schummer obtaining positive outcomes

Copyright © 2008 Gary J. Schummer PhD APC., Unauthorized duplication or distribution is illegal.

Maximizing Treatment EfficacyMaximizing Treatment EfficacyIn ADD/ADHDIn ADD/ADHD

Gary J. Schummer, Ph.D.Neuropsychologist

Clinical Director of the A.D.D. Treatment CenterTorrance, California, U.S.A.


Skill level of the technician who collects Skill level of the technician who collects the EEG, the Data Acquisition Instrument the EEG, the Data Acquisition Instrument (DAI) and databases used, the skill level of (DAI) and databases used, the skill level of the interpreter of the data, ability of the the interpreter of the data, ability of the doctor to complete, explain, and doctor to complete, explain, and implement a treatment plan implement a treatment plan

Frequency of the training – number of Frequency of the training – number of sessions per week, length of time for each sessions per week, length of time for each session, “spaced” verses “massed” session, “spaced” verses “massed” trainingtraining

Frequently changing the reward and Frequently changing the reward and inhibits or rarely changing theseinhibits or rarely changing these

Therapist as “friend” or on the “pedestal”.Therapist as “friend” or on the “pedestal”.

Factors Factors ThoughtThought To Impact Outcome To Impact Outcome (But We Have No Data) (But We Have No Data)


Train amplitude first, then coherence, or Train amplitude first, then coherence, or train coherence first then amplitude, or train coherence first then amplitude, or some combination of the twosome combination of the two

The degree of bonding between the parent The degree of bonding between the parent and child and the developmental age of and child and the developmental age of the childthe child

Therapy done by the “Doctor” or a Therapy done by the “Doctor” or a technician closer to patient’s agetechnician closer to patient’s age

How important is therapist-patient How important is therapist-patient rapport?rapport?

Are patients better trained in single rooms Are patients better trained in single rooms (minimizing noise) or multi-station rooms (minimizing noise) or multi-station rooms (noise level that of a typical classroom).(noise level that of a typical classroom).

Factors Factors ThoughtThought To Impact Outcome To Impact Outcome (But We Have No Data)(But We Have No Data)


Factors Known To Negatively Factors Known To Negatively Impact OutcomeImpact Outcome

Chaotic or dysfunctional home Chaotic or dysfunctional home PTSD – Emotional or physical abusePTSD – Emotional or physical abuse ““Stuck” cofactors (addiction, OCD, Stuck” cofactors (addiction, OCD,

Tourette’s Syndrome, ODD)Tourette’s Syndrome, ODD) Early Attachment IssuesEarly Attachment Issues Bipolar Disorder as a co-occurring Bipolar Disorder as a co-occurring

conditioncondition History of head traumaHistory of head trauma Physician, Teacher or other authority Physician, Teacher or other authority

figure verbally negative about therapy.figure verbally negative about therapy.


Factors Known To Negatively Factors Known To Negatively Impact OutcomeImpact Outcome

Separated or divorced parentsSeparated or divorced parents Chronic sleep disregulationChronic sleep disregulation If behavioral and psychological If behavioral and psychological

overlay issues are ignoredoverlay issues are ignored Distance of the commute to the Distance of the commute to the

officeoffice Long Term: If you don’t taper Long Term: If you don’t taper

patient or educate them as to the patient or educate them as to the possibility of the condition returning.possibility of the condition returning.


Factors Known To Negatively Impact Factors Known To Negatively Impact OutcomeOutcome

Personality of patient is aggressive, Personality of patient is aggressive, hostile, argumentative, oppositionalhostile, argumentative, oppositional

Overly narcissistic adolescents Overly narcissistic adolescents Borderline or passive dependent PDBorderline or passive dependent PD ““Liberal” non-structured parentingLiberal” non-structured parenting On medication at initiation of NFBOn medication at initiation of NFB Using illicit drugs while in treatmentUsing illicit drugs while in treatment Inaccurate diagnosis.Inaccurate diagnosis.


Factors Known To Positively Impact Factors Known To Positively Impact OutcomeOutcome

Higher skill level of the clinicianHigher skill level of the clinician Parents either maintain or obtain therapy Parents either maintain or obtain therapy Therapist maintains frequent contact Therapist maintains frequent contact

with a spouse (adult) or school (kids), with a spouse (adult) or school (kids), [CAUTION][CAUTION]

Parent (or spouse’s) willingness to be an Parent (or spouse’s) willingness to be an active part and supporter of the active part and supporter of the treatment, (i.e., being diagnosed and treatment, (i.e., being diagnosed and treated simultaneously) treated simultaneously)

Knowledgeable informed parents Knowledgeable informed parents regarding the abuses of medication in regarding the abuses of medication in developing brains. developing brains.


