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To Fit In Or Not:Integrating Social & Emotional Communication Interventions
& Software, NF, HRV, & Alpha-stim to Improve Behavioral Outcomes
North Carolina Biofeedback Society, 2011
Presented by: Emily Stevens, Ph.D., LPC, BCN
TECHNOLOGY IS CHANGING MENTAL HEALTH TREATMENT
Neuro-Cognitive Enhancement Model for Success (NEMS)
...Defined as utilizing different techniques and technology as an adjunct to treatment to help an individual develop the skills needed to perform successfully and effectively.
Interactive brain-based model for treatment.
Includes a combination of software based interactive programs, neurofeedback, and non-invasive stimulation based technology combined with therapy.
To Fit in or Not….
Social Competence
• Increased numbers of children showing behavioral and social issues….
• Increased numbers of children being diagnosed…– Autism/Asperger Spectrum– Severe Mood Dysregulation (Bipolar)– Anxiety– Socially awkward, insecure
• Social Anxiety is key to long-term development of emotional issues and addiction.
• Goal: Intervention & Prevention
• We have been using brain-based treatment to improve symptoms associated with ADHD, anxiety, depression, OCD etc… but we have not spent a lot of time focusing on what brain research is teaching us about social communication and how to train it and/or improve it.
• Research has continued to teach us about the development of emotional communication starting at birth and what is happening in the brain when we interact with others.
What is causing the behaviors that we are observing?
• Neurological, Social, Genetic, Environmental?
• Or are we all simply a disorder? Westernized medicine & mental health has attempted to simplify this idea with the current psychopharmacological approach to treatment.
Ex: Childhood Bipolar?
• Severe Mood Dysregulation, Temper dysregulation disorder, behavioral disorders– Sleep– Inability to self-sooth by 18 months of age– Chronic irritability– Carb craving– Temperature dysregulation– Anxiety, separation anxiety– Chronic fight or flight– Poor emotion and social recognition/ communication
• What is causing the behaviors we are seeing?
• Systems…..– Dysregulation of arousal– Immature nervous system– Fight of flight – dysregulated stress response system
Tips for Emotional and Social Communication
Limbic – Amygdala Support
What have we learned about the amygdala? Emotion Recognition?
Amygdala
The Amygdala is also knownas the “Hub of Fear”
Poe’s Heart and The Mountain Climber
The Effects of Nurture impact... The Early Emotional Recording
• Starting at birth… from 0-2 years of age…
• “Depressed” preschoolers are more tuned in to negative facial expressions.
• Sadness, Shame and Fear were the ones they responded to most.
– FACE: Facial Affect Comprehension Evaluation Test
• “Depressed” teenagers and adults tend to interpret happy facial expressions as neutral and neutral expressions as sad.
» NIMH 5 year study, Washington Univ., 2000
More Research…
• Violent and aggressive teenage girls fail to spot anger or disgust in faces compared to normal peers. – Anti-social behavior tends to show in girls in their teen years and not
when they are younger and is on the increase in females 14-18.– Boys w child onset of CD also have difficulties recognizing anger
and disgust but adolescent males do not according to other studies.– Biological Psychiatry, 2010
• Fearless 3-4 year olds who demonstrate fearless behavior have less empathy and more aggression toward peers which is correlated with genetic/parental influence.
– They do not recognize facial expressions of fear or distress in a classmate or initiate helping the distressed peer.
– They are described as generally aggressive, take advantage of friends, emotionally shallow and lack regret or guilt
– The heart rate in children with fearless behavior was slower to start compared to peers.
– University of Haifa, Faculty of Education, Israel, Nov 13, 2010
• Teenagers antisocial conduct and judgements about aggressive behaviors influences each other at early, middle and late adolescence.
• Social decision making and behavior continue to influence each other over time.
• Efforts to change these behaviors are more effective if interventions address how adolescents make decisions about acting aggressively.
• Awareness of what is driving their behavior…– J. Child Development, Mar/Apr 2008
Face Test, The Eyes Test www.autismresearchcentre.com
DANVA : Diagnostic Analysis of Nonverbal Accuracy http://www.psychology.emory.edu/clinical/interpersonal/danva.htm
http://www.creducation.org/resources/nonverbal_communication/assessment_with_danva.html
Assessment
Interview or Questionnaire Instruments
• CDI (Child Depression Inventory), RADS-2 (Reynolds Adolescent Depression Scale)
• Children’s Inventory of Anger, Aggression Questionnaire, Adolescent Anger Rating Scale, Conduct Disorder Scale
• ARI Adolescent Risk Inventory
• Adjustment Scales Inventory, Reynolds Adol Adjustment Screening Inv.
