Theta-beta training (Lubar)

1. Introduction

Version followed: the Lubar-derived theta/beta protocol ("Protocol 3") as set out in the practice review by Monastra, Lynn, Linden, Lubar, Gruzelier and La Vaque (2005, Journal of Neurotherapy), with the Neurofeedback Collaborative Group double-blind trial (2021; 25-month follow-up 2023) as the most rigorous recent test of the same method. Device settings, scalp sites, frequency limits and reward thresholds are deliberately left out; only the trained bands are named.

Theta/beta training is EEG biofeedback (neurofeedback) for attention-deficit/hyperactivity disorder (ADHD). It grew from Joel F. Lubar's work, which began with controlled studies in the mid-1970s and was taught through the Southeastern Neurofeedback Institute in Knoxville, Tennessee, where he was co-director from 1979 [source: FNNR obituary, 2024]. Lubar's 1991 review describes about 15 years of work on EEG-based assessment of ADHD and treatment by EEG biofeedback [source: Lubar 1991, PubMed abstract]. The core idea of change is operant learning: the child gets moment-to-moment feedback (a game, animation or tone) and is rewarded when the EEG shows more activity in a beta band (the low-beta or "beta-1" range) and less activity in the slower theta band. The theory is that ADHD involves cortical under-arousal or "slowing", and that repeated reinforced practice brings the EEG closer to age norms and attention improves with it [source: Monastra et al. 2005]. The theory and the specific effect are now contested. The best-blinded trial found no specific effect over a sham (see Status below).

Cross-references: 045 Alpha training (Kamiya) covers the operant-EEG origins. 047 Sensorimotor-rhythm training (Sterman) is the SMR protocol, the other main band-training protocol for ADHD (Monastra et al.'s Protocols 1 and 2). 049 Slow cortical potential training (Birbaumer) covers the SCP protocol. 046 Alpha-theta training and the Peniston protocol covers a different, deep-state protocol that is not used for ADHD.

Status at a glance (as of October 2026, per the sources named)

NEBA is a diagnostic aid, not a treatment. In 2013 the FDA allowed the Neuropsychiatric EEG-Based Assessment Aid (NEBA) onto the market through the de novo route. It measures the EEG theta/beta ratio in patients aged 6 to 17. Its labelling says it supports a clinician's ADHD diagnosis alongside a full clinical evaluation. It is "not a standalone" tool, and its result serves only as confirmatory support or as a reason for further testing [source: Blue Shield of California medical policy, 2024 version, summarising FDA labelling]. That clearance says nothing about neurofeedback treatment. The same policy treats theta/beta-ratio assessment as investigational. It reports that a 2016 American Academy of Neurology advisory found it unknown whether adding the theta/beta ratio improves diagnostic certainty, and that the theta/beta ratio is not consistently altered in ADHD [source: Blue Shield policy]. Whether NEBA is still sold is [uncertain].
Practice-review rating (2005). Using the AAPB/ISNR efficacy criteria, Monastra et al. rated EEG biofeedback for ADHD "probably efficacious" (level 3 of 5). They noted small samples and no control for patient and therapist factors [source: Monastra et al. 2005]. Sherlin, Arns, Lubar and Sokhadze (2010) wrote an ISNR position paper arguing for recognition as an evidence-based treatment [source: Journal of Neurotherapy abstract page].
Blinded trial. The Neurofeedback Collaborative Group randomised 144 children aged 7 to 10 to theta/beta neurofeedback or a sham of identical appearance. Both groups improved substantially. Neurofeedback was not better than sham at treatment end or at 13 months, and the authors found no support for a specific effect [source: NCG 2021, JAACAP abstract]. At 25 months, after 38 sessions, there was still no group difference on the primary outcome. The authors attributed most of the improvement to nonspecific, "psychotherapeutic or behavioral" effects. The neurofeedback group was marginally less likely to need medication [source: NCG 2023, JAACAP abstract].
Meta-analyses. A 2024 JAMA Psychiatry meta-analysis of 38 RCTs with probably blinded ratings (Westwood, Cortese, Sonuga-Barke, Brandeis and colleagues) found no significant reduction in inattention or hyperactivity/impulsivity. It found "insufficient evidence to recommend neurofeedback as a front-line treatment" [source: University of Southampton news, 11 Dec 2024]. The earlier Cortese et al. (2016, JAACAP) meta-analysis of neurofeedback RCTs is cited in the literature for the point that unblinded parent ratings favour non-drug treatments [source: National Elf Service blog 2019; meta-analysis itself not verified, uncertain].
NICE (England). NG87 (published March 2018, updated September 2019) recommends ADHD-focused parent training and support, and CBT for some young people. In the sections checked, neurofeedback was neither recommended nor mentioned [source: NICE NG87 PDF; the final part was not verified, so whether NG87 or its evidence reviews say more is uncertain]. Do not describe NICE as having issued an explicit "do not offer" unless you have checked the full guideline [uncertain].
US paediatrics. An AHRQ-type systematic review in Pediatrics (Goode et al. 2018) judged the evidence for neurofeedback insufficient [source: National Elf Service review of Goode et al.]. The AAP's 2019 ADHD guideline does not mention quantitative EEG assessment [source: Blue Shield policy]. Whether the AAP guideline addresses neurofeedback treatment is [uncertain].
Who delivers it. Licensed health professionals with neurofeedback training. In the US the main credential is BCIA certification in neurofeedback (EEG biofeedback). Lubar served on the BCIA board, and the Academy of Certified Neurotherapists that he led became part of BCIA's EEG specialty certification [source: FNNR obituary]. See Section 2 for the route.