Factors Predicting SuccessFactors Predicting Success 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10

| _ | | | _ | || _ | | | _ | | Less Likely To Succeed More Likely To Succeed

LifeLife GoalsGoals graduate HS graduate college become a professional graduate HS graduate college become a professionalMotivation Motivation Poor OK Good Poor OK GoodHobbies Hobbies play video games play board games read for recreation play video games play board games read for recreation PersonalityPersonality pessimist, introvert pessimist, introvert optimist, optimist,

extrovertextrovertIllness Illness malingering, secondary gains malingering, secondary gains patient dislike illness patient dislike illnessTherapist interactsTherapist interacts with clientwith client Constantly Often Rarely Constantly Often RarelyAgeAge Young children Adults Adolescents Young children Adults Adolescents TreatmentTreatment done in the home done at clinic done in the home done at clinicGenderGender male ( male ( tolerant of boredom) tolerant of boredom) female (female ( pleasing adults) pleasing adults)RelationshipsRelationships Many positive Few positive Many positive Few positive


Factors Impacting OutcomeFactors Impacting Outcome 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9

10 10 | _ | | | _ | || _ | | | _ | | Less Likely To Succeed More Likely To Succeed

MuMu a lot some very little none a lot some very little noneTeacherTeacher poor relationship good relationship superior relationship poor relationship good relationship superior relationshipClassroomClassroom disorganized & lacks structure organized & structured disorganized & lacks structure organized & structuredSchoolSchool Low or high expectations Realistic expectations Low or high expectations Realistic expectationsIQIQ Very low <60 Average ~100 Above average >130 Very low <60 Average ~100 Above average >130 FinancialFinancial low income, low income, insurance higher income, insurance higher income, insuranceinsuranceExerciseExercise No exercise Some exercise Aerobic exercise No exercise Some exercise Aerobic exerciseSleepSleep Poor sleep hygiene, variable onset times Good sleep, regular hours Poor sleep hygiene, variable onset times Good sleep, regular hoursIssuesIssues Neglect Adopted Parentified Indulged Handles responsibility Neglect Adopted Parentified Indulged Handles responsibilityFriend/FamilyFriend/Family NFB ExperienceNFB Experience Poor OK Good Poor OK GoodSame sex parentSame sex parent Negative to therapy Positive to therapy Negative to therapy Positive to therapy


Factors Impacting OutcomeFactors Impacting Outcome 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 | _ | | | _ | || _ | | | _ | | Less Likely To Succeed More Likely To Succeed

ADD/ADHD TypeADD/ADHD Type Inattentive Impulsive Hyperactive Inattentive Impulsive Hyperactive Self-Consciousness Self-Consciousness Don’t want to be seen at the Center Oblivious to this Don’t want to be seen at the Center Oblivious to thisParent who brings kid hasParent who brings kid has Severe ADD Moderate-Mild ADD No ADD Severe ADD Moderate-Mild ADD No ADDParent starts NFB Parent starts NFB No In the future Simultaneously No In the future SimultaneouslyPersonalityPersonality Passive Assertive Aggressive Explosive Passive Assertive Aggressive ExplosiveSame sex parentSame sex parent Is out of the home a lot Is a participative parent Is out of the home a lot Is a participative parentCommitmentsCommitments Overcommitted Makes NFB a priority Overcommitted Makes NFB a priorityPain LevelsPain Levels Low Moderate High Low Moderate HighDisregulated siblingsDisregulated siblings 2 or more 1 None 2 or more 1 NoneExpectationsExpectations High or unreasonable Moderate Appropriate High or unreasonable Moderate AppropriateInitial Initial reactivity reactivity None Some None Some


Recommendations (Therapist)Recommendations (Therapist)

Bring your skill level up to incorporate the latest Bring your skill level up to incorporate the latest PROVEN technologies and therapy delivery systemsPROVEN technologies and therapy delivery systemsDon’t assume other professional’s diagnosis is Don’t assume other professional’s diagnosis is accurate (positive treatment outcome is based on accurate (positive treatment outcome is based on accurate diagnosis)accurate diagnosis)Use proven (valid and reliable) assessment toolsUse proven (valid and reliable) assessment toolsConsider the value of utilizing “professional” power Consider the value of utilizing “professional” power dynamics as an aid to treatment with NFB clienteledynamics as an aid to treatment with NFB clienteleKeep in mind that NFB is a unique interventionKeep in mind that NFB is a unique interventionConsider possibly focusing your practice more Consider possibly focusing your practice more exclusively on quality implementation of NFB training.exclusively on quality implementation of NFB training.



