Neurofeedback 101: A Crash Course for Professionals · Identify five types of brain wavesand associated states ... training the brain to improve function, flexibility, and efficiency

1/10/19

1

Neurofeedback101:ACrashCoursefor

Professionals Katherine Thorn, LCPC, BCN

Elizabeth Schroth, LCPC, BCN

Copyright Schroth and Thorn

Learning Objectives �  Define and distinguish Biofeedback and Neurofeedback

�  Identify five types of brain waves and associated states

�  Recognize common information provided on a brain map

�  Broadly understand how the brain map informs neurofeedback

�  Explain how brain dysregulation manifests in different disorders and how neurofeedback interventions can help

�  Recognize clients who are appropriate referrals for neurofeedback


New Paradigms

Mind Brain


What is Neurofeedback? (NFB)

�  NFB is a method of training brainwaves to alter the function of the brain

�  Improves the function, flexibility, and efficiency of the brain

�  It is used to help people reduce symptoms of a variety of disorders �  ADHD

�  Depression

�  Anxiety

�  TBI, Stroke �  Seizures as well as others


1/10/19

2

What is Biofeedback?

� Neurofeedback is rooted in the principles of biofeedback

� Biofeedback is the process of using instrumentation to provide information to the body that a person is not typically aware of


Biofeedback

Copyright Schroth and Thorn ; Photo Credit: Ed Hamlin

Biofeedback �  Heart Rate Variability (Heart Math Institute, Inner

Balance)

�  Thermal (Handwarming)

�  Blood pressure

�  Breathing (e.g., Belly Biofeedback – Diaphramatic Breathing)

�  EEG (Electroencephalogram)


Recap: What is Neurofeedback?

Neurofeedback is a system for training the brain to improve function, flexibility, and efficiency.

Based on biofeedback, it reflects information back to the person which allows them to modify the way their brain works.


1/10/19

3

Operant Conditioning � The individual is rewarded for his/her

training efforts during NFB training � Auditory Feedback � Visual Feedback

� The reward process is called “reinforcement” (Behaviorism)


Long-lasting Learning � Once we learn something it becomes a

part of our behavior

� Follow up studies in neurofeedback show that the effects continue for up to 30 years (Soutar, 2011)


What to Expect? �  Initial consultation � Evaluation

� Brain Map & Symptoms Measures � Treatment begins with a thorough

assessment � 2-3 sessions a week � 20-30 minutes of feedback � Session total time 45mins-1 hour � Typically 20-50 sessions to complete

treatment Copyright Schroth and Thorn

When do people start to feel better?

�  Each individual responds differently to NFB

�  The greater their sensitivity to neurofeedback the more quickly they feel effects

�  Sensitivity to drugs often predicts sensitivity to NFB

�  Some individuals feel changes in 1-5 sessions for others it can be 15-20 sessions


1/10/19

4

What’s happening in the brain?


Optimal Functioning


Brain dysregulation: •  when the brain “gets stuck” and operates

from one of three states of arousal level

UNDER AROUSED

OVER AROUSED

MIXED

Inattentive, Disorganized,

Easily Distracted Daydreamy

Stressed, Hyperactive,

Impulsive Sleep Issues

Inattentive, Anxious Angry


Brainwaves Delta

1-4 hz

Theta 5-8 hz

Alpha 9-12 hz

Beta 13-19 hz

High Beta 20-39 hz

Slow

Fast

Sleepy

Relaxed Inward Focus

Thinking

Tension, Anxiety


1/10/19

5

QEEG comparison


Case 1: Jonny 10 year old ADHD


Bessel Van Der Kolk �  Harvard Psychiatrist

The drawings above are from a 10-year-old child who had been diagnosed with ADHD. She drew the first one prior to neurofeedback and the last one after three months of neurofeedback treatment. Picture courtesy of Dr. Bessel van der Kolk, Medical Director of the Trauma Center in Boston, MA