2. Framework

The course is outpatient and individual: a child, a trainer at the EEG station and a parent nearby. It runs in five phases. Session counts are given as sources publish them.

Phase 1: Intake and diagnostic confirmation (1–3 appointments). Goals: confirm an established ADHD diagnosis made by a qualified clinician from history, rating scales and observation, never from an EEG alone; screen out conditions that affect attention. The 2005 review lists exclusions such as age under 6, neurological disease, substance misuse, and medical or psychiatric conditions that impair attention [source: Monastra et al. 2005]. NICE says diagnosis should not rest on rating scales or observation alone [source: NICE NG87 1.3.2]. Move on when the diagnosis is documented, medical causes have been considered, consent and assent have been obtained, and the family has had the evidence explained. [synthesis for the consent step]

Phase 2: Pre-treatment assessment (1–2 appointments). Goals: baseline measures and protocol selection. The 2005 review lists intelligence testing, behaviour rating scales, a continuous performance test (CPT) and a quantitative EEG (QEEG). It recommends QEEG before any protocol, to locate the type of EEG abnormality and guide protocol choice. In one cited trial, QEEG evidence of cortical slowing was an entry requirement [source: Monastra et al. 2005]. Theta/beta training is the protocol for the slowing pattern. Children without that pattern may be better suited to other protocols (047, 049) or to no neurofeedback. Move on when baseline parent and teacher ratings, CPT and EEG findings are recorded and a written plan names the protocol. [synthesis]

Phase 3: Training (most of the course). Goal: learning, repeated reinforced change in the trained bands, practised across many sessions. Per Monastra et al. (2005), each session opens with a short baseline recording without feedback, followed by feedback segments that start short and lengthen, for about 30–45 minutes of feedback in total. Quantitative progress is reviewed after every session. Schedules may be massed (several sessions a week) or spaced (about weekly). Courses in the studies ranged from 20 to 50 sessions, averaging 43 in one study [source: Monastra et al. 2005]. The NCG trial gave 38 sessions [source: NCG 2023]. Review progress at fixed points, for example every 10 sessions, against baseline ratings and in-session data. [synthesis for review points]

Phase 4: Transfer to school and home (overlaps Phase 3). Goals: carry attentional gains into class and homework through parent counselling in reinforcement strategies, teacher coordination and accommodations (IEP or Section 504 plans in the US). Social-skills training with contingency management is also suggested [source: Monastra et al. 2005]. In England, with consent, contact the school about the diagnosis, the treatment plan and reasonable adjustments [source: NICE NG87 1.4.12]. Specific in-session transfer exercises are given in Section 4 and marked [synthesis].