If you’re considering implementing QEEG into your practice, If you’re considering implementing QEEG into your practice, plan a budget of at least $5,000 if you’re going to lease the data plan a budget of at least $5,000 if you’re going to lease the data acquisition instrument (DAI) and ~$12,000 to purchase itacquisition instrument (DAI) and ~$12,000 to purchase itBudget continuing education time in the range of ~40 hours to Budget continuing education time in the range of ~40 hours to bring your skill level up (assuming you’ve mastered basic NFB bring your skill level up (assuming you’ve mastered basic NFB information and have an average NFB clinician’s level of information and have an average NFB clinician’s level of knowledge regarding EEG) knowledge regarding EEG) Money will be spent on DAI, QEEG courses, to replace income Money will be spent on DAI, QEEG courses, to replace income lost from studying and not working, professional supervision lost from studying and not working, professional supervision and on-going consultation with an expert, and other “start-up” and on-going consultation with an expert, and other “start-up” costs (caps, electrodes, paying EEG technician, costs costs (caps, electrodes, paying EEG technician, costs associated with the inevitable hardware and software issues associated with the inevitable hardware and software issues you’ll likely have to repeat data collection sessions, etc.).you’ll likely have to repeat data collection sessions, etc.).



For risk management purposes, if not proficient in doing NFB, For risk management purposes, if not proficient in doing NFB, disclose in signed paperwork your level of expertise especially if disclose in signed paperwork your level of expertise especially if you are treating a disorder that is outside the scope of your you are treating a disorder that is outside the scope of your typical clientele. Also, identify who is supervising you and get typical clientele. Also, identify who is supervising you and get signed releases to do so. Since there are no clearly identified signed releases to do so. Since there are no clearly identified “Standards of Care” for NFB outside of BCIA certification, these “Standards of Care” for NFB outside of BCIA certification, these are individually determined but certification as a NFB provider are individually determined but certification as a NFB provider by BCIA should be a minimal requirement.by BCIA should be a minimal requirement.At first, limit the scope of your practice to treating those At first, limit the scope of your practice to treating those disorders that you have successfully treated in your clinical disorders that you have successfully treated in your clinical practice and branch out when appropriately supervisedpractice and branch out when appropriately supervisedIn CA (check in your state) you need a license to charge a fee In CA (check in your state) you need a license to charge a fee to the public and certification should not be confused with to the public and certification should not be confused with licensure.licensure.


General RecommendationsGeneral Recommendations

Turn off the feedback when patient isn’t paying Turn off the feedback when patient isn’t paying attention to it or you need to speak to the patient (this attention to it or you need to speak to the patient (this sends a message to the patient that the A/V feedback sends a message to the patient that the A/V feedback is important)is important)Stress the importance of consistency in training, don’t Stress the importance of consistency in training, don’t treat new patients in one session per week (use treat new patients in one session per week (use practical models to explain this)practical models to explain this)Make sure to meet with both parents (child) or the Make sure to meet with both parents (child) or the spouse (adult) to assess their perspective (desire and spouse (adult) to assess their perspective (desire and support for, agreement with, etc.) on this treatmentsupport for, agreement with, etc.) on this treatmentMeet at regular intervals with the parent (child) and Meet at regular intervals with the parent (child) and occasionally with the spouse (adult).occasionally with the spouse (adult).



