Olson, & Raz, 2017 ). In this study, the authors used a decommissioned magnetic resonance imaging (MRI) machine as a prop with nine ADHD children. They told the children it was an inactive “brain machine” and the authors would “use it as a suggestion” to “help their brain heal itself.” While in the MRI, the authors “gave the children positive verbal suggestions to promote relaxation, focus, and confidence.” They report that in follow-up interviews, parents of two children “reported near complete remission of symptoms, and six reported improvements in areas such as confidence, self-control, and social skills” (p. 709) The authors then claim that “In essence, this study provided neurofeedback-like treatment, but instead of focusing on a specific physiological mechanism, we emphasized suggestion-based healing” ( Thibault et al., 2018 , p. 708, 709). Four points in response below:

First, besides the inherent potential for multiple biases in an unpublished, uncontrolled, open-label hypnosis study, we have no evidence of functional deficits or improvements in ADHD symptoms using standardized measures for such deficits in the children themselves. Instead, just post-treatment “qualitative” interviews conducted by the authors with the children’s parents of domains unrelated to ADHD’s core symptoms (e.g., “confidence, self-control, and social skills”). Furthermore, we have no data indicating the diagnoses were correct. One would assume an accurate differential diagnosis was conducted at some point in these children’s evaluation procedures; however, this is not clear given the lack of information available. Finally, this is a hypnosis feasibility study using an MRI machine as a prop, not “neurofeedback-like treatment.” It is hard to see how this study provides anything more than anecdotal support for a new experimental treatment.

Second, Thibault and colleagues ignore the evidence suggestive of NFB’s specificity and effectiveness in treating the “neural signatures” of ADHD. For example, in their double-blinded within-subject reversal design studies, Lubar and Shouse ( Lubar & Shouse, 1976 ; Shouse & Lubar, 1979 ) demonstrated both (a) the functional relationship between the sensory motor rhythm (SMR) and manifestation of hyperkinetic behaviors and (b) that through real-time SMR feedback paired with operant conditioning, ADHD children could learn to self-regulate SMR with the resulting improvements or worsening in their hyperkinetic behaviors based on whether they were reinforced to increase or decrease SMR. In their clinical utility of EEG article, Loo and Barkley (2005) state, “To demonstrate that EEG changes are responsible for treatment effects, reporting of actual EEG changes and correlation with treatment outcome must be shown” (p. 72). Four studies have met this challenge by correlating the extent of NFB subjects’ learning to self-modulate the targeted EEG with treatment outcome and found that those subjects demonstrating the greatest learning experience the most improvement on ADHD outcome measures ( Drechsler et al., 2007 ; Gevensleben et al., 2009 ; Janssen et al., 2016 ; Lubar, Swartwood, Swartwood, & O’Donnell, 1995 ). These findings provide further evidence that enhancing EEG self-regulation is the mechanism of change from NFB treatment versus “neurosuggestion” or other placebo effects. Furthermore, two randomized controlled trials (RCT) have compared electromyographic (EMG) biofeedback with NFB to control for both nonspecific effects and the effects of self-regulation training ( Bakhshayesh, Hansch, Wyschkon, Rezai, & Esser, 2011 ; Strehl et al., 2017 ). Both of these studies found that subjects learned to self-modulate the targeted physiological mechanism (either EMG or EEG) with NFB demonstrating significant superiority over EMG in reducing ADHD symptoms and this despite the fact that EMG subjects demonstrated more pronounced learning to self-regulate. Finally, in one RCT SM combined with NFB was found superior in multiple outcome domains at the end of treatment and 6-month follow-up to SM combined with attention training that used the identical instructions and game sequences as NFB except that the feedback was not based on subjects’ EEG thereby suggesting a specific effect for NFB as an augmentation to SM ( Li, Yang, Zhuo, & Wang, 2013 ). Lia and colleagues also found that the combined SM/NFB subjects used significantly lower doses of SM during follow-up and reported fewer adverse side effects.