Phase 5: Ending and follow-up. In Monastra et al. (2002), as summarised in the 2005 review, training continued until the QEEG was within the age-norm range and stayed there across three consecutive full-length sessions [source: Monastra et al. 2005; the numeric criterion is omitted here]. The review notes relapse or deterioration when training stopped early [source: Monastra et al. 2005]. In practice, end when (a) agreed EEG and behavioural targets are met and stable; (b) a planned course has finished without meaningful change on blinded or teacher measures, in which case stop and refer to evidence-based care; or (c) the family chooses to stop. Repeat the baseline measures at the end and at follow-up (for example 3 and 12 months). [synthesis]

Certification route (US, BCIA). BCIA neurofeedback certification requires at least a bachelor's degree from a regionally accredited institution in a BCIA-approved health care field such as psychology, medicine or nursing. Licensed registered nurses are accepted with an associate degree [source: StressTherapy Solutions summary of BCIA requirements, 2025] [uncertain: secondary]. The didactic hours, the neuroanatomy/physiology requirement, mentored sessions and case conferences, the written exam and recertification should be checked on BCIA's own pages; they are not verified here [uncertain: not verified]. Certification does not replace a licence. Practise within your own licence and scope, especially when diagnosing ADHD or interpreting a QEEG. [synthesis]

3. Guiding principles

Diagnosis comes before training, and the EEG never makes the diagnosis. Practical meaning: start only with a documented clinical ADHD diagnosis. Treat any theta/beta-ratio figure, including NEBA's, as supporting information only. [source: Blue Shield policy on NEBA labelling; NICE NG87 1.3.2]
Assess before you train. Practical meaning: get rating scales, CPT and an EEG assessment first, and choose theta/beta only when the EEG pattern fits. [source: Monastra et al. 2005]
Neurofeedback is operant learning. Practical meaning: rewards must be immediate, contingent and frequent enough to keep the child engaged. The difficulty is shaped as the child improves, as the clinician sets it. [source: Monastra et al. 2005 on reward rates and review after each session; settings omitted]
Data-driven sessions. Practical meaning: look at the session's quantitative record every time and adjust the plan from data, not impressions. [source: Monastra et al. 2005]
Neurofeedback is an add-on within multimodal care. Practical meaning: pair it with parent counselling, school coordination and, where indicated, social-skills work. Do not offer it as a replacement for guideline-recommended treatment. [source: Monastra et al. 2005; NICE NG87 1.5; Westwood et al. via Southampton news]
Honest evidence disclosure. Practical meaning: tell families that the best-blinded trial found no specific effect over sham, as well as what earlier reviews claimed. [source: NCG 2021/2023; Monastra et al. 2005] [synthesis for the duty]
Therapist factors matter. Practical meaning: warmth, confidence, real understanding of the protocol and faithful delivery affect outcomes. Treat the relationship as an active ingredient. [source: Monastra et al. 2005; NCG 2023's attribution of change to nonspecific effects]
Medication decisions belong to the prescriber. Practical meaning: never suggest reducing or stopping stimulants. Report changes such as irritability to the prescriber. [source: Monastra et al. 2005 reports irritability or hyperactivity in some children combining training with stimulants] [synthesis for routing]
The child is the client. Practical meaning: get the child's own assent, ask for the child's views, and stop if the child repeatedly withdraws assent. [source: NICE NG87 1.5.4 on encouraging children's views] [synthesis]
Fidelity and finishing. Practical meaning: deliver the planned protocol consistently and plan the ending, since early stopping was linked with relapse. [source: Monastra et al. 2005]
Measure what matters outside the room. Practical meaning: use teacher ratings and other ratings that are as blind as possible, because unblinded parent ratings can favour non-drug treatments. [source: National Elf Service on Cortese 2015/2016; Westwood et al. 2024]

4. Intervention inventory

The published sources describe assessment, the training session, parent counselling, school coordination and ending. They do not publish detailed therapist scripts. All example language below is illustrative. Steps that go beyond the sources are marked [synthesis].

