The use of neurofeedback as a clinical intervention for refugee children and adolescents
FASSTT conference 2017
FASSTT 2017 Paper presentationTrix Harvey, NFB/Biofeedback clinic team leader at STARTTSS1
FASSTT Conference
• 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.
2
Contents
What is Neurofeedback?
Neurofeedback is ...
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.
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.
»Arousal
»Sleep/wake cycles
»Cognitive processing
»Sensory processing
»Inhibition of motor responses
»Moods and emotions
»Memory
What can NFB training affect?
Neurofeedback Case Study: Yalda
5IraqBorn 2004
JordanYear 1 – 3
Australia (Arrived in 2013 – Age 9)
19 13 410
52 36
• 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)
Neurofeedback case study: Trauma history
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“May you rest in peace and have a better life”
7
• Losses/grief (extended family, friends still in Jordan) “leaving my country and leaving everything behind”
Neurofeedback case study: Trauma history
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
Approach to neuropsychological intervention:
8
• 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
Neurofeedback case study: Presenting
symptoms upon referral
9
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)
Neurological testing:Electroencephalogram (EEG)Event Related potentials (ERP)Observations & interviewNFB Arousal model
AssessmentApproach to neuropsychological assessment:
Cognitive tests:• Digit span• Verbal fluency task• Children’s Colour trail
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 ScaleSocial problemsAnxious – ShyEmotional liabilityCognitive problems - Inattention
AssessmentApproach 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)
AssessmentApproach to neuropsychological assessment:
Assessment
AssessmentApproach 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
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
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
AssessmentApproach to neuropsychological assessment:
Mapping EEG results to symptoms
15
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 11 – 12 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/consolidation network
• Migraines
• PTSD symptoms
• Fear & Anxiety
• Low self esteem
• Grief & loss
Additional Presenting symptoms after
assessment:
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Explaining Neurofeedback to Clients
Describing NF as a “computer game” or “mind training” can be
motivating
This helps young people to engage more easily with the
counselling process
For young people
“NF helps your brain to work in a better way, and to be more balanced, so you feel more in
control of your life”
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Neurofeedback session Neurofeedback Session
Reducing excessive (tall) slow brain waves helps the brain function better
Examples of
excessive slow
brainwaves
19
Working collaboratively
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.
Neurofeedback training is a collaborative process
20
21
Neurofeedback Progress tracking
High school Teacher’s rapport 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
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
“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
“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…
Neurofeedback therapy reported changes
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35 nfb sessions from 15 July 2015 – 8 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
• 15th session: No headache during session!
• 17th session: No Headache all week… and learnt to do the splits!• 19th session: “Not feeling scared about going to high school anymore”• 20th session: “ I don’t get anymore headaches, just because of you helping me…”
• POST Assessment & another 15 nfb sessions at High school
SELF RAPPORT
Neurofeedback case study: Results
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0
1
2
3
4
5
6
Sad
Sad
Linear (Sad)
0
2
4
6
8
10
12
22
-Ju
l-1
5
23
-Ju
l-1
5
05
-Au
g-1
5
18
-Au
g-1
5
15
-Se
p-1
5
08
-Oct
-15
13
-Oct
-15
21
-Oct
-15
26
-Oct
-15
28
-Oct
-15
5-N
ov-
15
24
-Mar
-16
31
-Mar
-16
30
-Ju
n-1
6
Withdrawn
Withdrawn
Linear (Withdrawn)
0
2
4
6
8
10
12
Distracted
Distracted
Linear (Distracted)
0
2
4
6
8
10
12
Disrupted sleep
Disrupted sleep
Linear (Disruptedsleep)
Neurofeedback case study: Self report
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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 2017
25
0
5
10
15
20
25
30
35
40
45
Jul-15 Jun-16 Sep-16
Child PTSD symptom scale
Psychometric assessment scores Pre & Post PTSD
Child PTSD symptom scale Pre & Post NFB treatment
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0
2
4
6
8
10
12
14
Depression Anxiety Stress
Jul-15
May-16
Sep-16
Psychometric assessment scores Pre & Post DASS21
Severe
Normal
Moderate
Extreme
Mild
0
5
10
15
20
25
30
35
Jul-15 Sep-16
General Self Efficacy scale
DASS21 (modified) Pre & Post Nfb treatment:
General Self Efficacy scale Pre & Post Nfb treatment:
Assessment: PRE nfb score: POST nfb score:
Verbal fluency: (test cognitive function) A score of less than 17 is a cause of concern
Sep 2014 10
March 201718
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
Sep 2014
Forwards = 4Backwards = 2
Total = 6
March 2017
Forwards = 6Backwards = 5
Total = 11
Color Trails CT1: Measure sustained attention, sequencing, and other executive skills
Sep 2014 Severely impaired
March 2017Below ave
Color Trails CT2: Measure sustained attention, sequencing, and working memory
Sep 2014 Severely impaired
March 2017Mild to moderately impaired
TOVA score: -7ADHD
-0.91Normal
Cognitive assessment comparison:
27
T.O.V.A comparison:
TOVA Results
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0
20
40
60
80
100
120
Q1 Q2 Q3 Q4 H1 H2 Total
RT Variability
Before nfb (22/7/15)
After nfb (5/5/16)
0
20
40
60
80
100
120
Q1 Q2 Q3 Q4 H1 H2 Total
Omission Errors
Before nfb
After nfb
0
20
40
60
80
100
120
Q1 Q2 Q3 Q4 H1 H2 Total
Commission Errors
Before nfb
After nfb
0
20
40
60
80
100
120
Q1 Q2 Q3 Q4 H1 H2 Total
Response time
Before nfb
After nfb
Coherences PRE & POST
Neurofeedback case study: EEG Results
29
• Less slow activity frontally and temporally• Less alpha coherences frontally
Questions?
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