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Optimising Performance in Development and Attention Disorders: Foundations and Progress in a Mixed-Methods, International, Multisite Feasibility Study
Leslie Sherlin, PhD CMPC, QEEGD, BCN, BCB, ECP
ACKNOWLEDGEMENT OF COUNTRY
I would like to acknowledge the Turrbul people who are the Traditional Custodians of the land of Brisbane. I would also like to pay respect to the Elders both past, present and emerging and extend that respect to other Aboriginals present.
ACKNOWLEDGEMENTS• I wish to thank the board and organizers of ANSA and the
conference for the opportunity to participate in the conference proceedings.
• As the current president, I would like to acknowledge and thank the ANSA members, who are affiliate members, and any others who are members of the International Society of Neurofeedback and Research. Our continued collaboration together strengthens our mutual presence.
• As a board member of the Biofeedback Certification International Alliance, I bring kind regards and appreciation for the collaboration between the BCIA and the BCIA-A. Additionally I would like to commend the Australasia community for making certification and demonstration of competency so important.
ACKNOWLEDGEMENT- Thanks to Ottawa University, Surprise, Arizona, USA
- Thanks to Sam at the Brisbane Apple Store ;-)
Optimising Performance in Development and Attention Disorders:
PERFORMANCE VS. PATHOLOGY
“[What information consumes is] the attention of its recipients. Hence a wealth of information creates a poverty of attention.”
Herbert SimonNobel winner, Economics (1978)
PERFORMANCE VS. PATHOLOGY
Microsoft attention spans, Spring 2015
PERFORMANCE VS. PATHOLOGY
DEVELOPMENT DISORDERS• The neurodevelopmental disorders are a group of
conditions with onset in the developmental period. • The disorders typically manifest early in development,
often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning.
• The range of developmental deficits varies from very specific limitations of learning or control of executive functions to global impairments of social skills or intelligence.
DEVELOPMENT DISORDERS• The neurodevelopmental disorders frequently co-occur;
and specifically many children with attention-deficit/hyperactivity disorder (ADHD) also have a specific learning disorder.
• For some disorders, the clinical presentation includes symptoms of excess as well as deficits and delays in achieving expected milestones.
MODELS FOR NFB IN ADHD
• There are a number of models for cognitive development and attention processes.
• Each of these models have implications for NFB however some are more complex for practical implementation or less well understood.
• These models of pathophysiology are well described in Björn Albrecht, Henrik Uebel-von Sandersleben , Holger Gevensleben and Aribert Rothenberger (2015). Pathophysiology of ADHD and associated problems—starting points for NF interventions? Frontiers in Human Neuroscience, Volume 9;Article 602.
MODELS FOR NFB IN ADHD
• Two of these models are well founded in the previous literature of ADHD and neurofeedback and are being implemented widely amongst NFB providers and have been successfully implemented in performance populations
• Reward processing deficiency
• Resting state brain activity disruption
COGNITIVE / REWARD PROCESSING • Cognitive deficits may
emerge from dysfunctions particularly in fronto-striatal or meso-cortical brain networks.
• Problems with reward processing may be associated with dysfunctions in the mesolimbic dopaminergic system (Sagvolden et al., 2005; Sonuga-Barke, 2005).
RESTING STATE/DMN • Deficits are also seen in the resting
state or the Default- Mode-Network (DMN) activity which suggests that there is a disruption of neuronal networks engaged in task processing, leading to difficulties in state regulation and periodic attentional lapses (Sonuga-Barke and Castellanos, 2007; Castellanos and Proal, 2012).
RESTING STATE/DMN • ADHD may be associated with a number of cognitive
deficits.
• These deficits are most likely consequences of the disorder and are not causal.
• This is important because it suggests that cognitive therapies may improve performance on specific tasks but not the etiology and symptoms of ADHD (Cortese et al., 2015).
FOUNDATIONS FOR PERFORMANCE NFB• Brain activity at rest, recorded when individuals are
awake, relaxed and not engaged in any particular task, is characterized by complex oscillations that may reflect important features of arousal and attention that may change with development (Banaschewski and Brandeis, 2007; Rothenberger, 2009).