4.1 Intake, referral screen and diagnostic confirmation

Purpose / when: First contact. Establish that ADHD is diagnosed and that neurofeedback is a reasonable add-on. [source: Monastra et al. 2005; NICE NG87 1.3]
Steps: (1) Get the diagnostic report. If none exists, refer for a full ADHD assessment (paediatrician, child psychiatrist or specialist service) rather than diagnosing from an EEG. (2) Take a developmental, medical, neurological, sleep, family and school history. (3) Screen against the exclusions the 2005 review lists: under age 6, neurological disease (including seizures and head injury), substance misuse, and medical or psychiatric conditions that impair attention. Refer for medical review where these are present or unclear. (4) Record current medicines and the prescriber's contact details. (5) Ask what treatments the family has already tried, especially parent training and medication, and their expectations and costs. [source: Monastra et al. 2005 for exclusions] [synthesis for steps 1, 2, 4, 5]
Example language (illustrative): "Before we talk about brain-wave training, I need to be sure we know what is going on. That means the full ADHD assessment and checking nothing medical is affecting attention."
Watch for: pressure to "get an EEG diagnosis"; untreated sleep problems, anxiety, learning disorder or seizures; a family that has been told neurofeedback replaces all other care.

4.2 Pre-treatment assessment battery

Purpose / when: Before training. Sets the baseline and selects the protocol. [source: Monastra et al. 2005]
Steps: (1) Collect parent and teacher behaviour ratings using validated licensed scales; do not reproduce their items. (2) Give a continuous performance test. (3) Arrange intellectual or learning assessment where indicated. (4) Arrange an EEG/QEEG assessment, recorded and interpreted by someone trained and licensed to do so. Neurofeedback certification alone does not qualify you to read a clinical EEG. Any suspected epileptiform or other abnormality goes to a neurologist. (5) Decide whether the theta/beta (slowing) pattern is present. If it is not, consider other protocols (047, 049) or no neurofeedback. (6) Write a plan naming the protocol, the measures and the review points. [source: Monastra et al. 2005 for steps 1, 2, 4, 5] [synthesis for steps 3, 6 and the referral rule]
Example language (illustrative): "This recording is not a test of whether you have ADHD. It shows the pattern we would be training, and gives us a starting point to compare against later."
Watch for: confusing NEBA or any theta/beta-ratio figure with a diagnosis or a treatment indication. NEBA's labelling restricts it to ages 6 to 17 and to use with a full clinical evaluation [source: Blue Shield policy]. Ratings from a teacher who knows about the training are not blind; note this in records.

4.3 Informed consent, child assent and evidence disclosure

Purpose / when: Before any training. Repeat at each review. [synthesis; NICE NG87 1.5.3–1.5.5 on revisiting treatment discussions and children's views]
Steps: (1) Give the parent or person with parental responsibility written information covering what the training involves, the time and cost, the published course lengths (Section 2), and the evidence: the 2005 "probably efficacious" rating, and the double-blind trial in which neurofeedback was not better than sham although both groups improved. Name the guideline-recommended alternatives (parent training; CBT for some young people; medication via a prescriber). (2) Explain the side effects reported in the sources: Monastra et al. describe irritability or hyperactivity in some children who combined training with stimulants. Ask the family to report fatigue, headache or sleep change. [source: Monastra et al. 2005 for irritability; synthesis for the others] (3) Get the child's assent in age-appropriate words and record it. Agree a signal the child can use to pause. (4) Explain confidentiality and its limits, including safeguarding duties. (5) Get separate written consent for each contact with school or the prescriber. [source: NICE NG87 1.4.12–1.4.13] (6) For young people with capacity or competence (for example Gillick competence in England), seek their own consent according to local law. [synthesis; jurisdictional rules not verified, uncertain]
Example language (illustrative): to the parent: "Some families notice real improvement. In the most careful study, though, children who got real feedback and children who got a convincing imitation improved about equally. So I can't promise that the brain-wave part is what helps." To the child: "You'll play a game that moves when your brain is in focus mode. You can say 'pause' any time."
Watch for: consent obtained under marketing pressure; a parent who hopes to avoid medication without discussing it with the prescriber; a child who agrees only to please.

