Efficacy of a Multisensory Audiovisual Entrainment Neurofeedback for Academic Anxiety Regulation and Divergent Thinking: A Randomized Controlled Trial Study

Background Academic anxiety is a major psychological concern among adolescents and has consistently been associated with impaired executive functioning, attentional control, emotional regulation, autonomic imbalance, and reduced creative cognition. Neurophysiological evidence indicates that these impairments are accompanied by dysregulated cortical alpha oscillations and reduced parasympathetic nervous system activity. Neurofeedback enables individuals to voluntarily regulate neural oscillatory activity through real-time electroencephalographic feedback, whereas audiovisual entrainment facilitates neural synchronization using rhythmic photic stimulation and binaural auditory stimulation. Despite encouraging evidence supporting each intervention independently, limited research has investigated their integration within an adaptive closed-loop neurofeedback architecture capable of delivering individualized reinforcement based on ongoing neural activity.

Objectives The primary objective of this study is to determine whether an Audiovisual Entrainment Neurofeedback (AVE-NFB) system produces greater increases in resting-state absolute alpha-band power than isolated neurofeedback, isolated audiovisual entrainment, or sham intervention.Secondary objectives are to evaluate changes in academic anxiety, autonomic nervous system regulation, divergent thinking, and the durability of treatment effects during one-week and one-month follow-up assessments.

Study Design This study is a multicenter, four-arm, parallel-group, randomized controlled trial involving 240 participants recruited from two senior high school centers. Participants will be randomly assigned to one of four intervention groups: (1) Combined AVE-Neurofeedback; (2) Neurofeedback Only; (3); Audiovisual Entrainment Only & (4) Sham Control. Each participant will complete 12 intervention sessions across a six-week period (administered twice weekly). Outcome assessments will be conducted at: (1) Baseline (Week 0); (2) Immediately Post-intervention (Week 6); (3) One-week Follow-up (Week 7); (4) One-month Follow-up (Week 10)

Closed-Loop Neurofeedback Mechanism The Audiovisual Entrainment Neurofeedback (AVE-NFB) employs a fully adaptive closed-loop brain-computer interface integrating real-time EEG monitoring with synchronized audiovisual entrainment.EEG signals are continuously acquired using the Emotiv Epoc X 14-channel research-grade EEG headset at a sampling frequency of 256 Hz from saline-based electrodes positioned at AF3, F7, F3, FC5, T7, P7, O1, O2, P8, T8, FC6, F4, F8, and AF4, mapped according to the International 10-20 system. Each intervention session begins with a standardized 5-minute calibration period consisting of 3 minutes of eyes-closed resting state followed by 2 minutes of eyes-open resting state. Calibration data are used to establish each participant's individualized resting absolute alpha-band activity (8-12 Hz).During neurofeedback training, EEG signals undergo automated quality control, including artifact detection for eye blinks, excessive movement, and poor electrode contact across all 14 channels. Only artifact-free epochs are processed for online estimation of absolute alpha-band power using short overlapping analysis windows averaged across the frontal and temporoparietal regions of interest.The individualized reinforcement threshold is initialized at 110% of the participant's median resting absolute alpha power obtained during calibration. Throughout each training session, this threshold is dynamically adjusted by a physiological controller driven by rolling Heart Rate Variability (RMSSD) estimates. Positive reinforcement is delivered only when alpha power remains continuously above this adaptive threshold for at least 2 consecutive seconds while signal quality satisfies predefined artifact acceptance criteria.

Successful threshold attainment automatically activates synchronized audiovisual reinforcement consisting of: (1) Alpha-frequency rhythmic photic stimulation; (2) Binaural beat auditory stimulation centered within the alpha range; (3) Non-directive relaxation guidance & (4) Continuous visual performance feedback. Whenever alpha activity decreases below the reinforcement threshold or excessive artifacts are detected, audiovisual reinforcement is immediately attenuated or suspended until stable neural activity resumes. This adaptive reinforcement paradigm is designed to strengthen voluntary alpha self-regulation through operant conditioning rather than passive sensory stimulation.