Third, the authors fail to acknowledge that in eight head-to-head comparisons with SM (see Table 2 ), NFB resulted in essentially equivalent improvement in treating ADHD’s core symptoms ( Duric, Assmus, Gundersen, & Elegen, 2012 ; Flisiak-Antonijczuk, Adamowska, Chładzińska-Kiejna, Kalinowski, & Adamowski, 2015 ; Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003 ; Gelade et al., 2017 ; Meisel, Servera, Garcia-Banda, Cardo, & Moreno, 2013 ; Moreno-García, Meneres-Sancho, Camacho-Vara de Rey, & Servera, 2019 ; Rossiter, 2004 ; Rossiter & La Vaque, 1995 ). These eight studies comprised 581 subjects and in only one head-to-head comparison ( n = 32) has SM been found superior to NFB ( Ogrim & Hestad, 2013 ). These comparative effectiveness studies provide strong evidence that NFB is an evidence-based treatment for ADHD.

Studies Comparing NFB With SM in Treating ADHD’s Core Symptoms.

Note. IQ = intelligence quotient; NFB = neurofeedback; EEG = electroencephalogram; SM = stimulant medication; TOVA = Test of Variables of Attention; SMR = sensory motor rhythm; CBRS = Conners’ Behavior Rating Scale; BASC = Behavior Assessment System for Children; BADDS = Brown Attention Deficit Disorder Scales; ES = effect size; CMADBD-P = Clinician’s Manual for the Assessment of Disruptive Behavior Disorders–Rating Scale for Parents; ADHD-RS-IV = ADHD Rating Scale-IV; ODDRS-IV = Oppositional defiant disorder rating scale based on DSM-IV ; BRIEF = Behavior Rating Inventory for Executive Function; CPT = Continuous Performance Test; DSM = Diagnostic and statistical manual of mental disorders ; PA = physical activity; SDQ = Strength and Difficulty Questionnaire; SWAN = Strengths and Weaknesses of ADHD symptoms and Normal Behavior Scale; MPH = methylphenidate; BT = behavior therapy; ADDES = Attention Deficit Disorder Evaluation Scale; IVA = Integrated Visual and Auditory; CPT = Continuous Performance Task; RCT = randomized controlled trials; QEEG = quantitative EEG; ERP = evoked response potential; MTA = multimodal treatment study of children with ADHD; PH = pharmacology.

Fourth, Thibault and colleagues fail to acknowledge the extensive evidence from NFB studies whose training methodology mirror the best practices of operant conditioning. These studies consistently find NFB subjects learn to self-modulate the targeted EEG, this learning is associated with improvements on a wide variety of ADHD outcome measures of interest, and both are sustained at follow-up (e.g., Leins et al., 2007 ; Strehl et al., 2017 ; Strehl et al., 2006 ) even up to 2 years later ( Gani, Birbaumer, & Strehl, 2008 ). These findings demonstrating the sustained ability to self-modulate the targeted EEG during follow-up with ongoing symptomatic improvement are unlike anything in the placebo literature. Findings further buttressed by Doren et al.’s (2018) recent meta-analysis documenting the sustained effects on ADHD outcomes for NFB subjects in RCTs.

The NFB Field Shares the Blame

Although NFB’s origins are based in the science of learning, the field has been negligent at ensuring that clinicians, researchers, and device manufactures adhere to this science. Examples include the following:

• Monitoring within-session learning curves is not standard practice for NFB clinicians, and in fact it is our observation that most clinicians do not assess for evidence of learning.
• The vast majority of NFB studies do not assess for evidence of learning even though this is the presumed mechanism of change. It is only recently that this is required for publication in the industry-sponsored journal NeuroRegulation when authors claim to provide operant conditioning of the EEG.
• Virtually all device manufacturers include an auto-thresholding option despite Sherlin and colleagues (2011) clarion call that such systems violate learning science and “could effectively train in the opposite direction and result in an increase in aberrant and negative (EEG) behaviors” (p. 299). Unfortunately, this option is used by many, if not most, clinicians, particularly those who oversee multiple “NFB” sessions at a time.