4.4 Psychoeducation and orientation

Purpose / when: Session 1 and repeated briefly. Builds a shared model and an ethic of practice. [synthesis grounded in the operant rationale of Monastra et al. 2005]
Steps: (1) Explain feedback learning with an analogy, such as learning to balance on a bike from what the bike tells you. (2) Show the display and sensors, and let the child touch them. (3) Explain that the brain cannot be "forced" and that relaxed effort works best. (4) Give parents a one-page summary of the plan and their role.
Example language (illustrative): "The screen is like a mirror for your attention. When your brain does the focused thing, the game rewards you, and over many tries your brain learns the trick."
Watch for: the child believing they are being "read" or "zapped". Nothing is put into the brain; equipment only records.

4.5 Sensor application, equipment and electrical safety

Purpose / when: Every session, at the start. [synthesis; the cited sources give no hygiene or safety procedures]
Steps: (1) Use equipment marketed for EEG biofeedback and maintained to the manufacturer's safety instructions (for example battery-powered or isolated amplifiers), and keep mains equipment away from the child. (2) Clean and inspect sensors between clients according to infection-control policy. (3) Prepare skin gently. Check for broken skin, lice or allergies, and stop if the skin is irritated. (4) Check signal quality and artifacts (blinks, jaw clench, movement) before training, and teach the child to keep still and relax the jaw. Artifacts can create false rewards. (5) Never connect any stimulating device. Theta/beta training is recording-only feedback. Scalp sites and settings follow the protocol the treating clinician chooses and are not given here.
Example language (illustrative): "This paste is a little cold. It just helps the sensor hear your brain clearly."
Watch for: sensory sensitivity (common in neurodivergent children), so allow a gradual introduction; artifact-driven "success".

4.6 Session baseline (no-feedback recording)

Purpose / when: Opening minutes of each session. Gives a same-day comparison. [source: Monastra et al. 2005 describe a brief warm-up without feedback]
Steps: (1) The child sits quietly with eyes open, without feedback. (2) Note the state of the day: sleep, medication taken, hunger, mood. (3) Compare with previous baselines.
Example language (illustrative): "For a couple of minutes, just look at the dot and breathe normally. No game yet."
Watch for: on poor-sleep or unmedicated days, keep expectations flexible and record the context. [synthesis]

4.7 Feedback training segments (theta down, beta up)

Purpose / when: The core of every training session. [source: Monastra et al. 2005, Protocol 3: reward the beta-1 band and inhibit theta, based on Lubar's work]
Steps: (1) Start the game or animation. The child earns points, movement or tones when beta activity is high enough and theta low enough, as the clinician has set the criteria. (2) Run several segments with short breaks, lengthening segments as tolerance grows. (3) Shape difficulty so rewards come often enough to stay motivating, and tighten as the child succeeds. The clinician makes this judgement from the data; no numbers are given here. (4) Use varied displays to keep interest. (5) Keep talk minimal during segments so the feedback, not the trainer, does the teaching. [source: Monastra et al. 2005 for segment structure and reward pacing] [synthesis for step 5] For adolescents and adults, Lubar also describes suppressing an expanded slower band; Monastra et al. note this has not been tested in controlled group studies [source: Monastra et al. 2005] [uncertain].
Example language (illustrative): "Let's see if you can keep the rocket flying a bit longer this round." Afterwards: "What were you doing in your head when it was going well?"
Watch for: frustration from too few rewards; boredom from too many; muscle tension or eye movement standing in for real change.

