Linda Walker, MHR, LPC, BCN, BCB

Transcription

1 Linda Walker, MHR, LPC, BCN, BCB

2 Caution: Critically Evaluate the Research! Complex interplay among biological systems Comorbidity Common Symptoms may have very different etiologies Developmental issues Family factors Longevity of the problem ONE SIZE DOESN T FIT ALL

3 Comorbidity Illustration from Joseph Biederman and Stephen Faraone, Harvard Mahoney Neuroscience Institute Letter, Winter 1996 Volume 5 Number 1

4 ADHD: Historical findings Jasper (1937): Over half of EEG findings are abnormalities at 2-6 Hz in 1 or more regions, often frontal Lindsley&Cutts (1940): 2-5 Hz abnormalities 2-3 times more common with behavior problems Capute et al. (1968): Over 50 percent had EEG abnormalities Wikler (1970): Slow wave abnormalities and transient discharges Herrmann: Increased Gamma Matousek (1984): higher relative delta in posterior and theta/alpha ratio Matsuura (1993): higher average amplitude delta and higher percentage of delta and slow theta and lower percentage of alpha over time Janzen (1995): higher theta in eyes-closed, resting condition, but no differences in beta band Chabot&Serfontein: increased relative and absolute theta in frontal and frontal midline regions, diffuse decrease in mean frequencies in alpha and beta bands Lazzaro: (1998)increased theta and alpha1 frontally, reduced relative beta posteriorly Clarke (1998): increased relative and absolute theta, decreased relative beta and alpha across all sites Lubar (1991), Monastra (1999, 2001) Larger theta-beta ratio with ADHD, especially at frontal sites; t/b ratio could discriminate between ADHD and normals

5 ADHD findings Quintana, et al: 15-20% of subjects have high frontal beta, not T/B ratio Barry, for resting EEG: Higher relative theta (most reliable); lower relative alpha & beta Elevated T/B & T/A ratios Reduced cortical differentiation (hypocoherence) Models of maturational lag and developmental deviation inadequate to account for symptom profile Differences in diagnostic criteria and clustering of symptoms complicate findings Arns: Increased theta and decreased beta predominantly fronto-central

6 ADHD From Arns, Brain Resource International database: 275 non medicated individuals with ADHD Theta Absolute Beta Relative Beta However: Arns also found a subgroup with increased beta suggesting a large variability in QEEG profiles within a behaviourally homogenous population of children with ADHD

7 ADHD subtypes

8 Assessment Test of attention (TOVA, IVA, CNS Vital Signs) Behavioral observation inventories Assessment in multiple environments QEEG or EEG assessment

9 Designing effective treatment Intensity/priority AND: No Contraindications (e.g. unaddressed medication or physical issues, client consent, ability to complete treatment, etc.)

10 Intervention strategies Learning theory Immediate, tangible, discreet, massed and spaced practice, primary and secondary reinforcement Transfer of learning Directed at multiple personalities Sensors vs. perceivers, thinkers vs. feelers Sensitive to multiple intelligences Applicable to the real world ENGAGES THE LEARNER!

11 Secondary reward

12 Clark 15, male, Identified as incorrigible by juvenile court Prior Dx ADHD, by school psychologist Impulsive, poor boundaries, manipulative Clearly acknowledges attention problem and asks for help In DENIAL of other behavioral issues, trauma, family situation Cites strength in English, but difficulty in mathematics

13 BASC-2 self report Pre/post

14 BASC-2 teacher report Pre/post

15 BASC 2 parent report Pre/post

16 TOVA

17

18 Treatment CBT to address manipulation NFB for focus and cognitive function HRV Biofeedback as a tool to center Cognitive tasks along with NFB to build comprehension and listening skills Team approach to Integrate consistent structure and boundaries across environments

19 NFB intervention Primary and secondary rewards using points system Sound and images tailored to age and tastes Graduated system of challenge Traditional nfb to address regional findings coupled with Z-score nfb to address global findings Use of listening tasks and math tasks while practicing focus

20

21

22 Behaviorally Appropriate conduct in office Conversation about books and politics College exploration Went to live with uncle Afraid for his future

23 T-Dub 17, male Earnest, thought he couldn t learn Highly anxious School told mom to put him on Ritalin Explosive Then more meds Expelled from school Temper took him places

24 Basc-2 Self Report Pre/post

25 BASC-2 Teacher Pre/Post

26 BASC-2 Parent Pre/Post

27 T-Dub

28

29 Treatment HRV biofeedback Integrate breathing skills into a de-escalation routine take a breather Temperature and skin conductance biofeedback to build sympathetic awareness and parasympathetic shift NFB for attention and cognitive function Listening tasks during NFB to enhance comprehension and listening strategies CBT to catch negative self messages Team approach to enforce de-escalation technique

30 HRV Shape and pace the breathing Increase respiratory sinus arrhythmia to produce LF power Heart-breath coherence RSA recovery in response to stressors Daily home training Construction of practical breathing routine Tracking practice

31 Temp biofeedback Utilize coached relaxation to increase temperature Increase finger temperature to over 90 and hold for 5 minutes Increase finger temperature to over 90 and hold for 10 minutes Create own relaxation script

32 Skin conductance Learn to increase and decrease skin conductance with agitating thoughts vs relaxing thoughts

33 NFB Sound and images to suite teenage tastes Sensitivity of how trainee learns Points system Flexibility to accommodate learning Traditional neurofeedback (primary) 40 sessions, frontal sites Followed by Z-score neurofeedback for global intervention, 10 sessions

34 Post treatment

35 Behaviorally Actually applied take a breather Dean s honor role Re-enrolled at regular high school More optimistic about capabilities No more aggressive episodes Trouble with temper, but took a breather