As with any form of operant conditioning, there are learners and nonlearners. The same is true with NFB and it is learners who experience the most improvement on ADHD outcome measures. Given this fact, it is an indictment of the field that there are no studies comparing strategies to identify those practices that best promote subjects’ learning to self-modulate the targeted EEG. Consequently, there is no empirical guidance to determine which operant training methodologies are most effective in maximizing learning— and this in a field with a 75+ year history of basic and applied research .

Finally, the NFB field and its detractors continue to conduct research that violates behavioral principles, and both sides cite such substandard research when it supports their viewpoint. This practice must stop. Evidence of learning trumps all, and if there is no evidence of learning, operant conditioning of the EEG did not occur.

There is plenty of blame to go around, yet if the field is to evolve and progress, we must demand training methodologies that follow learning principles and proof that learning occurred from all who claim to perform NFB. Hence, our critique of Thibault and colleagues, and the sham-controlled studies on which their argument is based, is also a plea to NFB researchers and clinicians to demonstrate that their methods are consistent with the best practices in behavioral learning. If both sides can agree to this rigor, it will promote clarity and consistency in the NFB literature that is not present today and provide guidance to necessary steps for advancing it forward.

Most importantly, we hope our Guest Editorial conveys the truth that learning methodology matters. With this caveat, we strongly recommend operant conditioning of the EEG for the treatment of ADHD, either as a standalone treatment or augmentation to other evidence-based treatments. As for prescribing “neurosuggestion therapy” for the treatment of ADHD, more research is required since its underlying premise is unproven and evidentiary base anecdotal.

Author Biographies

H. Edmund Pigott is a licensed psychologist trained as a scientist-practitioner. He enjoys deconstructing and documenting errors in published research.

Rex Cannon is a neuroscientist and an accomplished author, researcher, and Editor-in-Chief for Neuroregulation. He is a staunch supporter of non-pharmaceutical, evidence-based practices to aid individuals to improve performance. He currently directs science and operations for Knoxville Neurofeedback Group and the development of treatment models for Intrauterine Drug Exposure (IUDE) and addictions.

Mark Trullinger is a PhD Candidate in the International Psychology Department of The Chicago School of Professional Psychology, Washington, D.C. He studies the barriers to the acceptance of innovative medical devices and technologies in mental healthcare. He is a Registered Psychology Associate in Maryland and the Managing Director of NeuroThrive, LLC.

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: H.E.P. is board certified in neurofeedback and has consulted for Amen Clinics, Brain Resources, CNS Response, and the International Society of Neurofeedback and Research. He is also on the scientific advisory board of Narbis, a neurofeedback technology company. R.C. is board certified in neurofeedback and Editor-in-Chief of the journal NeuroRegulation . M.T. is board certified in neurofeedback.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The International Society of Neurofeedback and Research, Biofeedback Certification International Alliance, and Association of Applied Psychophysiology and Biofeedback contributed equally to the open access publication fees with our deep gratitude.

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Board members and staff.

Estate Sokhadze, PhD President

Estate (Tato) Sokhadze  received a Ph.D. in Human Physiology in 1988 in Novosibirsk, Russia. He completed a post-doctoral fellowship in Psychopharmacology at Wake Forest University in 2001-2003, and post-doctoral training in Cognitive Neuroscience at Rice University in 2004. His research interests include application of dense-array EEG/ERP brain mapping, neurofeedback, TMS, and other applied psychophysiological techniques in psychiatric research.