• Symptoms Assessment-45 (13 & up)
• Revised Children’s Manifest Anxiety Scale, Multidimensional Anxiety Scale for Children, Social Phobia & Anxiety Inventory
• Feelings, Attitudes & Behavior Scale for Children
• Jeannie & Jeffrey Illustrated Interview for Children– (online @ www.jbrf.org)
• www.schoolpsychiatry.org Table of Screening tools & rating scales
Social & Emotional Development
• Social Development:• What are your natural tendencies?
» shy, awkward, defensive, explosive, negative• How often do you see happy/angry/sad faces?• What do children observe in the media?
• Do you feel like you belong? Do you have a sense of belonging?
• Social exclusion changes brain function and can lead to poor decision making and diminished learning ability.
» Journal of Social Neuroscience, Nov., 2006
• Students who feel “disconnected” from their school environments are at higher risk for poor and unsafe behavior.
• Key areas identified:– I feel close to people at school– I feel like I am part of this school– I am happy to be at this school– The teachers at this school treat people fairly– I feel safe in my school
» J. Pediatrics, 2000, Nov.
Emotion Recognition Interventions
• What do emotions and feelings look like?• Posters, pictures, magazines, movie clips• Scrap book• Observation Exercises• Mood Adjustment Exercises:
• Changing mood with facial expression and thoughts.
“Re-record the Limbic”
Step 1: What do they look like? Emotion Recognition Exercises
Step 2: What do they sound like?Hearing and Expressing EmotionsAppropriate Emotional ExpressionDeveloping a Full Range of Emotional Expression
Step 3: How do I act?Body Language and Physical Expression of Emotions
Emotional Communication cont.
• Thoughts, Feelings & Actions Graph• Behavior/Situation, My thoughts, My feelings, My
actions• Anger Buttons/ Pushing My Buttons Drawing• Make a list of emotions
• Make the face, Describe a time when I felt…• Sad, rejected, excited, insecure, silly, hopeful…
• How Would You Feel Activity: Provide a list of scenarios and have the child describe how they would feel or react
• Draw a picture of a body: Where do I feel my feelings?
Social Communication
• Effective conflict resolution is built on strong communication skills.• Keys to support effective social communication and conflict
resolution.– Have the child describe & discuss their feelings.
– Teach mirroring: listening & paraphrasing.
– Teach empathy, connection/relate to thoughts and feelings of others, understanding others leads to the ability to compromise.
– Teach compromise.
» What is negotiable and what is non-negotiable.
» How does it relate to your personal values.
– Teach basic rules of conduct: no name calling, the past is the past…
– Teach active listening, restate, paraphrase, summarize
Social Competence
• The ability to achieve personal goals in social interaction while at the same time maintaining positive relationships with others over time and across situations.
Social Skills Software
• Social Skill & Emotion Recognition Software– www.socialskillbuilder.com (4-18 years)
• Teach social cues• Teach appropriate responses• Teach physical boundaries
• www.autismcoach.com» Fun with Feelings (6-11 yrs)» Smart Alex (5-15 yrs)» MindReading (5 – adult)
• FaceSay Social Skill Program » www.facesay.com (school age)
Studies to Support the use of Software:
• Social Skill Software: School Rules & My School Day– Pilot Study 2004 Virginia Public Schools: On average, students who
used My School Day software gained 10 percent in every category of the Vineland Adaptive Behavior Scales, compared to a 3 percent gain when using traditional methods alone.
– Areas of Improvement w Technology Based Intervention:– Daily Living Skills– Socialization:– Adaptive Behavior– Communication
For Example: School Rules
• Complex peer relationships• Subtle social cues• Appropriate Social
Interactions
Cognitive age: 8-18
Over 350 Video Scenarios
Percent of Test Sample Demonstrating Positive Gains in VABS Subtests
20%
40%
20%
40%
80%
60%
60%
60%
0 20 40 60 80 100
Communication
Adaptive Behavior
Socialization
Daily Living Skills
Traditional Therapy Group Experimental Group
• Social skills are the basis for all of our relationships throughout life…it impacts school, work, family and all our social interactions.
• Charts & tools for monitoring social and behavioral progress:– Book: Skills Training for Children w/ Behavior Disorders
by: M. Blookquist
Managing the Stress Response System
Role in Emotion Recognition and Social Communication
CES & HRV biofeedback
Altered Pituitary-Adrenal Axis (Heim et al., 2001)
• Early adverse life situations – induce persistent changes in corticotropin-releasing factor –
• Multiple studies - Progressive sensitization to stress in children as well as early maternal stress sensitizes infants causing a stress-response system (HPA) that breaks down.