3 Tenants 1. Brain produces electrical

activity that can be measured 2. This electrical activity correlates

with mental states 3. This activity can be trained

through learning (operant and classical conditioning)


1/10/19

6

Case 2: “Tom” 36 year old

Trauma/Anxiety


Case 3: “Ann” 80 year old

Insomnia/Memory Issues


Appropriate Referrals for NFB

�  Mood disorders

�  Anxiety

�  ADHD and issues with focus, attention, and executive functioning

�  Insomnia and sleep issues

�  ASD, Asperger’s Syndrome, Sensory Processing Issues

�  Stress-related physical issues, like migraines, IBS, and headaches

�  Trauma symptoms

�  Post-concussive issues (after a couple of weeks)


Not Appropriate Referrals for NFB

�  Currently taking benzodiazepines

�  Changing medications (wait until stable)

�  Untreated addiction (unless as part of treatment program)

�  Actively suicidal (not suicidal ideation)

�  Active eating disorders

�  Really negative situations (negative relationship/abuse/bullying) – progress in NFB may be slower unless these are addressed

�  Systemic issues: need to figure out these underlying issues first

�  Metabolic issues, Hormonal, Infection, Nutrition Copyright Schroth and Thorn

1/10/19

7

Appropriate NFB Providers

�  Look for board certified providers. �  Board certification is highest standard and is given by

BCIA, the international certifying board.

�  Can locate BCN providers at bcia.org

�  Important for clients to find a clinician with convenient location and scheduling to accommodate multiple appointments a week

�  Clinician with experience with population and issues

�  Clinical license


Over 40 years of research shows that neurofeedback can be helpful with a number of different psychological and neurological conditions.

ADHD ! Anxiety ! Panic Attacks!Insomnia ! Chronic Pain! Bedwetting!Migraine ! Fibromyalgia ! TBI !Tension Headache! PTSD ! Depression!Learning Disorders ! Autism / Asperger�s ! Tics !

As well as other conditions


AmericanAcademyofPediatrics–Oct2012

27

Level 1- Level 2- Level 3- Level 4- Level 5- Problem Area BEST SUPPORT GOOD SUPPORT MODERATE SUPPORT MINIMAL SUPPORT NO SUPPORT Anxious or Avoidant Cognitive Behavior Therapy Assertiveness Training, Attention, CBT for Child and Contingency Management, Biofeedback, CBT with Parents Assessment/Monitoring, Attachment Therapy, Client Behaviors (CBT), CBT and Medication, Parent, Cultural Storytelling, Family Psychoeducation, Group Therapy Only, Play Therapy, Centered Therapy, Eye Movement Desensitization CBT with Parents, Education, Hypnosis, Relaxation, Stress Inoculation Psychodynamic Therapy, and Reprocessing (EMDR), Peer Pairing, Exposure, Modeling Rational Emotive Therapy Psychoeducation, Relationship Counseling, Teacher Psychoeducation

Attention and Behavior Therapy and Contingency Management, Education, Parent Biofeedback and Medication Parent Management Training Attention Training, Client Centered Therapy, CBT, Hyperactivity Behaviors Medication, Biofeedback, Management Training (with Problem Solving, or with and Social Skills, Relaxation, CBT and Anger Control, CBT and Medication, Family Parent Management Training, Teacher Psychoeducation), Physical Exercise (with or Self-Verbalization and Therapy, Parent Coping/Stress Management, Parent Self-Verbalization without Relaxation), Social Skills and Medication, Contingency Management, Management Training and Self-Verbalization, Problem Working Memory Training Social Skills Solving, Psychoeducation, Self-Control Training, Self-Verbalization and Medication, Skill Development

Autism Spectrum Intensive Behavior Therapy, Parent Management Training, Peer Pairing, Physical/ None Cognitive Behavior Therapy, Auditory Integration Training, Biofeedback, Eclectic Disorders Intensive Communication Social/Occupational Therapy Massage, Social Skills Therapy, Hyperbaric Treatment, Modeling, Structured Training Listening