4.8 Between-segment coaching and strategy talk

Purpose / when: Breaks between segments. Builds the child's awareness of the trained state and helps transfer. [synthesis; the 2005 review does not prescribe coaching content]
Steps: (1) Ask open questions about what helped (posture, breathing, "soft focus", counting). (2) Give a name to the strategy the child discovered, such as "steady mode". (3) Praise effort and specific discoveries, not the score. (4) Avoid supplying strategies that make the child tense, such as trying hard or squinting.
Example language (illustrative): "You said you imagined being a calm owl, and the game liked that. Let's call it owl mode and try it again."
Watch for: strategies that are really artifacts, such as holding the breath or staring; self-criticism after poor segments.

4.9 Session data review and progress charting

Purpose / when: End of every session. [source: Monastra et al. 2005 advise reviewing quantitative progress after each session]
Steps: (1) Review the session's band measures and the trend across segments and sessions. (2) Chart them with the child, for example as a sticker chart or progress graph. (3) Record context notes (sleep, medication, events). (4) Adjust next session's difficulty according to the protocol. (5) Send a brief note to the parent. [synthesis for steps 2, 3, 5]
Example language (illustrative): "Look, your focus line has been a bit higher in the last three sessions. That's your brain learning."
Watch for: reading meaning into single-session noise; in-session EEG change without behavioural change, which you must report honestly.

4.10 Parent counselling and home reinforcement

Purpose / when: Alongside training, for example a short parent segment every session and a longer review every few weeks. In the 2005 review, teaching parents reinforcement strategies was associated with better outcomes. [source: Monastra et al. 2005] NICE recommends ADHD-focused parent support for all families, and parent training where there are oppositional or conduct symptoms [source: NICE NG87 1.5.10–1.5.12].
Steps: (1) Teach specific praise and reward for attentive behaviour. (2) Set up a simple home token or points system linked to routines and homework. (3) Plan consistent consequences and calm routines. (4) Refer to a structured parent-training programme where indicated, rather than improvising one. (5) Review home charts each visit. [source: Monastra et al. 2005 for reinforcement] [synthesis for the detail]
Example language (illustrative): "In training, the game rewards focus within a second. At home, let's do something similar: notice and name focused effort quickly."
Watch for: parental exhaustion, conflict or mental-health needs (offer support or referral); reward systems that become punitive.

4.11 School coordination

Purpose / when: From the start, with consent, and at transitions. [source: Monastra et al. 2005 advise coordinating with teachers and describe IEP and 504 plans; NICE NG87 1.4.12 on contacting school when ADHD is diagnosed, symptoms change and at transitions]
Steps: (1) With written consent, contact the teacher or SENCO about the diagnosis, how it affects learning, the treatment plan and reasonable adjustments. (2) Ask the teacher to complete baseline and follow-up ratings. (3) Support the family in asking for formal accommodations (an IEP or 504 plan in the US; SEN support or an EHCP in England [synthesis]). (4) Agree one or two classroom cues that echo the child's training strategy. (5) Share progress at agreed intervals.
Example language (illustrative), to a teacher: "Sam is doing attention training with us. It would help if you could cue 'steady mode' quietly when he drifts, and tell us what you notice."
Watch for: over-sharing clinical detail; schools treating training as a substitute for accommodations.

4.12 Transfer and generalisation exercises

Purpose / when: Mid-course onward. Helps the trained state appear outside the clinic. [synthesis; the transfer procedures published by Lubar and later authors were not verified, uncertain. The 2005 review addresses maintenance of gains after training rather than in-session transfer methods]
Steps: (1) Ask the child to recall and name the strategy at the start of each segment. (2) Run short segments while the child does a school-like task (reading aloud, worksheets) with feedback present, then the same task without feedback. (3) Practise the cue at home before homework, in short spells with praise. (4) Pair with teacher cues (4.11). (5) Track carry-over on teacher and parent ratings.
Example language (illustrative): "Can you switch on owl mode without the game? Try it for this page of reading, then tell me how it went."
Watch for: in-clinic success without school change; reliance on the screen.