• From childhood to adolescence and early adulthood a decrease in power of slow Delta (1.3–3.5 Hz) and Theta (3.5–7.5 Hz) with an increase in faster Alpha (7.5–12.5 Hz) and Beta (12.5 − ∼ 25 Hz) (Matousek and Petersen, 1973; John et al., 1982).
FOUNDATIONS FOR NFB
• The theta/beta ratio during rest may not be generally impaired in patients with ADHD, but there is some evidence that problems may be present during task performance.
• Because NFB is a task in itself this may act as an appropriate intervention.
• Further applications of NF interventions may consider DMN interference by training the interplay between and connectivity within in the DMN and task-relevant networks.
PERFORMANCE TRAINING?• Performance psychology has included the study of the
psychological skills and knowledge necessary to facilitate and develop peak performance guidelines into best practice for sport, academic, business, fitness and the performing arts.
• Performance brain training is an approach to classifying, measuring and addressing the current state of ability on a given task with the intent for improvement.
• Training is teaching, or developing any skills or knowledge that relate to specific useful competencies.
NEUROFEEDBACK USE IN PERFORMANCE MODEL TRAINING• Focus on the performance itself and the interaction with
performance• Through the data and research we have learned that:
– Deviations may contribute to “symptoms” in one domain where it is a strength in another
– We should be cautious in how we approach their training that it be based on performance metrics and goals
– Higher performers respond faster to physiological training; similar to clinical experience where increased symptom severity may take longer
TWO IMPLEMENTATION FRAMEWORKS
• Trait Identification & Training (Resting State/DFM)– “Conditioning and Repairing”*
• State Identification & Training (Reward Processing)– “Skill Acquisition”*
*Holger Gevensleben, Gunther H.Moll,Aribert Rothenberger and Hartmut Heinrich (2015). Neurofeedback in attention-deficit/hyperactivity disorder – different models, different ways of application. Front. Hum. Neurosci., 21 October 2014 | https://doi.org/10.3389/fnhum.2014.00846
PRIMARY MECHANISMS• Activation• Deactivation• Stability• Flexibility
BRAIN TRAINING OBJECTIVES• To Create Brain States• To Create Volitional
Control• To Create Intensity• To Maintain Self-
Regulation Abilities
PERFORMANCE TRAINING GOALS
• To break through – an individual is performing well but keeps meeting their maximum without being able to get to the next level.
• To gain consistency – an individual’s performance is hit or miss. They are typically too influenced by their environment.
• To maintain excellence – an individual is at the top of their game and they want to utilize every tool for staying at their best.
PROTOCOLS IMPLEMENTED
• Frame up expectations
MONITORING PROGRESS
Time Point 1
A
Trait Range
Test Point (State)
Time Point 2
B
Trait Range
Test Point (State)
CTest Point (State)
Time
Perfo
rman
ce C
apac
ity
Foundations and Progress in a Mixed-Methods, International, Multisite Feasibility Study
Leslie Sherlin, Peggy Hill, Michelle Aniftos, Natalie Challis, et al
PURPOSE• NFB has multiple implementation strategies• This can vary based on clinical orientation, equipment,
the EEG metric being trained and even practical considerations of frequency and duration of the sessions.
• We find that all of these varying implementations are reported in both anecdotal evidence as well as formalized research investigations to have positive effect. However, the differences have prohibited the systematic large-scale implementation of a research design for any given symptom presentation.
PURPOSE• As is typical in commercial applications, each application
may have materials and language that promote the particular application as being superior.
• It is the belief from the providers of service that the NFB mechanism of action is the catalyst for clinical improvements rather than a specific implementation and that the implementation choice from the practitioner should be based on client characteristics or other commercial reasoning (e.g. user interface, cost, ease of use, etc) rather than claims of global superior efficacy.