• (J. Psychiatry, 2002; Biological Psychiatry, 2002)
• Penza et al., 2003– Neurobiological effects of childhood abuse: Early life
traumatic events appear to permanently render neuroendocrine stress response systems supersensitive. Childhood abuse increases vulnerability to depression and anxiety especially in females.
Conclusions…
There are no conflicts of interest to report
Trauma creates a stress hormone response that impacts the endocrine system and has a long term impact on the pituitary and normal hormone functioning when not treated properly.
New hope for anxiety, depression & aggression?Cranial Electrostimulation (CES)
Electrotherapy, Electromedicine & Alpha-Stim Technology
Cranial Electro-Stimulation (CES)
• Cranial electrotherapy stimulation (CES) is the application of low-level, pulsed electrical currents (usually not exceeding one milliampere), applied to the head for medical and/or psychological purposes.
• It is primarily used to treat both state (situational) and trait (chronic) anxiety, depression, insomnia, stress
related and drug addiction disorders, but it is
also proving indispensable for treating pain
patients. (Lichtbroun, Raicer & Smith, 2001; Kirsch & Smith, 2000; Thuile & Kirsch, 2000)
How do you use it?
• Cranial electrotherapy stimulation is a simple treatment that can easily be administered at any time. – The current is applied by easy-to-use clip electrodes that attach on the
ear lobes, or by stethoscope-type electrodes placed behind the ears.
• Patients experience the effects immediately and experience continued improvement overtime. – The ideal treatment time is 20 to 60 minutes, but some patients may
achieve the full benefits of a CES treatment within 10 minutes.
• Following CES, most people feel better, less distressed, and more focused on mental tasks. They generally sleep better and report improved concentration, increased learning abilities, enhanced recall, and a heightened state of well-being.
• The Alpha-Stim unit is FDA approved for anxiety & depression.• www.alpha-stim.com
Studies
• At present, there are over 100 research studies on CES in humans and 20 experimental animal studies (Kirsch, 1999).
• CES reduces aggression in violent in-patient population.» J. Neuropsychiatry Clin Neurosci. 17:4, Fall, 2005.
• 3 month course of CES
– 59% decrease in aggressive episodes from baseline
– 72% decrease in seclusions
– 58% decrease in restraints
– 53% decrease in PRN’s
• CES reduces aggression in violent neuropsychiatric patients.» Primary Psychiatry. March 2007.
• 3 month course of CES (48 patients: 83% responded positively to CES)
– 41% decrease in violent episodes, 48% decrease in patients w/ sudden assault syndrome.
– 40% reduction in restraints
– 42% reduction in PRN’s
Alpha-Stim Data:
Alpha-Stim Averages (ages 6-12)
42.0044.0046.0048.0050.0052.0054.00
TOTAL T-S
CORE
FRUST T-S
CORE
PHYS T-S
CORE
PEER T-S
CORE
AUTH T-S
CORE
T-S
core
s
Pre-Test
Post-Test
Pre and Post 20 sessions over 4-5 weeks Test: Childrens Inventory of Anger
Alpha-Stim Data Cont.
Alpha-Stim Averages (All Units Combined)
40.0042.0044.0046.0048.0050.0052.0054.00
T-S
co
res
Pre-TestPost-Test
29 Residents Ages: 6-18 years
Incidents on All Units
0
20
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60
80
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120
140
Incidents
# O
f In
cid
ents
Total
On Alpha-Stim
Off Alpha-Stim
Total number of incidents decreased using Alpha-stim technology
Heartmath HRV Training
• HRV = Heart Rate Variability Training
• Stress & Anxiety Management• Anxiety, aggression• Focus Techniques –
– “The Zone”• EM Wave PC
• www.heartmath.com
4. Auditory Visual Stimulation (AVS)
Also called Auditory Visual Entrainment
(AVE)
Auditory Visual Stimulation
• AVS allows the brain to be entrained at specific brainwave frequencies during the session.
• It has been described as “exercising the brain”
• Research has shown that:– Decreases stress-related chemicals– Reduces muscle tension, blood pressure and heart
rate, psychological symptoms.– Increases, IQ, performance, memory, attention
AVS...