4.13 Social-skills and contingency-management adjuncts

Purpose / when: For children with peer or behavioural difficulties. [source: Monastra et al. 2005 suggest social-skills training with contingency management]
Steps: (1) Identify one or two target skills, such as waiting a turn or joining play. (2) Teach them, rehearse in role-play and reinforce. (3) Link rewards to home and school charts. Group social-skills programmes may be used where available. [synthesis for steps]
Example language (illustrative): "Let's practise waiting for your turn in a game. You get a point each time you wait."
Watch for: skills that do not transfer to real settings.

4.14 Medication liaison and collaborative care

Purpose / when: Throughout, for any child on medication or being considered for it. [source: Monastra et al. 2005 report irritability or hyperactivity in some children combining training with stimulants, which resolved when the prescriber adjusted the dose] [synthesis for the routing]
Steps: (1) With consent, inform the prescriber that training is starting. (2) Ask parents to report mood, sleep, appetite and behaviour changes. (3) Pass reports of irritability, over-activation or other concerns to the prescriber promptly. (4) Never advise starting, reducing or stopping medication. If a family wants to reduce medication, refer them to the prescriber. (5) Note that neurofeedback did not outperform sham, and that the NCG group's lower medication need at 13 months was a secondary finding [source: NCG 2021].
Example language (illustrative): "Any change to Sam's medicine is a decision for Dr Lee. I'll let her know what we're seeing, and you can talk it through with her."
Watch for: families stopping medication on their own; unexplained mood change; worsening sleep.

4.15 Progress reviews and decision points

Purpose / when: At planned points, for example every 10 sessions. [synthesis]
Steps: (1) Repeat brief parent and teacher ratings. (2) Compare EEG trend, behaviour and functioning. (3) Hold a review meeting with the parent and child: continue, adjust protocol, add or switch to an evidence-based alternative, or stop. (4) Record the decision and the reasons.
Example language (illustrative): "We've done 20 sessions. The game scores are better, but school reports haven't changed. Let's decide together whether to continue, or put the time into the parent programme instead."
Watch for: sunk-cost continuation; families who feel they cannot stop.

4.16 Ending, follow-up and relapse planning

Purpose / when: Final sessions and after. [source: Monastra et al. 2005 on the normalisation-based ending criterion in Monastra et al. 2002, and on relapse when training stopped early]
Steps: (1) Agree the ending in advance once targets are stable, or once a planned trial has shown no benefit. (2) Space the last sessions. (3) Repeat the full baseline battery (ratings, CPT, and EEG where used). (4) Write a summary for the family, school and prescriber, with consent. (5) Write a maintenance plan: home routines, strategy cues, school accommodations, and warning signs that call for review. (6) Book follow-up assessments. [synthesis for steps 2, 4–6] Booster sessions are used by some practitioners; no cited source specifies them [uncertain].
Example language (illustrative): "You've learned owl mode. Now the job is to keep using it at school and at home. We'll check in again in three months."
Watch for: loss of gains at transitions such as a new school year or medication change; a family seeking open-ended training.

4.17 Safeguarding and child protection

Purpose / when: Throughout. Applies to every child client. [synthesis; standard child-protection practice, not specified in the cited neurofeedback sources]
Steps: (1) Hold current safeguarding training and follow your local child-protection procedures. Know your designated safeguarding lead and local referral routes. (2) Run sessions with clear sightlines or a parent present, especially because sensor placement involves touch. Explain each touch beforehand and ask permission. (3) Respect body autonomy: the child can refuse a sensor or a session. (4) Watch for and act on disclosures or signs of abuse or neglect. ADHD can coincide with family stress and higher risk of maltreatment. (5) Keep records, data and EEG files secure and share them only with consent or where the law requires. (6) Check that staff who are not licensed clinicians, such as technicians, have appropriate background checks (for example DBS checks in England) and supervision.
Example language (illustrative): "I'm going to put the sensor just here on your head. Is that OK? You can tell me to stop."
Watch for: discomfort with touch; unexplained injuries; coercive family dynamics around attendance.

5. Handling problems

Most guidance below is [synthesis]. Points from sources are tagged.