Delinquency and Anger Control, Assertiveness Communication Skills, Contingency Management, Client Centered Therapy, CBT and Teacher Training; Behavioral Family Therapy, Catharsis, CBT and Anger Disruptive Behavior Training, CBT, Multisystemic Functional Family Therapy, Parent Management Family Therapy, Moral Parent Management Training, Control, CBT with Parents, Collaborative Problem Therapy, Parent Management Training and CBT, Parent Management Training and Reasoning Training, Outreach Classroom Contingency Solving, Education, Exposure, Family Empowerment, Training, Parent Management Classroom Management, Problem Solving, Rational Counseling, Peer Pairing, Management, and CBT; Parent Family Systems Therapy, Group Therapy (!!), Imagery Training and Problem Solving, Emotive Therapy, Relaxation, Therapeutic Foster Care, Self-Control Training Management Training and Training, Parent Management Training and Peer Social Skills Transactional Analysis Self-Verbalization; Physical Support, Play Therapy, Psychodynamic Therapy, Exercise; Stress Inoculation Self-Verbalization, Skill Development, Wraparound

Depressive or Withdrawn CBT, CBT and Medication, CBT Client Centered Therapy, Cognitive Behavioral None Problem Solving, Self-Control Life Skills, Play Therapy, Psychodynamic Therapy, Behaviors with Parents, Family Therapy Psychoeducation, Expressive Writing/Journaling/Diary, Training, Self-Modeling Psychoeducation, Social Skills Interpersonal Therapy, Relaxation

Eating Disorders None CBT, Family Therapy, Family Systems Therapy None None Client Centered Therapy, Education, Goal Setting

Elimination Disorders Behavior Alert; Behavior Alert Behavioral Training and Dietary Care; Behavioral Behavior Alert and Medication None Assessment/Monitoring, Assessment/Monitoring and and Behavioral Training; Training, Hypnosis, and Dietary Care; CBT Medication, Behavioral Training and Medical Care, Behavioral Training; Behavioral Biofeedback, Contingency Management, Dietary Care, Training, Dietary Care, and Dietary Care and Medical Care, Hypnosis, Medical Medical Care (with or without Care, Psychoeducation Biofeedback)

Mania None Cognitive Behavioral Psychoeducation None None Family-Focused Therapy, Psychoeducation

Substance Use CBT, Community Assertive Continuing Care, CBT and Medication, CBT Drug Court, Drug Court with Goal Setting Behavioral Family Therapy, CBT and Functional Family Reinforcement, Family with Parents, Contingency Management, Family Multisystemic Therapy and Therapy, Client Centered Therapy, Drug Court and Therapy Systems Therapy, Functional Family Therapy, Goal Contingency Management Multisystemic Therapy, Education, Family Court, Group Setting/Monitoring, Motivational Interviewing/ Therapy (!!), Motivational Interviewing/Engagement Engagement (with and without CBT), Multidimensional with CBT and Family Therapy, Multisystemic Therapy, Family Therapy, Purdue Brief Family Therapy Parent Psychoeducation, Problem Solving, Project CARE (!!), Psychoeducation

Suicidality None Attachment Therapy, Counselors Care, Counselors None None Accelerated Hospitalization, Counselors Care and Care and Support Training, Multisystemic Therapy, and Anger Management Social Support Team

Traumatic Stress CBT, CBT with Parents Exposure None EMDR, Play Therapy, Client Centered Therapy, CBT and Medication, Psychodrama CBT with Parents Only, Interpersonal Therapy, Psychodynamic Therapy, Psychoeducation, RelaxationNote: Level 5 refers to treatments whose tests were unsupportive or inconclusive. The symbol (!!) indicates that at least one study found negative effects on the main outcome measure. The risk of using treatments so designated should be weighed against potential benefits. This report updates and replaces the “Blue Menu” originally distributed by the Hawaii Department of Health, Child and Adolescent Mental Health Division, Evidence-Based Services Committee from 2002–2009.

