neurofeedback for affect disregulation and impairment of
TRANSCRIPT
Why Biofeedback?Improves outcome
Treats the source of the problem
Advantages over alternatives:
• Medications: (if effective) treating
symptoms; side effects
• Psychotherapy: can be long; not for
everybody— talking therapy
• Sometimes has better results than
alternatives
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Biofeedback
Biofeedback is a self regulation technique to achieve
voluntary control of physiological functions which are
normally regulated autonomously (i.e. without
conscious awareness).
Regulation of physiological activity can positively
impact cognitive, physical, and emotional functioning
Ed Hamlin, 2015
2
Biofeedback:How Does it work?
A learning process based on operant conditioning
Increase/decrease a behavior through the use of positive
or negative reinforcement
(Wikipedia)
3
Neurofeedback
Brain Plasticity Assumption: brain activity can be changed
Biofeedback on brain waves (measured by EEG)
Learning to alter particular brain waves improves the self-
regulation of brain state
Better brain regulation -> better functioning
Ed Hamlin, 2015
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Band
Location
Bandwidth to be treated -> Normalize
• Too little (based on a norm)-> reward or increase
• Too much (based on a norm) -> reduce or inhibit
Individual vs. predefined protocol
Protocol in the child study:
Bandwidths: Reward upper theta and/or alpha, inhibit delta, theta, high beta
Location: right temporal and right parietal 5
No Free Lunch:
Adverse Reactions
Every intervention has adverse reactions (including psychotherapy)
NFB Examples: headaches, tiredness, sleeping disruptions, attention, impulsivity, adverse mood changes (e.g. anxiety)
When addressed, side-effects can be mitigated or even eliminated
Most side-effects are mild, transient and reversible :-)
Modify the protocol (i.e. adjust bands or change location)
Essential for practitioner to monitor reactions because clients may not correlate side effects to NFB 6
The Impact of
Neurofeedback on Children
with Development Trauma:
A Randomized Control
Study
7
Goals
• It was successful with adults. Are children any different?
• Pilot study of NFB with children who have experienced developmental trauma:
• Feasibility of NFB with children who have experienced multiple adversities
• Establish best measurement strategy
• Clinical signal – does NFB lead to reduced symptoms that are commonly seen in trauma-impacted children?
Inclusion Criteria• Ages 6-13
• Suffered from at least two types trauma
• Clinically significant symptoms on
• (a) Child Behavioral Checklist (CBCL) (internalizing or externalizing scales) or
• (b) posttraumatic stress symptoms as manifested in K-SADS or posttraumatic stress symptoms PTSD Screen
• Stable condition (meds, therapy, hospitalization)
• Commit to the study
Exclusion Criteria
• History of epilepsy, seizure or head injury
• Received prior NFT for the past 5 years
• Currently on benzodiazepine medication
• Safety concerns: at home, suicide attempt, serious self
harm behavior and psychiatric hospitalization in the past
6 months
• Live farther than 65 miles from the Trauma Center
Demographics
Trauma History Profile
0
5
10
15
20
25
30
35
40
Series1
No.
of child
ren
Participant
Flow Chart
• Inclusion / Exclusion
• Assigned to group
• Timeline of treatment
*Follow up assessment for waitinglist/control group was the starting point for the NFB treatment; Note that one participate underwent a NFB baseline assessment
because of starting NFB 3 months after completing the follow up assessment. NFB protocol similar to the NFT group. Dropped out(n=2): Individual Emergencies after
Followup/NFT Baseline
Midpoint Assessment
(n=33)
Endpoint Assessment
(n=32)
Follow up Assessment
(n=28)
Baseline Assessment (n=48)
Excluded (n=12): Family reasons, (n=4), Did not
meet criteria (n=3)*, Couldn’t commit (n=2), Lost
communication (n=2)
*Excluded b/c TBI and time commitment (n=1)
Screened in
(n=57)
Excluded (n=9):
Lost communication (n=7),
Personal reasons (n=2)
Figure 1. Flow Chart
Allocation and
Randomization
(n=37)
Waitlist/Control Group (n=17)
Dropped out (n=1): Not satisfied
with group assignment
Active NFT Group (n=20)
Received 12 NFB sessions
Dropped out (n=3): Personal and
family reasons
6 weeks post baseline assessment
(n=16)
Received 12 NFT (n=17)
Dropped out (n=1): Family
reasons
6 weeks post midpoint
assessment (n=16)
Dropped out (n=2): Lost
communication
Completed 24 NFT (n=16)
Dropped out (n=2): Lost
communication & individual
emergency
4 weeks post endpoint
assessment (n=14)*
4 weeks upon completing NFB
(n=14)
Neurofeedback Protocol• Location: T4-P4
• Reward band of 3HZ from one HZ below PDR to
one HZ above PDR
• PDR is the highest amplitude measured in
PZ eyes closed.
• Inhibition: 2-4HZ;4-8 (or less, if PDR is lower);
and 22-36HZ.
