We have been working successfully with the ADHD population—children and adults—for almost forty years, based on research that was done even earlier. Throughout this period, we have had to contend with counter-pressure from neurofeedback critics in the medical community. Such criticism of an aspirational modality suffices to keep most other research and medical professionals from getting involved. The criticism from these quarters has just reached its most strident extreme with the publication of the paper titled “Neurofeedback for ADHD: Time to Call It Quits?” by James McGough of the UCLA Department of Child Psychiatry. It can be found here: https://psychiatryonline.org/doi/full/10.1176/appi.ajp.20220861
I felt obligated to respond, even in the knowledge that critics in science tend to go to their graves with their critical posture intact. Professor McGough has not responded, so I am publishing my response as an open letter. If you would like to add your voice, Professor McGough can be reached here: James J. McGough, M.D., M.S. jmcgough@mednet.ucla.edu
Dear Professor McGough:
I read your article titled “Neurofeedback for ADHD: Time to Call It Quits?” a while back, and I feel a professional obligation to respond, even though your skepticism is deep-seated and of long standing. I don’t think you will want this to be your epitaph. The studies you are familiar with are dated, and they weren’t capable of reflecting the state of the art even in their time.
What is it, you might ask, that has given clinicians their strategic advantage over academic researchers in judging the merits? It is ‘black swan events’ in first instance, which in this case are not even rare. Extraordinary outcomes have been the tall poles in the tent, as they indicate what is possible, on the one hand, and they can’t be written off to a placebo effect, on the other. (A forty-point increase in measured IQ score, from 72 to 112, in a pre-teen is a case in point.). Another principal factor is real-time effects, such as our ability to abort migraines in a matter of minutes in a substantial fraction of cases. A third factor is the ubiquity of adverse effects. Paraphrasing Tolstoy: “Every dysregulated brain is dysregulated in its own way.” We uncover various vulnerabilities in the early sessions.
We met in 1997 at UCLA after the sudden death of Professor Dennis Cantwell. The issue was whether our joint proposal to evaluate neurofeedback was to go forward, and you stated that the proposal would have to be totally rewritten. Likely what was troubling you about the proposal were the very features that were conditional for our involvement. You also conveyed a lack of enthusiasm about the project.
I understood that you were early in your career, and that a misstep at this point would be a significant risk to your professional future. Dennis Cantwell, on the other hand, had not been at such risk. In the spirit of ‘noblesse obliges,’ he said that “we have an obligation to evaluate what is being offered to the public.” His interest had been stirred by the reports of sudden child deaths with Ritalin. “ADHD is a bad thing, but it doesn’t kill you, and neither should the remedy. If there is something here, we need to know.” There was no implication of ‘buy-in’ or pre-judgment on his part. But after discussions with us at our office, he was also looking forward to the collaboration. He was not expecting to come up empty.
Another factor in our reticence was that we had moved on. Our method had migrated beyond standard operant conditioning. Presenting the real-time dynamics of the training band in feedback was found to enhance the responsiveness, clinical efficiency, and clinical effectivity of neurofeedback over what could be accomplished with conventional operant conditioning in the standard SMR-beta protocols that made it into the journals.
This more naturalistic, continuous feedback, in the absence of any discrete rewards, is appropriately termed Endogenous Neuromodulation. This in turn led to discovery of the principle of Optimal Response Frequency (ORF) by my wife Sue Othmer. That was a process rather than an event, with the principle firmly established by 1997. The implications were huge. It placed clinicians in an observational role to discern the optimal reinforcement parameters in each case, which alters the paradigm from a top-down, prescriptive process to a bottom-up, non-prescriptive trajectory. For purposes of a formal study, there was no longer a standard protocol to put to the test, and proficiency of the trainer had become a paramount issue.
It might be said in passing that such a discovery is very unlikely to have emerged out of standard research designs. It required the fertile ground of numerous, wide-ranging, extended clinical encounters, a large variable space attended by a disciplined, prepared mind. Sue Othmer was a scientist in the naturalist tradition of Konrad Lorenz and Nikolaas Tinbergen, teasing out the ‘ethology of brain behavior’ in our highly dysregulated clients.
Sue Othmer’s Ph.D. dissertation work—1966-1971— had been conducted under the guidance of Ross Adey, Director of the UCLA Brain Research Institute at the time. Her major adviser was Frank Rosenblatt of Cornell’s Department of Neurobiology. Sue’s dissertation topic, investigating the attentional mechanisms of the cat via a conditioning technique, assessed by way of evoked potentials, had been directly relevant to her present clinical work on several levels. Rosenblatt’s accidental death in 1971 derailed Sue’s consummation of the Ph.D. program at its last stage, defense of the dissertation, as UCLA would not consider the transfer of her academic credits from Cornell.