This report is intended to guide practitioners, educators, youth, and families in developing appropriate plans using psychosocial interventions. It was created for the period November 2012–April 2013 using the PracticeWise Evidence-Based Services (PWEBS) Database, available at www.practicewise.com. If this is not the most current version, please check the American Academy of Pediatrics mental health Web site (www.aap.org/mentalhealth) for updates.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Original document included as part of Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit. Copyright © 2011 American Academy of Pediatrics, revised October 2012. All Rights Reserved. 7KH�$PHULFDQ�$FDGHP\�RI�3HGLDWULFV�GRHV�QRW�UHYLHZ�RU�HQGRUVH�DQ\�PRGLÀFDWLRQV�PDGH�WR�WKLV�GRFXPHQW�DQG�LQ�QR�HYHQW�VKDOO�WKH�$$3�EH�OLDEOH�IRU�DQ\�VXFK�FKDQJHV�

EVIDENCE-BASED CHILD AND ADOLESCENT PSYCHOSOCIAL INTERVENTIONS

Page 1 of 1COMMUNITY RESOURCESDECISION SUPPORT FOR CLINICIANS

Strength of Evidence Definitions Level 1: Best Support I. At least 2 randomized trials demonstrating efficacy in one or more of the following ways: a. Superior to pill placebo, psychological placebo, or another treatment. b. Equivalent to all other groups representing at least one Level 1 or Level 2 treatment in a study with adequate statistical power (30 participants per group on average) and that showed significant pre�post change in the index group as well as the group(s) being tied. Ties of treatments that have previously qualified only through ties are ineligible. II. Experiments must be conducted with treatment manuals. III. Effects must have been demonstrated by at least 2 different investigator teams.

Level 1- Level 2- Level 3- Level 4- Level 5- Problem Area BEST SUPPORT GOOD SUPPORT MODERATE SUPPORT MINIMAL SUPPORT NO SUPPORT Anxious or Avoidant Cognitive Behavior Therapy Assertiveness Training, Attention, CBT for Child and Contingency Management, Biofeedback, CBT with Parents Assessment/Monitoring, Attachment Therapy, Client Behaviors (CBT), CBT and Medication, Parent, Cultural Storytelling, Family Psychoeducation, Group Therapy Only, Play Therapy, Centered Therapy, Eye Movement Desensitization CBT with Parents, Education, Hypnosis, Relaxation, Stress Inoculation Psychodynamic Therapy, and Reprocessing (EMDR), Peer Pairing, Exposure, Modeling Rational Emotive Therapy Psychoeducation, Relationship Counseling, Teacher Psychoeducation

Attention and Behavior Therapy and Contingency Management, Education, Parent Biofeedback and Medication Parent Management Training Attention Training, Client Centered Therapy, CBT, Hyperactivity Behaviors Medication, Biofeedback, Management Training (with Problem Solving, or with and Social Skills, Relaxation, CBT and Anger Control, CBT and Medication, Family Parent Management Training, Teacher Psychoeducation), Physical Exercise (with or Self-Verbalization and Therapy, Parent Coping/Stress Management, Parent Self-Verbalization without Relaxation), Social Skills and Medication, Contingency Management, Management Training and Self-Verbalization, Problem Working Memory Training Social Skills Solving, Psychoeducation, Self-Control Training, Self-Verbalization and Medication, Skill Development

Autism Spectrum Intensive Behavior Therapy, Parent Management Training, Peer Pairing, Physical/ None Cognitive Behavior Therapy, Auditory Integration Training, Biofeedback, Eclectic Disorders Intensive Communication Social/Occupational Therapy Massage, Social Skills Therapy, Hyperbaric Treatment, Modeling, Structured Training Listening