Assess improvements from a wider range of individuals than Assess improvements from a wider range of individuals than only a parent or spouse, if feasible, due to reliability issues with only a parent or spouse, if feasible, due to reliability issues with these sources of informationthese sources of informationConsider training sessions of less than 30 minutes duration or Consider training sessions of less than 30 minutes duration or less frequent training for more severely impacted disorders (ex. less frequent training for more severely impacted disorders (ex. Autistic Spectrum Disorder, Head Injury) – reason is unknown Autistic Spectrum Disorder, Head Injury) – reason is unknown but probably related to diminished integration capacity.but probably related to diminished integration capacity.Depending on level of intensity, duration, and frequency, Depending on level of intensity, duration, and frequency, negative effects should be tolerated when initiating treatment or negative effects should be tolerated when initiating treatment or sometimes after changing protocols. The most common is an sometimes after changing protocols. The most common is an increase in reactivity in boys in the first 6-10 sessions. It should increase in reactivity in boys in the first 6-10 sessions. It should be minimal and controllable. This is an indication that the child be minimal and controllable. This is an indication that the child is coming out of the “fog” of ADD/ADHD. It may also be seen in is coming out of the “fog” of ADD/ADHD. It may also be seen in remediating low-frequency coherence issues.remediating low-frequency coherence issues.


General RecommendationsGeneral RecommendationsHOW TO DETERMINE WHEN TO END TRAINING?HOW TO DETERMINE WHEN TO END TRAINING?

Attention Deficit Disorder is NOT a deficit of attention, Attention Deficit Disorder is NOT a deficit of attention, in fact, individuals with ADD have superior attention in fact, individuals with ADD have superior attention when engaged in tasks they enjoy (“Hyperfocus”) or when engaged in tasks they enjoy (“Hyperfocus”) or that capture their interest because it is novel that capture their interest because it is novel If you carefully examine the readings of an ADD If you carefully examine the readings of an ADD patient patient during the first 20 sessionsduring the first 20 sessions of NFB it will of NFB it will appear they are getting worse (especially in the appear they are getting worse (especially in the problematic low frequency). This is because they are problematic low frequency). This is because they are doing the exact same thing they typically do in all doing the exact same thing they typically do in all tasks involving sustained mental effort that are tasks involving sustained mental effort that are ordinary in your office. I call this sinking into the “fog” ordinary in your office. I call this sinking into the “fog” of ADD.of ADD.



The first session of NFB is inherently the ADD The first session of NFB is inherently the ADD patient’s most interesting, and therefore, by definition, patient’s most interesting, and therefore, by definition, most novel experience of NFBmost novel experience of NFBIt yields a reasonable and physiologically attainable It yields a reasonable and physiologically attainable set of scores that become the criteria I urge them to set of scores that become the criteria I urge them to work toward as their subjective experience of NFB work toward as their subjective experience of NFB morphs from an extraordinary experience (moving morphs from an extraordinary experience (moving something on the screen using only their brain) to an something on the screen using only their brain) to an ordinary experience (after 30 sessions, making “Pac-ordinary experience (after 30 sessions, making “Pac-Man” move is about as much fun as completing a Man” move is about as much fun as completing a sheet of math problems or writing an essay).sheet of math problems or writing an essay).



You’ll note that an ADD patient typically has their You’ll note that an ADD patient typically has their lowest Standard Deviation [SD] readings, and highest lowest Standard Deviation [SD] readings, and highest amplitude [mV] reading on reward and lowest amplitude [mV] reading on reward and lowest amplitude readings on the inhibits amplitude readings on the inhibits during their first during their first session of NFBsession of NFBThese are reasonable to use as goals, and if the ADD These are reasonable to use as goals, and if the ADD patient is able to attain them (or even close to them) patient is able to attain them (or even close to them) the patient’s ADD will likely no longer be the problem it the patient’s ADD will likely no longer be the problem it waswasThis works well assuming the patient isn’t too young, This works well assuming the patient isn’t too young, immature, or oppositional. immature, or oppositional.


General RecommendationsGeneral Recommendations HOW TO DETERMINE WHEN TO END TRAINING?HOW TO DETERMINE WHEN TO END TRAINING?

In cases where you have very young children or oppositional In cases where you have very young children or oppositional children this first session may not be all that reliable of a children this first session may not be all that reliable of a measure of progress. measure of progress. Another way involves examining their best score during one Another way involves examining their best score during one period of the 30-minute session. Typically, even very young period of the 30-minute session. Typically, even very young children or oppositional children will have one good period.children or oppositional children will have one good period.Criteria for knowing when to stop a protocol or change to a new Criteria for knowing when to stop a protocol or change to a new protocol is not agreed upon by experts in this field; so it remains protocol is not agreed upon by experts in this field; so it remains a bit of an art. One day we will have norms for each age based a bit of an art. One day we will have norms for each age based upon initial level of severity. Lacking these, we currently need upon initial level of severity. Lacking these, we currently need to base this decision on multiple factors which typically don’t to base this decision on multiple factors which typically don’t involve the opinion or evaluation of the child (if under 10 or 11)involve the opinion or evaluation of the child (if under 10 or 11)I look at multiple factors, the most important of which are:I look at multiple factors, the most important of which are:


General RecommendationsGeneral Recommendations HOW TO DETERMINE WHEN TO END TRAINING?HOW TO DETERMINE WHEN TO END TRAINING?