By following the brain’s lead, the training proliferated both in terms of placements and training frequency, the latter eventually covering the range of 100 Hz to 0.1 micro-Hz and below. By way of the ORF principle, we were able to tease out the frequency rules that govern the entire frequency range. This covers a range of functional domains, extending to the realm of astrocyte networks. This targets homeostatic and homeodynamic mechanisms—i.e., core state regulation.
In the perspective of the regulatory hierarchy, core state regulation must be our first objective. Stability of the system is foundational; regulation of tonic, central arousal follows. That in turn is correlated with autonomic regulation, affect regulation, and interoception, which are each targeted by choice of placement.
The frequency domain is also hierarchically organized. Thus, endogenous neuromodulation in the infra-low and ultra-low frequency regimes targets core state regulation most directly. The ORFs are not directly observable in the EEG. They can only be identified by virtue of their effects, which the neurofeedback procedure renders discernible. Thus, the evolution of endogenous neuromodulation out of standard operant conditioning was the precondition for the discovery of the ORF principle. As endogenous neuromodulation could not have evolved organically out of standard research designs, this could only have happened in the clinical realm. The governing theory for the optimal response frequencies is Synergetics, by Hermann Haken.
The criticality of the ORFs is most directly apparent in application to cerebral instabilities—from migraines, seizures and panic to asthmatic episodes and nocturnal myoclonus—which have all been shown to be responsive to training at an ORF with inter-hemispheric placements at homotopic sites. Referring to homeostasis, Claude Bernhard once stated that “Stability of the internal state is the precondition for the unencumbered life.” This statement generalizes beyond the autonomic nervous system.
Our involvement in this work goes back to 1985 when our epileptic son benefited from the training and thus drew our attention to this emerging modality. Our experience with our son was so compelling that we already ‘knew’ this technique would be transformative for the field of mental health. My wife and I both changed careers to pursue this new initiative, beginning with the computerization of the method. Yet what has transpired since has exceeded our early expectations by way of evolution of the technology and the refinement of the protocol schema and the models.
There have been three generations of instrumentation design. The last exemplar of the first generation, with software dating back to 1985-1987, was just retired from clinical work about a year ago. It had served as the workhorse for most of one clinician’s career. The second generation, in 2002, was a modest evolution of the first, with updated software, and is still on the market. The first two generations each attracted several thousand practitioners, mainly in the US. But by 1997 we were already teaching in Europe and in Australia.
The third generation, in 2007-8, was designed to probe the Infra-low frequency (ILF) regime, the natural turf for core state regulation. ILF training has by now attracted some 7000 practitioners in over 40 countries. Our professional training course is being conducted in 15 countries and in nine languages. We have a professional teaching team of about 100.
By now, well over two million people have benefited from the protocols we have developed. I estimate that on average every 3-4 seconds someone is being hooked up for a session somewhere, and of course our work represents only a fraction—albeit a large fraction—of what is happening in the domain of closed-loop neuromodulation generally.
The Russian neurologist A.A. Ponomarenko encapsulates the model: “There are no discrete mental disorders; their diversity is a reflection of malfunctions in central regulatory systems.” If we target core state regulation at the outset, brain-based dysfunctions become more tractable in considerable generality.
The frequency domain offers us an over-arching integrative model for neurology and psychiatry, a unifying perspective that has been lacking. (“The DSM does not carve nature at its joints.” – Science Magazine editorial.) A key finding is the extreme subtlety with which even major functional improvements may be elicited. In consequence, we can now claim the realization of a systematic, bottom-up, brain-guided process for the enhancement or restoration of the brain’s functional competence in considerable generality. The method is function-focused rather than deficit-focused.
An extensive literature is now available on our method. Our publications are available on ResearchGate and on Academia.edu. A mechanisms study on our method was just published by the fMRI research group at the University of Zürich. The head of the University research hospital is an author on the paper. The study results support our claims of validity for the method. The target frequency was 0.1 micro-Hz. This was a replication of an earlier study, performed under the direction of Olga Dobrushina in Moscow, under the auspices of the Russian Ministry of Health, published in 2020. The replication was performed under tighter constraints. Yet other publications on our method have been published by the Institute of the Human Brain of the Russian Academy of Sciences in Saint Petersburg.
A controlled study in application to treatment-resistant cases of PTSD and TBI was recently published. It was sponsored by the Veterans Administration. When VA scientists were briefed on the results, their collective response was to say, “these results are unprecedented in our experience.”
Our method is now in use with the LA Unified School District. Their pilot study demonstrated stunning results, an average 40% reduction in primary complaints over twenty sessions. It is in use with some 37 agencies in LA County that serve the public with government support. It is in use by three states in their juvenile justice systems, and it is being used in the German prison system with youthful offenders. It was a large-scale outcome study by Child and Adolescent Psychiatric Clinics in Munich that got neurofeedback accepted in application to ADHD by the adjudicating agency in German psychiatry. In application to ADHD, it is the natural complement to pharmacotherapy.