Delinquency and Anger Control, Assertiveness Communication Skills, Contingency Management, Client Centered Therapy, CBT and Teacher Training; Behavioral Family Therapy, Catharsis, CBT and Anger Disruptive Behavior Training, CBT, Multisystemic Functional Family Therapy, Parent Management Family Therapy, Moral Parent Management Training, Control, CBT with Parents, Collaborative Problem Therapy, Parent Management Training and CBT, Parent Management Training and Reasoning Training, Outreach Classroom Contingency Solving, Education, Exposure, Family Empowerment, Training, Parent Management Classroom Management, Problem Solving, Rational Counseling, Peer Pairing, Management, and CBT; Parent Family Systems Therapy, Group Therapy (!!), Imagery Training and Problem Solving, Emotive Therapy, Relaxation, Therapeutic Foster Care, Self-Control Training Management Training and Training, Parent Management Training and Peer Social Skills Transactional Analysis Self-Verbalization; Physical Support, Play Therapy, Psychodynamic Therapy, Exercise; Stress Inoculation Self-Verbalization, Skill Development, Wraparound

Depressive or Withdrawn CBT, CBT and Medication, CBT Client Centered Therapy, Cognitive Behavioral None Problem Solving, Self-Control Life Skills, Play Therapy, Psychodynamic Therapy, Behaviors with Parents, Family Therapy Psychoeducation, Expressive Writing/Journaling/Diary, Training, Self-Modeling Psychoeducation, Social Skills Interpersonal Therapy, Relaxation

Eating Disorders None CBT, Family Therapy, Family Systems Therapy None None Client Centered Therapy, Education, Goal Setting

Elimination Disorders Behavior Alert; Behavior Alert Behavioral Training and Dietary Care; Behavioral Behavior Alert and Medication None Assessment/Monitoring, Assessment/Monitoring and and Behavioral Training; Training, Hypnosis, and Dietary Care; CBT Medication, Behavioral Training and Medical Care, Behavioral Training; Behavioral Biofeedback, Contingency Management, Dietary Care, Training, Dietary Care, and Dietary Care and Medical Care, Hypnosis, Medical Medical Care (with or without Care, Psychoeducation Biofeedback)

Mania None Cognitive Behavioral Psychoeducation None None Family-Focused Therapy, Psychoeducation

Substance Use CBT, Community Assertive Continuing Care, CBT and Medication, CBT Drug Court, Drug Court with Goal Setting Behavioral Family Therapy, CBT and Functional Family Reinforcement, Family with Parents, Contingency Management, Family Multisystemic Therapy and Therapy, Client Centered Therapy, Drug Court and Therapy Systems Therapy, Functional Family Therapy, Goal Contingency Management Multisystemic Therapy, Education, Family Court, Group Setting/Monitoring, Motivational Interviewing/ Therapy (!!), Motivational Interviewing/Engagement Engagement (with and without CBT), Multidimensional with CBT and Family Therapy, Multisystemic Therapy, Family Therapy, Purdue Brief Family Therapy Parent Psychoeducation, Problem Solving, Project CARE (!!), Psychoeducation

Suicidality None Attachment Therapy, Counselors Care, Counselors None None Accelerated Hospitalization, Counselors Care and Care and Support Training, Multisystemic Therapy, and Anger Management Social Support Team

Traumatic Stress CBT, CBT with Parents Exposure None EMDR, Play Therapy, Client Centered Therapy, CBT and Medication, Psychodrama CBT with Parents Only, Interpersonal Therapy, Psychodynamic Therapy, Psychoeducation, RelaxationNote: Level 5 refers to treatments whose tests were unsupportive or inconclusive. The symbol (!!) indicates that at least one study found negative effects on the main outcome measure. The risk of using treatments so designated should be weighed against potential benefits. This report updates and replaces the “Blue Menu” originally distributed by the Hawaii Department of Health, Child and Adolescent Mental Health Division, Evidence-Based Services Committee from 2002–2009.