Valerie DeLar, MA CCC-SLP Secretary

Valerie DeLar, MA CCC-SLP, completed a BA in Psychology at Franklin and Marshall College in Lancaster, PA, and then went on to work as a computer programmer and systems analyst in the banking and insurance industries. Subsequently, she earned a master’s degree in Speech and Hearing Science from the University of Maryland, College Park, MD. She served as a Speech-Language Pathologist and research associate at Kernan Hospital (part of the University of Maryland Medical System in Baltimore, MD), where she participated in grants and publications related to language rehabilitation for stroke patients. She has been utilizing neurofeedback and neuromodulation techniques in private practice and in clinical settings since 2008. She worked with speech-language therapy clients utilizing neurofeedback at Upstate Pediatric Speech Therapy Services in Mauldin, SC for three years and now is owner/principal in her private practice Path to Vibrant Living located in Burke, VA where she focuses primarily on helping to improve academic performance.  

Mark Zinn, PhD Treasurer

Mark Zinn obtained his Ph.D. in Psychology at DePaul University, working with Dr. Leonard Jason. He has a diversified background in quantitative EEG, psychology, computer science, graphic arts, piano performance, and applied psychophysiology. Between 2012 and 2014, Mark was a research consultant for the ME/CFS Initiative team headed Dr. Jose Montoya at Stanford University School of Medicine. During that time, he was involved in two major studies utilizing techniques in EEG to yield objective measurements for evaluating cognitive impairment in patients with ME/CFS, linking the patients’ symptoms to brain regions. Currently, Mark is a director and investigator at the NeuroCognitive Research Institute in Chicago, IL, where he conducts studies which model brain connectivity in patients using 3-D neuroimaging EEG techniques.

Jon Frederick, PhD Sergeant-At-Arms

Jon Frederick, PhD earned his degree in psychology in Dr. Joel Lubar’s lab at the University of Tennessee. He has worked as a postdoctoral fellow at the UT Health Sciences Center-Houston and the University of Minnesota, researching topics such as MRI in Autism, evoked potentials in ADHD and the efficacy of neurofeedback for dementia. His research focuses on mechanisms of learning in physiological self-regulation and interactions between EEG state discrimination and standard neurofeedback training. Dr. Frederick has authored or co-authored 53 scientific publications and conference presentations. He is currently in clinical practice in Lafayette, CO.

Mary Blair Dellinger, LPC, BCN

Mary Blair Dellinger is a Licensed Professional Counselor in the state of South Carolina. She completed her Masters in Professional Counseling at Liberty University. A graduate of Psychology and Neuroscience from the University of South Carolina in Columbia, Dellinger is BCIA Board Certified in neurofeedback. She has eight years experience working at a private practice in Greenville, SC conducting neurofeedback with adults and children. She has specialized training in use of advanced procedures such as LORETA neurofeedback, neurostimulation techniques, and BCIA certification in Heart Rate Variability (HRV) biofeedback. She was an editor for the recent publication  Neurofeedback: The First Fifty Years .

Tom Collura

Thomas Collura is the Founder and President of BrainMaster Technologies, Inc., and Clinical Director of the Brain Enrichment Center, Bedford, Ohio, and is an Instructor with Stress Therapy Solutions, Beachwood, Ohio. He holds degrees in philosophy, biology, biomedical engineering, and mental health counseling, from Brown University, Case Western Reserve University, and Walden University. He has held staff and clinical positions with AT&T Bell Laboratories, the Cleveland Clinic Department of Neurology, and Siemens Medical Systems. He is a Diplomate of the Quantitative EEG Board, and Board Certified in Neurofeedback with the BCIA. He has received the Hans Berger Award of Merit from the AAPB, and is a fellow of the ISNR, and has received the ISNR Lifetime Achievement Award. He is a Past President of the ISNR and the AAPB. He is the author of “Technical Foundations of Neurofeedback” and co-editor of the “Handbook of QEEG and Neurotherapy,” both published by Taylor Francis. He holds numerous patents and has published in the areas of EEG, evoked potentials, and neurofeedback systems. His continuing interests are in EEG and QEEG in clinical and research applications, evoked potentials, and mental health and personal optimization applications. Certified as trainer by Biofeedback Certification Institute of America (BCIA)