There is no longer any question that our method will be revolutionary for psychiatry and neurology, with implications for the fields of child development, education, criminal justice, addiction treatment, violence prevention, and for the aging brain. The method works well with infants, targeting core state regulation. This raises prospects of moving toward a prevention model in mental health, as it is more efficient to tackle issues that are latent rather than manifest.
I invite you to take a few minutes to read a brief summary of our experience with our epileptic son ( https://news.eeginfo.com/on-the-life-of-brian-othmer/ ). I also invite you to take 11 minutes of your time to listen to a Vimeo that was recently presented at a rehabilitation conference in England (https://vimeo.com/1180517928/fb51dcc5bd?share=copy&fl=sv&fe=ci)
I look forward to hearing from you.
Respectfully,
Siegfried Othmer, Ph.D.
Chief Scientist, The EEG Institute
Woodland Hills, CA 91367
www.eeginfo.com
www.eeginstitute.com
www.homecomingforveterans.org
www.brianothmerfoundation.org
Here are some key references:
Carlson J, Ross GW, Tyrrell C, Fiame B, Nunokawa C, Siriwardhana C, Schaper K, Infra-Low Frequency Neurofeedback Impact on Post-Concussive Symptoms of Headache, Insomnia and Attention Disorder: Results of a Randomized Control Trial, EXPLORE (2025), doi: https://doi.org/10.1016/j.explore.2025.103137
de Matos NMP, Staempfli P, Seifritz E, Bruegger M, Disassembling Infra-Low-Frequency Neurofeedback: A neurophysiological investigation of its feedback
components, NeuroImage (2025), doi: ttps://doi.org/10.1016/j.neuroimage.2025.121647
Dobrushina, Olga R.; Vlasova, Roza M.; Rumshiskaya, Alena D.; Litvinova, Liudmila D.; Mershina, Elena A.; Sinitsyn, Valentin E.; Pechenkova, Ekaterina V. (2020): Modulation of Intrinsic Brain Connectivity by Implicit Electroencephalographic Neurofeedback. In: Front Hum Neurosci 14, S. 192. DOI: 10.3389/fnhum.2020.00192
Kaiser, D.A., Othmer, S. (2000). Effect of Neurofeedback on Variables of Attention in a Large Multi-Center Trial (2000), Journal of Neurotherapy, 4(1) 2000
https://www.researchgate.net/publication/233060756_Effect_of_Neurofeedback_on_Variables_of_Attention_in_a_Large_Multi-Center_Trial
Legarda SB, McMahon D, Othmer S, Othmer SF (2011): Clinical neurofeedback: case studies, proposed mechanism, and implications for pediatric neurology practice. In: J. Child Neurol. 26 (8), S. 1045–1051. DOI: 10.1177/0883073811405052.
https://www.researchgate.net/publication/51130738_Clinical_Neurofeedback_Case_Studies_Proposed_Mechanism_and_Implications_for_Pediatric_Neurology_Practice
Othmer S, Othmer SF, Legarda SB (2011): Clinical Neurofeedback: Training Brain Behavior. In: Treatment Strategies – Pediatric Neurology and Psychiatry (2(1)), S. 67– 73. https://www.researchgate.net/publication/284506346_Clinical_neurofeedback_Training_brain_behavior
Othmer S, Othmer SF, Kaiser DA, Putman J (2013): Endogenous Neuromodulation at Infralow Frequencies. In: Seminars in Pediatric Neurology 20 (4), S. 246 – 257.
DOI: 10.1016/j.spen.2013.10.006.
https://www.researchgate.net/publication/259455519_Endogenous_Neuromodulation_at_Infralow_Frequencies
Othmer S, Kropotov J, Ioannides A, editors (2023). Endogenous Neuromodulation in the Infra-Low Frequency Regime, Special Topics Edition, Frontiers of Human Neuroscience (2023) https://www.frontiersin.org/research-topics/24349/endogenous-neuromodulation-in-the-infra-low-frequency-regime#articles
Othmer S, Othmer SF (2023) Endogenous Neuromodulation at Infra-Low Frequency: Method and Theory DOI: 10.20944/preprints202310.1085.v2
Schmidt C, Laugesen H, Infra-low frequency neurofeedback training in Dravet Syndrome: a case study, Epilepsy & Behavior Reports (2023),
doi: https://doi.org/10.1016/j.ebr.2023.100606
Schneider H, Riederle J, Seuss S (2022): Therapeutic Effect of Infra-Low-Frequency Neurofeedback Training on Children and Adolescents with ADHD. In: Vahid Asadpour (Hg.): Brain-Computer Interface, Bd. 9: IntechOpen (Artificial Intelligence, 9).
Theis T, Bolduan U, Seuß S, Spallek J, Wandernoth B and Mayer-Pelinski R (2025) ILF-neurofeedback in clinical practice: examining symptom change and performance metrics across diagnostic groups. Front. Hum. Neurosci. 19:1601187.
doi: 10.3389/fnhum.2025.1601187