This report is intended to guide practitioners, educators, youth, and families in developing appropriate plans using psychosocial interventions. It was created for the period November 2012–April 2013 using the PracticeWise Evidence-Based Services (PWEBS) Database, available at www.practicewise.com. If this is not the most current version, please check the American Academy of Pediatrics mental health Web site (www.aap.org/mentalhealth) for updates.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Original document included as part of Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit. Copyright © 2011 American Academy of Pediatrics, revised October 2012. All Rights Reserved. 7KH�$PHULFDQ�$FDGHP\�RI�3HGLDWULFV�GRHV�QRW�UHYLHZ�RU�HQGRUVH�DQ\�PRGLÀFDWLRQV�PDGH�WR�WKLV�GRFXPHQW�DQG�LQ�QR�HYHQW�VKDOO�WKH�$$3�EH�OLDEOH�IRU�DQ\�VXFK�FKDQJHV�

EVIDENCE-BASED CHILD AND ADOLESCENT PSYCHOSOCIAL INTERVENTIONS

Page 1 of 1COMMUNITY RESOURCESDECISION SUPPORT FOR CLINICIANS

Evidence Base for NF for ADHD

Year Journal

Sam

ple

Con

trol

Ran

dom

Key Results/Conclusions

2009 *Journal of Child Psychology and Psychiatry 102 � �

Results indicate clinical efficacy of NF for children with ADHD.

2006 *Neuroscience Letters 20 � � Results suggest NF has the capacity to functionally normalize brain systems mediating selective attention and response inhibition in ADHD children. 2006

*Applied Psychophysiology and Biofeedback 20 � �

2009 Clinical EEG and Neuroscience

1,194 N/A

N/A Meta study concluded NF is efficacious & specific for ADHD.

2012 BMC Psychiatry 130 � � NF is as effective as methylphenidate.

2002 Applied Psychophysiology and Biofeedback 100 �

NF showed significant improvement in behavior, Ritalin did not. NF group showed normalisation of EEG, Ritalin group did not.

2005 Child and Adolescent Psychiaric Clinics of North America

100 �

NF group still showed improvement 2 years after end of NF, Ritalin effect ended on cessation of medication. 80% of NF group reduced Ritalin by > 50%; 85% of Ritalin group increased dose, 0 reduced.

2007 Applied Psychophysiology and Biofeedback 38 � �

2 different NF protocols showed improvement in all 4 measures.

2008 International Journal of Bioelectromagnetism 38 � � Improvements still present from NF 2 years after original trial.


1/10/19

8

Recent Developments

ü Neurofeedback is considered an evidenced-based practice by the American Psychological Association

ü American Academy of Pediatrics recognized neurofeedback as a Level-1: Best Support Intervention for ADHD in 2012

ü Substance Abuse Mental Health Services Administration (SAMHSA) added a neurofeedback protocol to National Registry of Evidence-Based Program and Practices (NREPP)


www.isnr.org : International Society for Neurofeedback and Research. This site contains a comprehensive bibliography of outcome research in neurofeedback, organized by disorder, as well as journal articles, provider list and other information.

www.bcia.org: National credentialing organization for biofeedback providers. Includes information on providers and standards.

www.aapb.org: Association for Applied Psychophysiology and Biofeedback is the national biofeedback organization. Includes information and a provider list.

Resources: Web Sites


Resources – Books

•  A Symphony in the Brain by Jim Robbins •  Getting Rid of Ritalin by Robert W. Hill, Ph.D and

Eduardo Castro, M.D •  ADD: the 20 Hour Solution by Mark Steinberg,

Ph.D. and Siegfried Othmer, Ph.D. •  The Healing Power of Neurofeedback by Steven

Larsen, Ph.D.

•  Neurofeedback in the Treatment of Developmental Trauma by Sebern Fisher

•  The Body Keeps the Score by Bessel Van Der Kolk


Thank you! Contact Us! Katherine Thorn Phone: 703-288-9595

[email protected]

Liz Schroth Phone: 301-602-4388

[email protected]

[email protected]


Both of our offices: 8700 Georgia Avenue, Suites 303

(Liz) & 304 (Katherine) Silver Spring MD 20910

Documents

Neurofeedback 101: A Crash Course for Professionals · Identify five types of brain wavesand associated states ... training the brain to improve function, flexibility, and efficiency