Neurofeedback for Affect Disregulation and Impairment of ...

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

1

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

4

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