The use of neurofeedback as a clinical intervention for refugee children and adolescents FASSTT conference 2017

Transcription

1 The use of neurofeedback as a clinical intervention for refugee children and adolescents FASSTT conference 2017 FASSTT 2017 Paper presentation Trix Harvey, NFB/Biofeedback clinic team leader at STARTTSS 1

2 Contents The work of STARTTS Neurofeedback clinic in providing neurofeedback treatment to refugee children & adolescents in a school setting. Explore different aspects of the clinical application of neurofeedback at schools and describe the assessment and therapy process. Illustrate effectiveness of neurofeedback in addressing psychological and cognitive difficulties and improving learning outcomes for refugee children and adolescents. FASSTT Conference 2

3 What is Neurofeedback? Neurofeedback is... A method of training the brain to produce brainwaves that are more regular and stable. More stable brainwave activity leads to better self-regulation of mood and emotions. An EEG is used to read the brain s electrical activity. When clients become aware of their own brainwave activity, they can learn to regulate this activity to produce healthier and more stable brainwaves.

4 What can NFB training affect?»arousal»sleep/wake cycles»cognitive processing»sensory processing»inhibition of motor responses»moods and emotions»memory

5 Neurofeedback Case Study: Yalda Iraq Born 2004 Jordan Year 1 3 Australia (Arrived in 2013 Age 9) 5

6 Neurofeedback case study: Trauma history Prosecution of Mandaens in Iraq War related traumatic events from Iraq I can remember everything that happened in Irac, like when the soldiers stopped our car asking for passports and I was crying for my toys I can t remember how we got to Jordan or Australia people attacking us, just because of what we believe in? Flee to Jordan (primary school age) May you rest in peace and have a better life 6

7 Neurofeedback case study: Trauma history Losses/grief (extended family, friends still in Jordan) leaving my country and leaving everything behind 7

8 Approach to neuropsychological intervention: STARTTS counsellor (May 2013 Jul 2015), & Neurofeedback counselling (Jul 2015 Nov 2016) Interventions: Sand tray & Art therapy Psycho-education (including family & teachers). Critical for creating informed framework for beliefs and regulating behaviour. Psychotherapy: Relaxation, grief & loss, mindfulness, strength based Neurofeedback therapy 8

9 Neurofeedback case study: Presenting symptoms upon referral Trauma Severe sleeping difficulties & Nightmares Bedwetting Emotional difficulties in family Some difficulties forming peer friendships Moderate anxiety, depression, concentration, learning difficulties, anger & behavioural problems. Psychological symptoms have severe impact on study and social functioning level and moderate on daily life activities 9

10 Assessment Approach to neuropsychological assessment: Psychological testing: Child PTSD Symptom scale score Depression Anxiety Stress scale (modified) General Self-Efficacy scale score O Conners Teacher s Rating Scale Psycho-physiological testing: Test of Variables of Attention (TOVA) Assessment Cognitive tests: Digit span Verbal fluency task Children s Colour trail Neurological testing: Electroencephalogram (EEG) Event Related potentials (ERP) Observations & interview NFB Arousal model

11 Assessment Approach to neuropsychological assessment: Psychological testing: (Jul 2015) Child PTSD Symptom scale score = 31 PTSD symptomatic Depression Anxiety Stress scale (modified) D= 12 (severe) A= 7 (moderate) S= 6 (normal) General Self-Efficacy scale score = 29 Good coping skills O Conners Teacher s Rating Scale Social problems Anxious Shy Emotional liability Cognitive problems - Inattention Assessment

12 Assessment Approach to neuropsychological assessment: Assessment Psycho-physiological testing: Test of Variables of Attention (TOVA) Low CNS arousal Poor focussed attention ADHD score = -7 Inattentive (more ommission errors)

13 Assessment Approach to neuropsychological assessment: Cognitive tests: Digit span: Forwards = 4 Test attention and short term memory Backwards = 2 Test working memory A score of not accurately repeating 5 is a cause of concern Assessment Verbal fluency task = 10 Test cognitive function A score of less than 17 is a cause of concern Children s Colour trail = Severely impaired Measure sustained attention, sequencing, and other executive skills

14 Assessment Approach to neuropsychological assessment: Assessment Neurological testing: EEG observation (25/9/2014): Scared, regular headaches, broken sleep, nightmares every night, can t fall asleep NFB Arousal model = under aroused

15 Mapping EEG results to symptoms First EEG report Nov 2014: - Muscle artifact frontally = Muscle tension - Low voltage fast EEG = Diet? - Slower content frontally - Alpha at 10 Hz Cognitively fine - C4 organised Mu = Developmental delay? - Bursts of Hz alpha = too fast anxiety/hypervigilance - T6 excess alpha and theta = social, perceptual and emotional issues - Frontal alpha hypercoherence = affect regulation - Vigilance issue = sleep issue Frontal lobe functions not well differentiated: Affect dysregulation Attentional difficulties Dissociation Right temporal alpha: Poor understanding of social cues Difficulties reading facial expression Dysfunction of the memory processing/consol idation network 15

