Brainmaster Case Study
Clinician Identifier, Credentials, and Date of Submission
J. Tarrant, Ph.D., BCIA-EEG 8/15/09
Case Identifier
NW
History/Symptom History
NW is a 9-year-old Caucasian female. She was attending a private catholic school during the course of treatment. NW was adopted at 5 months of age from the foster care system. Little is known about the birth parents. NW was referred for neurofeedback due to “mood swings,” impulse control problems and concentration difficulties. NW had previously received neurofeedback from a different practitioner with little success. She was taking 18 mg of Concerta once each day for a diagnosis of ADHD as well as GABA for irritability. NW had also received Craniosacral Therapy for several months prior to beginning neurofeedback, which was reported to have helped with some of the symptoms.
It was reported that NW is easily overstimulated and has a great deal of difficulty managing transitions. She was described as having a great deal of energy and previously had problems with trichotillomania (pulling out eyelashes and eyebrows). Apparently, the Craniosacral Therapy helped with these concerns, which were not present at the time that neurofeedback was initiated with this practitioner. NW’s mother rated the severity of her concerns as an “8” on a 10-point scale at the time of intake. Her diagnosis was ADHD, Combined Type.
Procedure
An initial qEEG assessment was conducted by a licensed psychologist who is also BCIA certified in EEG biofeedback. EEG data were digitally recorded at 19 electrode sites and referenced to linked ears using a Lexicor digital EEG acquisition system (Neurosearch-24). Data was analyzed using the Neuroguide database (Thatcher, 1998). When considering eyes open z scored FFT Absolute Power scores, NW showed excess theta, alpha, beta, and high beta activity in a range of cortical areas. The most deviant measurements were observed in high beta with z scores ranging from 1.51 to 2.89 at locations including PZ, P4, C4, F4 , T5, F7 and P3. There were numerous areas of hypocoherence, particularly focused in thetheta and alpha frequencies. There was also some significant hypercoherence in theta and alpha frequencies between T5 and T6.
The neurofeedback treatment was 38 sessions in length. EEG biofeedback equipment from Brainmaster was utilized. Specifically, the Atlantis 4 x 4 was used along with the ANI (Applied Neuroscience, Inc) Z DLL software. This software enables the BrainMaster 2.5 and 3.0 software to compute and use z scores in real time for assessment and training. A 4-channel live z-score program with independent upper and lower limits was used for all treatment sessions (percent ZOKUL). The percent of targets required was set to 94. This setting resulted in the occasional occurrence of “capturing” 100% of the measured variables. The upper and lower thresholds were adjusted independently to result in a success rate between 70 and 80%. In general, these thresholds were between 2.1 and 1.9 for the upper threshold and –2.0 and –1.9 for the lower threshold. Dual monitors were used and feedback was provided through visual and auditory control of DVD movies. Placement decisions were made by considering both qEEG data as well as functional localization of training. Electrode placement for sessions 1 through 26 were C3, C4, P3, and P4. For a portion of several sessions, immersive glasses were utilized to assist in disrupting excess beta activity. In general, the glasses, when used, were used for approximately 10 minutes during the middle portion of the training session. It is also noted that most sessions were started by engaging in a series of Brain Gym and Rhythmic Movement Training exercises. These exercises are designed to engage and coordinate the body and nervous system as well as integrating primitive and postural reflexes that may be interfering with normal development. The electrode placement for sessions 27 through 38 was F3, F4, CZ, and PZ.
Results
At session 27, it was noted that NW’s teacher had reported to the parents significant improvements in self-control although there were continuing concerns at home. At session 33, NW’s parents indicated the belief that many NW’s remaining behavioral problems in the home environment were due to family dynamics and old behavioral habits. This therapist discussed the possibility of referring the family for family therapy or consultation regarding behavioral strategies to use at home.
Behavior checklists (BASC-2) were completed by NW’s mother and primary teacher before beginning treatmentand again at the end of treatment. Comparative results are presented below and clearly show a dramatic improvement in all symptoms in the school environment (see table 1). In fact, while 7 of 14 scales were initially identified as “at risk” or “clinically significant” by NW’s teacher; none of the scales were elevated at post-testing. Interestingly, an examination of the parent checklists showed very little change in ratings over the course of therapy. There was a significant decrease in hyperactivity ratings, all others were virtually unchanged. As noted by NW’s parents, it is likely that the remaining difficulties in the home environment are related to behavioral habits.
A pre-post comparison of the most deviant absolute power and coherence z scores shows a striking normalization of brainwave activity (see table 2; figure 1). All of the z-scores identified as “deviant” at pre-testing were within the “average” range at post-testing.