Mark Trullinger

Mark Trullinger, MSc., BCN completed his masters in Psychology: Clinical Neuroscience from Wales, United Kingdom on International Scholarship and is currently a PhD Candidate in Washington D.C. His dissertation is on medical innovation in international healthcare. Mark is actively engaged in providing scientific and technical support to management of research projects and private enterprises within many settings. He is currently the Managing Director of NeuroThrive, LLC in Maryland and a consultant to various academic researchers, clinicians, and non-profits in the region. Mark’s expertise and experience are multidisciplinary and includes 5 peer-reviewed original research publications, numerous mental health grants, and designing and implementing clinician trainings in coordination with major universities. He has proven expertise in the healthcare industry: including over 8 years of clinical practice and 4 years BCIA certified, assistant behavioral director of one of the largest community mental health centers in the country, assistant program director and team lead for NeurExpand Brain Center, and chief operating officer of a neurology practice. He has served as a representative to the AMA CPT Editorial Panel meetings on behalf of multiple stakeholders and is a board member-at-large Foundation for Neurofeedback and Neuromodulation Research (FNNR). Mark has a history of passionate and high energy leadership across various organizations and settings. In his various roles, he always strives to advance value-driven business and practice. His leadership crosses a wide spectrum of professional settings and is directed toward achieving his goals of implementing healthcare practices that are culturally sensitive, purposeful, and innovative. Mark has lead multidisciplinary teams in clinical settings for achieving goals and elevating spirits and inspiration in team members while acting as a mentor and source of thought leadership. He has a record of being involved in co-curricular events such as, but not limited, to fundraising, participating and assisting in planning events, conferences, trainings, etc. Mark has always strived to continually learn and improve himself, while giving back through mentoring of junior members. Fun Fact: Mark enjoys learning to fly and international travel.

Thomas Feiner

Thomas Feiner QEEG-D, BCIA, Naturopath, is the founder and director of the Institute for EEG-Neurofeedback (IFEN).  He studied Occupational Therapist, and was one of the first Neurofeedback providers in Germany. Located in Munich, he runs a center for neurofeedback, where he utilizes modern brain-based assessments and offers treatments with innovative technologies, such as Photobiomodulation and Hyperbaric Oxygen Therapy for the treatment of brain disorders.  Feiner is an internationally sought-after instructor and speaker for Neurofeedback, Peak Performance and health and lifestyle related topics. The Institute for EEG-Neurofeedback offers certification programs for Neurofeedback worldwide and organizes workshops and international conferences. He is a founding member of the Global Neurofeedback Initiative (GNI). Furthermore, he founded the QEEG Research Unit to study the brainwave changes that occur during certain meditation states. Meanwhile, he has studied and analyzed over 5000 EEGs from meditators. Thomas Feiner published many articles and book chapters on neurofeedback, stress, and optimization and maintenance of human performance and brain health in general.  As head of the IFEN-Neuroscience laboratory, one of the largest private neuroscience research institutes in Germany, he has develops innovative tools for research and neurofeedback practitioners. Among them is the program “CAPITO” which he developed to measure and to monitor cognitive functions. Some features of this program are stimulus presentation and the evaluation of the results thanks to the sLORETA projection. This method leads to new insights into emotional decision-making processes through the so-called Gamma-Asymmetry. Another achievement of him and his team is a system that helps to administer and analyze cognitive evoked Brain Potentials. With their ERP-Analyzer it is also possible to measure Event-Related Potentials in a short amount of time. He also participates with international researchers in the study of so-called Heart beat evoked potentials (HEPs), a new field of research that provides valuable insights into heart-brain interaction with potential of showing mental disturbances from a very different perspective. In addition to running his center and institute, Thomas Feiner is also an inventor who, for example, invented the Free-Cap. This salt water cap he developed is already being used with great success in hundreds of practices around the world.  He also developed a new method of Z-Score training, in which individual components can be trained in a protocol that precisely targets deviant Z-scores.  Other neurofeedback protocols, such as the SCP training protocol for the Brain-Avatar platform, are also used by many practitioners. Since his interest has always been in optimizing the training process and breaking new ground, he has also become the father of a number of new neurofeedback games for virtual reality.  Thomas Feiner furthermore maintains a highly regarded neurofeedback blog, where he documents the latest developments in neurofeedback and brain training. He also sees it as his mission to raise awareness of brain health and optimal performance among the public, especially for children. He has also created numerous materials to help children with learning disabilities overcome their problems with writing and math.