• AVS has been used to treat:• Depression and Seasonal Affective
Disorder• Headaches and Migraines• PMS, Hypertension• ADHD, LD and poor performance• Stress
• What are other reported effects of AVS?• Improved reading and achievement
AVS Clinical Overview
• LD/ADHD: Russell and Carter, 1993, conducted a study on a group of learning disabled boys between 8 and 12 years of age. The boys were given 40 sessions of AVE stimulation at 10 Hz and 18 Hz and showed an average IQ increase of 8 points on the Raven IQ test and significant improvement (<. 01) in memory, reading and spelling.
• PMS:76% experienced a greater than 50% reduction in their PMS symptoms (Anderson, Medical College, London)
New Visions School Project
• New Visions School NeuroTechnology Replication Project 2000 - 2001, Michael Joyce
– This hallmark study is the largest, most convincing study showing the effectiveness of the DAVID Paradise driving a multiple system to treat children with attentional disorders. The data generated in the Neuro-Technology (NT) replication project are the result of the efforts of seven Minnesota public schools (five elementary, one middle and one K-12).
– Data was gathered for a total of 204 students from seven different school districts that participated in the NeuroTechnology Program statewide. The average student completed nearly 30 twenty-minute sessions over a period of three months, and gained eight months in grade-equivalent oral reading scores.
Initial results of :The effects of 14hz AVE on symptoms of depression and relative frontal alpha
Brain Response, Brain Changes or Placebo?
Study:Phase I
QEEG Correlates of Auditory Visual Entrainment Efficacy in Treatment Resistant Depression
Journal of Neurotherapy, Vol 13, April 2009Cantor & Stevens
Key Components
• Cognitive Software:– Working Memory, Attention, Focus, Following Directions, Impulse
Control, and Staying w/ Task• Captains Log: Next Generation & Working Memory• Happy Neuron• Earobics
– Emotion Recognition and Social Skill Training• Smart Alex• Fun w/ Feelings• School Rules
• Neurofeedback (Cz & F3)• HRV• AVS• Alpha-Stim CES
Producing Measurable Outcomes…Case Review 1: 14 yr Male11 Neuro, 4 AVS, 2 Earobics (A little goes a long way)
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0
75
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95
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85
103
83
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124113
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AudImpulse
VisImpulse
Aud Cons Vis Cons Aud Stam Vis Stam
Pre
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IVA Continuous Performance Test ( 85 and above are w/in normal limits)
Case Review 2: 11 Yr Female11 Neuro, 6 Captains Log
106
7470
85
75
93 96
123
111
91
112 114 115122
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Full ScaleAttn
AudImpulse
Vis Impulse Aud Cons Vis Cons Aud Focus Vis Focus
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IVA Continuous Performance Test ( 85 and above are w/in normal limits)
Case Review 3: 16 Yr Male8 Neuro, 1 Captains Log
87
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IVA CPT
Case Review 4: 13 Yr Male16 Neuro, 11 Captains Log
More Sessions = More Improvement
6880
9481
9886
101107
94
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Full Scale Attn Aud Impulse Vis Impulse Aud Cons Vis Cons
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IVA CPT
Plus: Depression Score on TSCC Pre: 71 and Post: 61
Case Review 5: 13 Yr Male24 Neuro, 6 Captains Log, 3 Earobics
36 3844
7783
7870
8983
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Full ScaleAttn
Aud Attn Vis Attn AudImpulse
Vis Impulse
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IVA CPT
Case Review 6: 13 yr Male21 Neuro, 10 Captains Log, 6 AVS
0 0
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88
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63
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10998
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Full ScaleAttn
Aud Attn Vis Attn AudImpulse
Vis Impulse
Pre
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IVA CPT
More Sessions = More Improvement
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111
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95 96 96
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Vis Cons Aud Cons Vis Speed AudSpeed
Vis Focus AudFocus
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Case Review 6 cont.
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03/31/07 05/30/07
Global Attention Scales
Solid Line (*) = Full Scale Dashed Line (+) = Auditory Dotted Line (X) = Visual
Areas of Improvement:Attention, Impulse Control, Consistency, Speed of Processing
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03/31/07 05/30/07
Hyperactivity
85 and above is within normal range
57 94
Lab Case Reviews Support:Measurable Outcomes in using NEMS
• Areas of Improvement:Attention, Impulse Control, Consistency, Stamina (staying
with the task)
• Other areas of Improvement Include:Anxiety, Depression, Thought Problems, Social Problems,
Internalization, and Externalization (Achenbach Self-Report)
Anxiety, Depression, Anger, PTSD, and Dissociation (TSCC – Trauma Symptom Checklist)
Conclusion of Technology Review:
Mental Health becomes Cutting-Edge
There are many tools available to include in the mental health “tool box” of treatment.
It is time for mental health to reference the current research and implement effective change in treatment approach!