RESEARCH QUESTIONS• The research question is to evaluate varying implementations
of Neurofeedback as a non-invasive intervention to reduce the symptoms of ADHD, and to inform a multi-site feasibility study designed to compare a number of commonly utilized NFB protocols/methods.
• Our proposal first compares the pre-post neurobiological characteristics as well as symptom presentations limited to the excessive frontal theta phenotype.
• The question remains, whether there is one NFB implementation, more than others, which is more efficacious for the treatment of symptoms of the ADHD-TB subtype of ADHD.
PURPOSE• This study is considered a multi-site demonstration
project meant to ascertain if a group of trained individuals and their clinics can successfully implement specific predetermined protocols, complete adjunctive interventions such as parent training, and can keep data needed to produce a quality research investigation.
• To prepare for this project, interested and qualified providers of various forms of neurofeedback have provided the authors with details of their equipment, clinic facilities, and available assessment materials.
TECHNIQUES• Commonly utilized NFT techniques indicated below will
be implemented to inform preliminary findings of this feasibility study: – TB, Theta-down/Beta-up amplitude (Monastra,
Monastra, & George, 2002); – ILS, InfraLow/Slow (Othmer; Holtmann, Pniewski,
Wachtlin, Wörz & Strehl, 2014); – ZS, Z-score (Thatcher & Lubar, 2015); and – LORETA, Low Resolution Electromagnetic
Tomography, (Congedo, Lubar, Joffe, 2004).
METHODS• Participants will be a sample of convenience recruited from within the private
practice clients of each of the participating providers of service. • Each provider will be included based on the appropriate registration, licensure,
or certification as dictated by their local government for the assessment, application of intervention and monitoring of the clinical presentation of ADHD.
• The participants selected will be screened for symptom presentation providing a singular diagnosis of ADHD (will be indicated as either inattentive type, combined type or hyperactive only type).
• Each subject will have rule out of multiple diagnosis. • Additionally the participants will be screened utilizing a quantitative
electroencephalography in order to maintain inclusion based on the theta/beta phenotype physiological presentation.
• Participants will all be between the ages of 10 and 50 years old and are both males and females in gender. Race and ethnicity demographic data will be collected.
METHODS• The providers of service are all voluntarily participating
with no remuneration or compensation for participation. • Each provider of service was solicited through the ANSA
or Qclub membership/work group. • Each provider has demonstrated the appropriate
registration, licensure or certification as required by local government and professional society.
• Additionally each provider is required to complete CITI ethics training on human subjects research in behavioral sciences.
METHODS• Each site will be under the approval of an Institutional Review
Board. • Each provider additionally must operate through a proven
legal business entity appropriately credentialed to conduct business of mental health services within their given geographical location.
• Locations and offices span across three countries of Australia, United States of America and New Zealand. All data will be deidentified of any personal or confidential information.
• The electronic session data file, the qEEG data files and symptom tracking information will all be submitted to a single database for storage at Ottawa University, Arizona.
MEASURES• 19 channel EEG
– Visually artifacted by the provider and randomly assigned for review by a second contributor to the study.
– EEG metrics are to analyzed via MatLab and statistics performed utilizing SPSS.
• Clinical symptoms– The PsychProfiler® is a clinically validated instrument that simultaneously
screens for 20 of the most common psychiatric, psychological and educational disorders in children, adolescents, and adults.
• Continuous Performance Test– In discussion for contribution.
• Plotted learning curves of target frequencies between and within sessions.
ANALYSIS• The study is a quasi-experimental design where no
random assignment is practical.• Mixed-effects regression with crossed random effects
analysis will be implemented to allow exploration of pre and post time points across a wide range of symptom presentation variables as well as EEG metrics consistent with targeted training parameters.
SUMMARY• Therefore, this study is the first step, a feasibility study, to
standardize and explore the degree of variance in implementation at different sites utilizing different practical applications (i.e. EEG metric rather than equipment).
• To evaluate the possibility of a large multi-site study with contribution from providers of service.
• Examine if there are characteristics of the individual, or provider, that suggest some implementation strategies may be more effective under certain conditions.