Rebecca Bassham

Rebecca Bassham is a health educator who after working as a medical imaging specialist studying the brain from the inside out, has committed her life to helping people to become healthier through facilitation of mind-body awareness. She is board certified in Neurofeedback (BCN), Quantitative EEG technologist (QEEG-T), and HRV, a licensed Radiologic Technologist (ARRT), has a BS degree in Exercise Science with a minor in Health promotions from CSUF, completed a fellowship in Special Imaging (CT and MRI) at Loma Linda University and studied Applied Psychophysiology at Saybrook University. Rebecca has worked in the field of health and wellness for over 30 years with experience to include employee health, facilitating lifestyle change programs, and promoting community health education and outreach through radio, television, and email news campaigns. After discovering the power and healing of neurofeedback within her own family, she embarked on her studies of applied neuroscience in 2010. Rebecca has worked in private practice, peak performance, and as a Psychophysiology Specialist at Pure Sports Recovery where her focus was with multi-traumatized recently retired NFL players. These clients present simultaneously with traumatic brain injury, PTSD, mood disorders, addictions, and/or chronic pain. Her multi-modality approach includes a wide variety of tools beginning with qEEG Brain Mapping, a psychophysiological stress profile, live 3D sLORETA Imaging, Neurofeedback, peripheral Biofeedback, and several neuromodulation technologies to foster optimal brain states. She is a BCIA-approved mentor for aspiring neurofeedback practitioners. Rebecca facilitates groups with life and wellness coaching to include brain fitness strategies, nutrition, exercise, goal setting, mindfulness, stress management, and time management for a holistic, alternative approach to improve cognitive function. She is also experienced with and certified in equine-assisted learning. Rebecca has mentored since 2015 with EEG authority Jay Gunkelman and has a sophisticated approach to qEEG data analysis, reporting, and treatment planning. At the heart of her rapid stabilization approach for the multiply traumatized is her bottom-up approach that emphasizes regaining brain cellular health and capacity via tight integration of brain stimulation and feedback-driven approaches.

Advisory Board

Former FNNR (ISNR Research Foundation) Board of Directors members

Marcie Zinn

Efthymios Angelakis

Martijn Arns

Ivette Bledsoe

Genie Bodenhamer-Davis

Helen Budzynski

Richard Davis

Jay Gunkelman

Ali Hashemian

Cynthia Kerson

Barry Sterman

Robert Thatcher

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Perspectives on Type III Statistical Errors: Exaggerating the Effects of Placebo in Neurofeedback

NeuroRegulation

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Cynthia Kerson

Objective: Additional treatments with persisting benefit are needed for ADHD. Because ADHD often shows excessive theta electroencephalogram (EEG) power, low beta, and excessive theta-beta ratio (TBR), a promising treatment is neurofeedback (NF) downtraining TBR. Although several nonblind randomized clinical trials (RCTs) show a mediumlarge benefit for NF, a well-blinded, sham-controlled RCT is needed to differentiate specific from nonspecific effects. Method: Experts in NF, ADHD, clinical trials, and statistics collaborated to design a double-blind multisite RCT. Results/ Conclusion: At four sites, 180 children aged 7 to 10 years with rigorously diagnosed ADHD and TBR ≥ 5 will be randomized to active TBR-NF versus sham NF of equal duration, intensity, and appearance. Sham, utilizing prerecorded EEGs with participant artifacts superimposed, will keep participants and staff blind. Treatment fidelity will be trained/ monitored by acknowledged NF leaders. Multidomain assessments before,...

