Why Biofeedback? Improves outcome. Treats the source of the problem. Advantages over alternatives:

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1 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

2 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 2 Ed Hamlin, 2015

3 Biofeedback: How Does it work? A learning process based on operant conditioning Increase/decrease a behavior through the use of positive or negative reinforcement 3 (Wikipedia)

4 Neurofeedback Brain Plasticity Assumption: brain activity can be changed Biofeedback on brain waves (measured by EEG) Learning to alter particular brain waves improves the selfregulation of brain state Better brain regulation -> better functioning 4 Ed Hamlin, 2015

5 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

6 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

7 The Impact of Neurofeedback on Children with Development Trauma: A Randomized Control Study 7

8 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?

9 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

10 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

11 Demographics

12 No. of children Trauma History Profile S 0

13 Participant Flow Chart Figure 1. Flow Chart Screened in (n=57) Excluded (n=9): Lost communication (n=7), Personal reasons (n=2) 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) Waitlist/Control Group (n=17) Dropped out (n=1): Not satisfied with group assignment Allocation and Randomization (n=37) Active NFT Group (n=20) Received 12 NFB sessions Dropped out (n=3): Personal and family reasons Inclusion / Exclusion Assigned to group 6 weeks post midpoint assessment (n=16) Dropped out (n=2): Lost communication Midpoint Assessment (n=33) Received 12 NFT (n=17) Dropped out (n=1): Family reasons Timeline of treatment 6 weeks post baseline assessment (n=16) Endpoint Assessment (n=32) Completed 24 NFT (n=16) Dropped out (n=2): Lost communication & individual emergency 4 weeks post endpoint assessment (n=14)* Follow up Assessment (n=28) 4 weeks upon completing NFB (n=14) *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

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

15 Measurements: BRIEF Behavior Rating Inventory of Executive Function Assessment of executive functions and self-regulation BRIEF Factor Structure Monitor Meta- Cognition Organization of Materials Plan/Organize Working Memory Initiate Emotional Control Behavioral Regulation Shift Inhibit

16 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).

17 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

18 Results

19 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

20 Score BRIEF Global (Behavior Rating Inventory of Executive Function) 185 BRIEF-Global Executive Time Point WL NF

21 BRIEF Behavioral Regulation BRIEF-Behavioral Regulation WL NF

22 BRIEF Metacognition (p=0.05) BRIEF-Metacognition WL NF

23 Score CBCL Externalizing (Child Behavior Checklist) CBCL-Externalizing Time Point WL NF

24 CBCL Internalizing 19 CBCL Internalizing WL NF

25 CAM (Children s Alexithymia Measure) 18 CAM-Total WL NF

26 Total Score TSCYC Global (Trauma Symptom Checklist for Young Children) 53 TSCYC Post-Traumatic Stress Total Time Point WL NF

27 TSCYC Anxiety 18 TSCYC-Anxiety WL NF

28 TSCYC Depression 16 TSCYC-Depression WL NF

29 TSCYC Arousal 26 TSCYC-Arousal WL NF

30 TSCYC Dissociation 15 TSCYC-Dissociation WL NF

31 KSADS (The Kiddie Schedule for Affective Disorders ) KSADS NF WL

32 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)

33 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

34 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)

35 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

36 Acknowledgements Bessel van der Kolk, Principal Investigator Joseph Spinazzola, Co-Investigator Hilary Hodgdon, Head of research operations Ed Hamlin, Project Supervisor Mark Gapen, Project Supervisor Ainat Rogel, Project coordinator Michael Suvak, Data analyst Allyse Melville, Evaluator and data Analyst Regina Musicaro, Interventionist Anna Kharaz, Project coordinator Lia Martin and CATS helpers Alice Knowlton, Evaluator Elizabeth Southwell, Evaluator and interventionist Margaret Bullerjahn, Evaluator Khaled Nasser, Interventionist Anne Sposato, Evaluator Maggi Price, Evaluator Julia Ozog, Evaluator Rachana Agarwal, Evaluator Richard Lupatnick, Interventionist Louloua Smadi, Evaluator and Interventionist Mara Renz Smith, Evaluator Alyssa Beth Brelsford, Evaluator