16 Additional Presenting symptoms after assessment: Migraines PTSD symptoms Fear & Anxiety Low self esteem Grief & loss 16

17 Explaining Neurofeedback to Clients For young people Describing NF as a computer game or mind training can be motivating This helps young people to engage more easily with the counselling process NF helps your brain to work in a better way, and to be more balanced, so you feel more in control of your life 17

18 Neurofeedback Neurofeedback Sessionsession

19 Reducing excessive (tall) slow brain waves helps the brain function better Examples of excessive slow brainwaves 19

20 Working collaboratively Neurofeedback training is a collaborative process For children The NF team includes the child, the family, the teachers, the child s counsellor, and the NF clinician. Sometimes others such as doctors are also involved. 20

21 Neurofeedback Progress tracking Term 1, 2016: X seems disengaged and almost seems medicated during class. She is very quiet and find it difficult to complete most tasks in class. When I engage her in conversation, she stares at me and rarely responds English teacher High school Teacher s rapport She has never shown competence in using the English language writing, reading and speaking Science teacher X is a student I worry about a lot. She always looks scared and worried. She does not engage in the lesson - Math teacher Term 2, 2016: X started off very shy, quiet and reluctant to speak She would often look away visibly uncomfortable About mid way last term she started to turn around. She now seems willing to speak to me and her peers. X also now asks questions and engages in positive conversations she seems to be making more of an effort in attempting tasks - Religion teacher I have noticed X coming out of her shell and is a little more engaged she is more confident to ask questions - History teacher I have found her more chatty and funny in the playground but in the classroom she is shy X is less shy and is more talkative in class this term Science teacher X engagement in maths lesson has improved dramatically. She appears happier and is more confident to try the work.. She has been working well 21

22 Neurofeedback therapy reported changes 35 nfb sessions from 15 July Dec 2016 at school Started nfb to up arousal work on emotional regulation. After second session: I feel a bit better in my brain maybe more comfortable Next 3-12 sessions: Headaches every session but Nightmares less, better sleep & better focus & mood! Changed protocol to target migraine 15 th session: No headache during session! 17 th session: No Headache all week and learnt to do the splits! 19 th session: Not feeling scared about going to high school anymore 20 th session: I don t get anymore headaches, just because of you helping me POST Assessment & another 15 nfb sessions at High school 22

23 Neurofeedback case study: Results 22-Jul Jul Aug Aug Sep Oct Oct Oct Oct Oct-15 5-Nov Mar Mar Jun Sad SELF RAPPORT Sad 4 Linear (Sad) 2 0 Withdrawn Withdrawn Linear (Withdrawn) Distracted Disrupted sleep Distracted Linear (Distracted) Disrupted sleep Linear (Disrupted sleep)

24 Neurofeedback case study: Self report Yalda reported the following got better: Habits (bedwetting, school, social interactions) Sleep (less nightmares, better sleep) Mood, emotional regulation Concentration Migraines disappeared I am happy! English Teacher s reported: X is a different student! She has made an 180 degree turn around History teacher Feb

25 Psychometric assessment scores Pre & Post PTSD Child PTSD symptom scale Pre & Post NFB treatment Jul-15 Jun-16 Sep-16 Child PTSD symptom scale 25

26 Psychometric assessment scores Pre & Post DASS21 DASS21 (modified) Pre & Post Nfb treatment: Severe Extreme Moderate Mild Jul-15 May-16 Sep-16 Normal 2 0 Depression Anxiety Stress General Self Efficacy scale Pre & Post Nfb treatment: Jul-15 Sep-16 General Self Efficacy scale 26

27 Cognitive assessment comparison: Assessment: PRE nfb score: POST nfb score: Verbal fluency: (test cognitive function) A score of less than 17 is a cause of concern Digit span: Forwards (test attention and short term memory) Backwards (test working memory) A score of not accurately repeating 5 is a cause of concern Color Trails CT1: Measure sustained attention, sequencing, and other executive skills Sep Sep 2014 Forwards = 4 Backwards = 2 Total = 6 Sep 2014 Severely impaired March March 2017 Forwards = 6 Backwards = 5 Total = 11 March 2017 Below ave Color Trails CT2: Measure sustained attention, sequencing, and working memory TOVA score: -7 ADHD Sep 2014 Severely impaired March 2017 Mild to moderately impaired Normal 27

28 TOVA Results T.O.V.A comparison: Q1 Q2 Q3 Q4 H1 H2 Total RT Variability Before nfb (22/7/15) After nfb (5/5/16) Q1 Q2 Q3 Q4 H1 H2 Total Response time Before nfb After nfb Before nfb After nfb Before nfb After nfb Q1 Q2 Q3 Q4 H1 H2 Total Commission Errors 0 Q1 Q2 Q3 Q4 H1 H2 Total Omission Errors 28

29 Neurofeedback case study: EEG Results Coherences PRE & POST Less slow activity frontally and temporally Less alpha coherences frontally 29

30 Questions? 20