Objective: Additional treatments with persisting benefit are needed for ADHD. Because ADHD often shows excessive theta electroencephalogram (EEG) power, low beta, and excessive theta-beta ratio (TBR), a promising treatment is neurofeedback (NF) downtraining TBR. Although several nonblind randomized clinical trials (RCTs) show a medium-large benefit for NF, a well-blinded, sham-controlled RCT is needed to differentiate specific from nonspecific effects. Method: Experts in NF, ADHD, clinical trials, and statistics collaborated to design a double-blind multisite RCT. Results/Conclusion: At four sites, 180 children aged 7 to 10 years with rigorously diagnosed ADHD and TBR ≥ 5 will be randomized to active TBR-NF versus sham NF of equal duration, intensity, and appearance. Sham, utilizing prerecorded EEGs with participant artifacts superimposed, will keep participants and staff blind. Treatment fidelity will be trained/monitored by acknowledged NF leaders. Multidomain assessments before, ...

Samuel Veissiere

Recent critical publications on neurofeedback raise a conundrum: Does EEG-neurofeedback (EEG-nf) work, and if so, how? In a series of papers, we reported that EEG-nf seems to help the symptoms of ADHD, but for different reasons than most advocates would expect—i.e., due to a placebo response (Thibault, Lifshitz, Birbaumer, & Raz, 2015; Thibault & Raz, 2017). In this Guest Editorial, we address ethical considerations concerning prescribing placebos and highlight how we can leverage prevailing brain-based beliefs about behavioral disorders to better treat patients. We conclude that clinicians can apply EEG-nf to ADHD as a form of clinical suggestion for patients with the time, finances, and inclination to pursue such a treatment.

Sarah N Wyckoff

Clinical EEG and Neuroscience

Anton Coenen , Ute Strehl

European Child & Adolescent Psychiatry

Günter Esser

Journal of the American Academy of Child and Adolescent Psychiatry

Paramala Santosh

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We, at NeuroThrive, provide comprehensive and individualized services for people from all walks of life. Our services are designed to improve brain health and function. During the course of the day our brain helps us perform every single action and function; yet it does not occur to most of us how important it is to take care of our brain and it's well-being. At NeuroThrive, our team provides science based treatments personalized to each individual to optimize brain functioning. We use cutting edge technology for Neurofeedback, customized cognitive-skills training, lifestyle behavioral change, and other neurotherapeutics in order to change and optimize specific brain areas for best overall brain functioning through neuroplasticity. We also serve those who have acquired or experience biological based brain disorders to reach their life goals  and maximize their quality of life and cognitive functions.  We are a full psychological practice and provide services for clinical and non clinical goals. It is essential to keep in mind that therapy is not a magic pill or a quick fix: therapy is a healing process that necessitates participation and investment from the patient and caretaker alike. But in the end, making small changes to self-defeating behavior and coping with feelings of sadness, fear, and pain can bring life-altering results.

We look forward to riding this wave with you! 

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How we, can help you., neurofeedback, stress reduce & meditation, brain mapping, counseling and brain coaching, cognitive skills, academic excellence, neuro-cognitive evaluation, executive coaching, meet the team.

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Mark Trullinger 

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The Interational Society of Neurofeedback & Research

Mark Trullinger, BCN

Mark has his BCN certification from BCIA and his QEEG-D certification from the QEEG Certification Board, with 8+ years of clinical practice.  He has attended AMA CPT Editorial Panel meetings as a volunteer to represent the interests of ISNR for the past few years.  Starting initiatives to modernize Neurofeedback coding and petition for inclusion as an AMA recognized organization in their CPT/RUC efforts going forward. He is also the managing director of NeuroThrive in Maryland, a private psychology practice with a strong track record of insurance reimbursement from many public and private payers and has numerous Neurofeedback publications.  He is also a student of International Psychology, completing his dissertation this year.  It is titled "Paradigm Shifting and Healthcare Professionals Impact on the Adoption of Innovative Medical Devices for Treating Mental Disorders:  Neurofeedback for ADHD in the U.S. and The Netherlands."