• Length of session: planed for 30 minutes
• In reality session was 6-12 minutes
• Twice a week for total of 24 sessions
Measurements: BRIEF Behavior Rating Inventory of Executive FunctionAssessment of executive functions and self-regulation
Meta-Cognition
BehavioralRegulation
Working Memory
Initiate
Plan/Organize
Inhibit
Shift
Emotional Control
Monitor
Organizationof Materials
BRIEF Factor Structure
Measurements• CBCL: The Child Behavior Checklist is a well-validated questionnaire which
assesses emotional and behavioral problems in school-age children
• BRIEF: The Behavior Rating Inventory of Executive Function (BRIEF) is a commonly used assessment of executive functions and self-regulation
• TSCYC: The Trauma Symptom Checklist for Young Children is a measure of symptoms that young children may present after experiencing a potential trauma, such as stress, anxiety, depression, and dissociation
• K-SADS for DSM IV-TR: The Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children is a common semi-structured diagnostic interview which incorporates both child and parent reports
• CAM: The Children’s Alexithymia Measure is used to screen children with alexithymia or difficulty in recognizing and expressing one’s feelings (Way et al., 2010).
Data Analysis
• Chi square: To calculate change PTSD diagnostic status
• Growth Curve Modeling (GCM): A statistical analysis that estimate
differences over time (longitude) between persons and changes within
the person.
• Show changes over time
• Accounts for missing data, differences between populations
• Was divided into: Baseline-Endpoint and Endpoint-Follow up
Results
Results Summary 24 sessions of NFT significantly improved symptoms of children
with developmental trauma:
• Behavioral (CBCL internalizing, CBCL externalizing)
• Cognition (BRIEF global) Emotions (BRIEF depression and
anxiety)
• Trauma symptoms (TSCYC total)
• Dissociation symptoms
• Significantly reduced the number of participants who met
criteria for PTSD according to K-SADS
BRIEF Global (Behavior Rating Inventory of
Executive Function)
135
140
145
150
155
160
165
170
175
180
185
1 2 3 4
Score
Time Point
BRIEF-Global Executive
WL NF
BRIEF
Behavioral Regulation
50.00
55.00
60.00
65.00
70.00
75.00
1 2 3 4
BRIEF-Behavioral Regulation
WL NF
BRIEF Metacognition (p=0.05)
90.00
95.00
100.00
105.00
110.00
115.00
1 2 3 4
BRIEF-Metacognition
WL NF
CBCL Externalizing
(Child Behavior Checklist)
10
12
14
16
18
20
22
24
26
28
30
1 2 3 4
Score
Time Point
CBCL-Externalizing
WL NF
CBCL Internalizing
9
10
11
12
13
14
15
16
17
18
19
1 2 3 4
CBCL Internalizing
WL NF
CAM (Children’s Alexithymia Measure)
8
9
10
11
12
13
14
15
16
17
18
1 2 3 4
CAM-Total
WL NF
TSCYC Global (Trauma Symptom Checklist for
Young Children)
35
37
39
41
43
45
47
49
51
53
1 2 3 4
Tota
l S
core
Time Point
TSCYC Post-Traumatic Stress Total
WL NF
TSCYC Anxiety
12
13
14
15
16
17
18
1 2 3 4
TSCYC-Anxiety
WL NF
TSCYC Depression
10
11
12
13
14
15
16
1 2 3 4
TSCYC-Depression
WL NF
TSCYC Arousal
10
12
14
16
18
20
22
24
26
1 2 3 4
TSCYC-Arousal
WL NF
TSCYC Dissociation
11
11.5
12
12.5
13
13.5
14
14.5
15
1 2 3 4
TSCYC-Dissociation
WL NF
KSADS (The Kiddie Schedule for Affective
Disorders )
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
1 2 3 4
KSADS
NF WL
Observations
• Its essential to see a therapist. Sensitive info was disclosed during
the sessions (from suicidal thoughts to gender issues).
• Length of session (6-12 minutes) too short? But it worked!
• Symptom checklist was essential to track the NFB changes
• Adjustment of the protocol were needed (and helpful)
Discussion• Can NFT eliminate symptoms?
• How to maintain the impact of NFB?
• Regression during follow up assessment
• Longer follow up is required
• Increase the number for sessions?
• Would more sessions, additional or individual tailored
protocols increase effectiveness of NFT?
• Participants were symptomatic, however, only one participant
met criteria for dissociation
Challenges• “Treatment resistant”
• Practical challenges:
• Initially, the children didn’t want to come
• Place electrodes on children who are sensitive to touch
• Engage the children during the session
• Sit still or present.
• Track the changes
• Differentiate NFB side effects from external stressors (many)
Limitations• Demographics: majority of the participants are adopted
children who live with middle-upper class stable family
• Pilot study:
• Small number of participants
• Small number of sessions
• Different types of trauma, different ages of trauma,
large age range
• One protocol: does it fit all?
• qEEG was not used to define the protocol
AcknowledgementsBessel van der Kolk, Principal Investigator
Joseph Spinazzola, Co-InvestigatorHilary Hodgdon, Head of research operations
Ed Hamlin, Project Supervisor Mark Gapen, Project SupervisorAinat Rogel, Project coordinator
Michael Suvak, Data analystAllyse Melville, Evaluator and data Analyst
Regina Musicaro, Interventionist Anna Kharaz, Project coordinator
Lia Martin and CATS helpersAlice Knowlton, Evaluator
Elizabeth Southwell, Evaluator and interventionistMargaret Bullerjahn, EvaluatorKhaled Nasser, Interventionist
Anne Sposato, Evaluator Maggi Price, EvaluatorJulia Ozog, Evaluator
Rachana Agarwal, EvaluatorRichard Lupatnick, Interventionist
Louloua Smadi, Evaluator and InterventionistMara Renz Smith, Evaluator
Alyssa Beth Brelsford, Evaluator