No EEG change after many sessions (stuck learner). Check signal quality and artifacts first. Then check difficulty shaping: too few rewards stalls learning. Then check sleep, medication timing and attendance gaps. If the EEG pattern was never clearly the slowing type, reconsider the protocol choice (Monastra et al. 2005 link protocol choice to QEEG subtype; see 047, 049). At a planned review, offer to stop and put the time into guideline-recommended care. [synthesis; source for subtype point: Monastra et al. 2005]
EEG improves but behaviour does not. This is an expected scenario given the blinded evidence [source: NCG 2021/2023]. Strengthen transfer (4.12), parent work (4.10) and school accommodations (4.11). If teacher ratings stay flat by the review point, recommend ending. [synthesis]
Behaviour improves but you cannot tell why. Tell the family honestly that the best trial suggests much of the improvement may come from nonspecific factors such as attention, structure, positive adult contact and expectation [source: NCG 2023]. Build on those deliberately: routines, praise, a regular therapeutic relationship. [synthesis]
Boredom, refusal or fidgeting (child non-adherence). Vary displays and games. Shorten segments and rebuild them. Add a session reward chart. Give the child choices (which game, when to break). Ask what is hard. If the child repeatedly withdraws assent, pause the course and review with the parent. Do not coerce. [synthesis]
Overwhelm or distress in session (sensory, frustration, anxiety). Stop feedback, remove sensors if the child asks, and use grounding or co-regulation with the parent. Restart later with easier criteria or a desensitisation step, such as sensors on with no task. Screen for anxiety or sensory processing differences, which may need their own treatment. [synthesis]
Parent non-adherence (missed sessions, no home practice). Revisit cost, travel and expectations. Problem-solve scheduling (massed vs spaced schedules are both described [source: Monastra et al. 2005]). Simplify home tasks to one routine. Check for parental ADHD, depression or family stress and offer support or referral. [synthesis]
Rupture with the parent (feeling misled or blaming the child). Name the disagreement, go back to the consent conversation and the evidence, and review the data together. Offer a second opinion or a change of treatment rather than defending neurofeedback. [synthesis]
Parent wants to stop medication because of training. Do not advise. Refer them to the prescriber and share observations with consent (4.14). Explain that the controlled evidence does not show neurofeedback is a substitute for medication. [synthesis; NCG 2021/2023]
Side effects (irritability, over-activation, sleep change, headache, fatigue). Record them. Report medication-related concerns to the prescriber [source: Monastra et al. 2005 on irritability with stimulants]. Ease difficulty or session length, and pause if symptoms persist. [synthesis]
Unexpected EEG findings. If you see possible epileptiform or other abnormal activity, stop training and refer to the GP or a neurologist. Neurofeedback training software is not a diagnostic EEG. [synthesis]
Pressure to use theta/beta ratio (or NEBA) as a diagnosis. Explain that NEBA's labelling restricts it to supporting a clinician's diagnosis within a full evaluation, and that some insurers consider it investigational [source: Blue Shield policy]. Route diagnosis to qualified assessors. [synthesis]
Marketing claims and cost pressure. Do not promise cure, permanence or "normalised brains". Quote evidence with attribution (Section 1), and avoid pre-paid packages that make it hard for families to stop. [synthesis]
Relapse after ending. Monastra et al. (2005) note deterioration when training stopped early. Re-assess, reinforce home and school supports, and consider a short review course only if prior gains were clear on teacher measures. [source: Monastra et al. 2005; synthesis for the response] [uncertain whether booster sessions are effective]
Disclosure of harm or safeguarding concern. Follow local child-protection procedure immediately (4.17), even mid-course. [synthesis]

Sources

Online sources:

Cited but not verified [uncertain]: Cortese et al. (2016), neurofeedback meta-analysis, JAACAP 55(6), 444–455 (details as cited by the National Elf Service); Monastra et al. (2002) (details as summarised in Monastra et al. 2005); Arns et al. (2020), European Psychiatry [uncertain: not verified]; the BCIA certification pages; the AAP 2019 ADHD guideline (only as summarised by Blue Shield).

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