1) The Standard Deviation (SD) – this measure should 1) The Standard Deviation (SD) – this measure should decrease as the patient reaches the point of maximum decrease as the patient reaches the point of maximum benefit (PMB) and be consistent in all bands (<3.0 in 3 benefit (PMB) and be consistent in all bands (<3.0 in 3 Hz wide bands, and larger but proportional in wider Hz wide bands, and larger but proportional in wider bands) bands) 2) Amplitude microvoltage readings hit a ceiling 2) Amplitude microvoltage readings hit a ceiling (reward band) and floor (inhibit bands) for ~3 sessions(reward band) and floor (inhibit bands) for ~3 sessions3) parent and teacher rating scales have improved3) parent and teacher rating scales have improved4) the goals agreed to at the start of treatment have 4) the goals agreed to at the start of treatment have been realized.been realized.



If co-occurring conditions are present we may work on If co-occurring conditions are present we may work on them in a second phase of treatment. For example, if them in a second phase of treatment. For example, if the QEEG indicated the presence of a Learning the QEEG indicated the presence of a Learning Disorder, we may begin to focus on that. Also, Alpha-Disorder, we may begin to focus on that. Also, Alpha-Theta training can be helpful in patient’s who remain Theta training can be helpful in patient’s who remain anxious after treatmentanxious after treatmentParents or adult patients should taper their NFB, not Parents or adult patients should taper their NFB, not just stop. I have 3 levels of tapering one average, just stop. I have 3 levels of tapering one average, another more conservative for younger children or another more conservative for younger children or those in puberty, and a fairly liberal one for those those in puberty, and a fairly liberal one for those patients that are older and have shown consistency patients that are older and have shown consistency through the training period.through the training period.



Referral to an ADD coach or educational Referral to an ADD coach or educational specialist is often made as NFB is winding specialist is often made as NFB is winding down. This is to help “fill in the gaps” of things down. This is to help “fill in the gaps” of things the child or adult missed when ADD was the child or adult missed when ADD was prevalent in their lifeprevalent in their lifeI often recommend continuing to focus on those I often recommend continuing to focus on those skills that impede a child’s progress the most skills that impede a child’s progress the most and that the child be given a course in “how to and that the child be given a course in “how to be a successful student” most often called be a successful student” most often called “Study Skills”.“Study Skills”.



Remember, organization and study skills are not Remember, organization and study skills are not something we’re born knowing. After NFB the patient something we’re born knowing. After NFB the patient is now more likely than ever to be able to change is now more likely than ever to be able to change behavior patterns that are dysfunctional. Often behavior patterns that are dysfunctional. Often parents have given up and they need to be parents have given up and they need to be encouraged and told to raise the bar of their encouraged and told to raise the bar of their expectationsexpectationsI assume that, during the treatment, the clinician has I assume that, during the treatment, the clinician has worked with a prescribing physician to titrate or worked with a prescribing physician to titrate or eliminate use of medication, as necessary, if not, a eliminate use of medication, as necessary, if not, a treatment summary should be sent to the prescribing treatment summary should be sent to the prescribing physician recommending a re-evaluation.physician recommending a re-evaluation.



Sometimes the best effect of NFB comes in the Sometimes the best effect of NFB comes in the year or so after the treatment ends. This is year or so after the treatment ends. This is because, during that year, the gaps get filled in because, during that year, the gaps get filled in (information doesn’t just show up in the brain (information doesn’t just show up in the brain when one does NFB)when one does NFB)So, in subjects where mastery of past So, in subjects where mastery of past information is necessary (Math, for example) information is necessary (Math, for example) additional time may be necessary and tutoring, additional time may be necessary and tutoring, if available, is the best method to accomplish if available, is the best method to accomplish this.this.


Thank You!Thank You!

Time for questions?Time for questions?

schummer obtaining positive outcomes

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