Behavior Assessment System for Children, 2nd Ed. (BASC-2):
The BASC-2 (Reynolds, C.R. & Kamphaus, R.W. (2004), is an integrated system designed to facilitate the differential diagnosis and classification of a variety of emotional and behavioral disorders of children and to aid in the design of treatment plans. Reports are based on the parent and teacher ratings of the child. Any scores in the Clinically Significant range suggest a high level of maladjustment. Scores in the At-Risk range identify either a significant problem that may not be severe enough to require formal treatment or a potential for developing problem that needs careful monitoring. NW’s primary teacher completed teacher reports. The parent report was completed by NW’s mother.
Scores are presented as T-scores and have a mean of 50 and a standard deviation of 10. Clinical scale scores falling between 60 and 70 are considered “at risk,” while scores 70 and above are considered “clinically significant.” Adaptive behavior scores between 30 and 40 are considered “at risk”. Adaptive behavior scores 30 and below are considered “clinically significant.” At risk scores will be identified with a single asterisk (*). Clinically significant scores will be identified with two asterisks (**).
Summary
In less than 40 sessions, 4 channel live z-score training was effective in dramatically reducing or eliminating a range of long-standing externalizing symptoms including hyperactivity, aggression, conduct problems, and adaptive skills in the school environment. The EEG showed significant normalization in all areas. Few changes were noted in the home environment, although there were indications that these concerns were related more to family dynamics and behavioral habits than neurological dysfunction. These results point to the important role neurofeedback can play in resolving neurological dysfunctions that may lead to ADHD symptoms. It also shows the importance of including other treatment strategies (i.e., family therapy) for maximal symptom reduction.
Table 1
BASC-2 Pre-Post Parent and Teacher Results
Parent
/Teacher
Pre / Post / Pre / PostClinical Scales
Hyperactivity / 72** / 61* / 79** / 57
Aggression / 70** / 73** / 74** / 50
Conduct Problems / 74** / 70** / 65* / 54
Anxiety / 42 / 40 / 38 / 38
Depression / 56 / 59 / 45 / 42
Somatization / 52 / 50 / 46 / 47
Atypicality / 58 / 57 / 67* / 56
Withdrawal / 58 / 58 / 53 / 55
Attention Problems / 69* / 64* / 66* / 59
Adaptive Behavior Scales
Adaptability / 36* / 39* / 40* / 54
Social Skills / 35* / 37* / 45 / 49
Leadership / 43 / 44 / 43 / 49
Activities of Daily Living / 35* / 39 / NA / NA
Functional Communication / 41 / 47 / 33* / 46
Study Skills / NA / NA / 41 / 58
Table 2
Eyes-Open Quantitative Electroencephalogram Pre-Post Comparison of Most Deviant Absolute Power and Coherence Z-Scores
Pre
/Post
Absolute PowerTheta
C3 / 1.54 / .35**
P3 / 1.79 / .29**
T5 / 1.86 / .39**
C4 / 1.52 / .28**
P4 / 1.73 / .46**
T6 / 1.66 / .55**
PZ / 1.54 / .28**
Absolute Power
Alpha
C4 / 1.80 / .71**
CZ / 1.58 / .62*
Absolute Power
Beta
F7 / 2.57 / -.30**
Absolute Power
High Beta
P3 / 2.89 / 1.09**
F7 / 2.57 / .66**
T5 / 1.79 / .45**
F4 / 1.51 / -.09**
C4 / 2.79 / .87**
P4 / 1.75 / .94*
PZ / 1.75 / .84*
Coherence
Theta
FP1-C3 / -2.29 / .19**
FP2-C4 / -2.76 / -.83**
FP2-T4 / -1.98 / -.56**
F4-C4 / -2.40 / -.95**
T5-T6 / 2.26 / 1.37*
Coherence
Alpha
Fp1-C3 / -2.70 / -.72**
F3-T3 / -2.19 / -1.04**
C3-F7 / -2.61 / -.99**
F7-T3 / -2.78 / -1.19**
FP2-C4 / -2.04 / -.87**
T5-T6 / 2.56 / 1.85*
Coherence
Beta
C3-F7 / -2.09 / -.60**
F4-C4 / -2.14 / -.60**
Post z-scores that changed between .5 and 1.0 standard deviations are identified with one asterisk (*). Post z-scores that changed greater than 1.0 standard deviation are identified with two asterisks (**).
Figure 1
Z-Score FFT Pre and Post Comparisons of Absolute Power and Coherence
Pre-Neurofeedback Absolute Power
Delta Theta Alpha Beta High Beta
Post-Neurofeedback Absolute Power
Delta Theta Alpha Beta High Beta
Pre-Neurofeedback Coherence
Delta Theta Alpha Beta High Beta
Post-Neurofeedback Coherence
Delta Theta Alpha Beta High Beta
References
Reynolds, C.R., Kamphaus, R.W. (2004). Behavior Assessment System for Children, 2nd
Ed. Manual. Circle Pines, MN: AGS Publishing.
Thatcher, R.W. (1998). Normative EEG databases and EEG biofeedback. Journal of
Neurotherapy, 2 (4), 8-39.