Topic: CPT Billing

Presentation Title: Update on the Work Towards CPT Codes and Third-Party Reimbursement

Friday, October 19 at 11:30 AM

ISNR, in partnership with AAPB and BCIA, have taken significant strides in the past few years toward pushing for insurance reimbursement. This presentation will provide a macro-level progress report on the CPT coding workgroup trying to modernize our codes, petitions for inclusion as a recognized organization for AMA activities for CPT coding and Relative-Value Unit (RVU) determinations, and national level efforts for insurance reimbursement.

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Meet the ISNR Committees

The ISNR does a lot, but it takes a lot of people to make it happen! Chairpersons of each committee are listed below. If you would like to get in touch with them, please click on the chairperson’s name to communicate by e-mail or reach out to Susan Alvarez, Executive Director, at  [email protected] .

Standing Committees

Executive Committee

Chaired by the current President of the Board, Tanya Morosoli, MSc

Personnel Committee

Ethics Committee

Chaired by  Robert Longo, LPC

ISNR values the credibility of our field and for this reason, the Ethics Committee’s role is to help improve the professionalism and ethical conduct of professionals and organizations utilizing neuroregulation techniques, including internationally.

It is important to mention that ISNR is not a legal entity nor a professional board that has authority to penalize or admonish clinicians or organizations.  This committee can only make recommendations in order to help those providers and organizations more clearly align their work with the ISNR Code of Ethics .

Any individual may file an ethics inquiry about an ISNR member to the ISNR Ethics Committee.

If you are concerned about the practice of a provider, please first address it with the provider.  If there is no resolution or the event is suspected to be illegal, please report it to the licensing board and/or other related agency.

The Ethics Committee is committed to maintaining a welcoming and safe environment for all our members.  Please click here to file a complaint.

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Chaired by Noel Larson Ford , the Conference Committee is responsible for planning and organizing the annual conference.

Nominations Committee

Chaired by Robert Longo, LPC , the Nominations Committee is responsible for seeking out and announcing nominations.

Structure Committee

Chaired by Robert Longo, LPC

Finance Committee

Chaired by the current Treasurer of the Board, Dr. Nicholas Colosi , the Finance Committee is responsible for keeping track of the financial well-being of ISNR.

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Ad-hoc committees.

Membership Committee

Chaired by Tanya Morosoli , MSc, BCN , the Membership Committee is responsible for keeping track of current members and reaching out to new members.

Student Advocacy Committee

J. Claire Gregory, PhD chairs the Student Advocacy Committee (SACom) of ISNR. The SACom acts as a liaison between students and the Society as a whole by sponsoring special meetings and activities and maintaining a student forum. The SACom works to increase both domestic and international student affiliate membership and to foster a lifetime affiliation with ISNR. The mission of the SACom is to attract and retain student members and to serve as a major resource promoting access to the benefits of the student membership in ISNR. Finally, the SACom is an advocate for the issues and concerns of the student affiliate members of ISNR.

Neuroregulation Guidelines Committee​

The Neuroregulation Guidelines Committee is Chaired by Dr. Michael Trayford .

Website Committee​

Public Education Committee

Chaired by Cynthia Wilson , the Education Committee is responsible for planning and implementing a continuing education program called ISNR University as well as running ISNR webinars.

Vetting Committee

Chaired by Alissa Paramo, MS, BCN , the Vetting Committee is committed to high standards that assure each vendor and each item being displayed at ISNR conference will meet ISNR criteria for quality, honesty, and reliability. For the list of the criteria, please click here .

Vendors – Please click here to fill out the vetting form.

Members – We welcome your feedback about any products being displayed at the ISNR conference. Please click here to submit your feedback.

Neuroregulation Journal

Rex Cannon, PhD is the editor of the NeuroRegulation Journal. If you are interested in submitting research articles to this publication, please contact Rex Cannon, PhD.

CPT Committee​

The CPT Committee is chaired by Mark Trullinger, PhD .

We’ve Moved…

To accommodate the organization’s growing needs, we have decided to move our office to a new location.

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