Vernice Si Toh, MBPsS

Asia Pacific Neurofeedback/ Biofeedback Conferences Penang, Malaysia 2016

Vernice Si Toh• Psychologist @ Spectrum of Life • MSc Clinical Child Psychology

– Anglia Ruskin University, Cambridge

• Member of PSIMA (Membership No. 318/15)

• Graduate member of BPS(Membership number: 410461)

• Division of Neuropsychology• Division of Educational and Child Psychology

• International Affiliate of APA (Membership No. 03495674)

• Division 40: Clinical Neuropsychology

Inattentive

ADHDHyperactivity -

impulsivity

Combined

(American Psychiatric Association, 2013)

Worldwide prevalence rate: 5.29%

2007 2008

Prevalence rate among school age in the US:

3 – 7%

Prevalence rate in

Malaysia: 1.61%

2011

96 over 2,766cases in Malaysia

201287 ADHD cases over 2,239

cases in Malaysia

Cormier, 2008Gomez & Hafetz, 2011Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007United Nations Children’s Fund, 2014

• Lubar & Shouse, 1976– Result shown hyperactivity and distractibility of the child improved.

• Shouse & Lubar 1978 – Effectiveness of EEG biofeedback in combination with drugs are more

effective than drugs alone.

• Shouse & Lubar 1979 – Larger open label study

– Findings similar as above. Effect sustained even after medication being withdrawn.

• Lubar, Swartwood, Swartwood, & O’ Donnell, 1995:– 19 children (8 – 19 years old) with ADHD

– 40 sessions

– Findings: 1) improved attention, 2) reduced impulsivity and hyperactivity behaviors.

• Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003; Hodgson, Hutchinson, & Linley, 2014; Monastra, Monastra & George, 2002; Rossiter, 2004; Rossiter & La Vaque, 1995

– Findings: comparable effect, especially on attentiveness and impulsivity

• Six-month follow up

– Meisel, Servera, Garcia-Banda, Cardo, & Moreno, 2014

• Neurofeedback training VS pharmacological intervention

• Significant academic performance detected in NFB group

– Gevensleben et al., 2010; Leins et al., 2007

• Behavioural improvements maintained after neurofeedback training

• Two years follow up

– Gani, Birbaumer, & Strehl, 2008: Effect is able to uphold

• Ten years follow up

– Tansey, 1993: long term symptom reduction

• Meta-Analysis of Neurofeedback in ADHD (Journal of Clinical EEG & Neuroscience, July, 2009) – Most of the studies are of theta/beta training or slow cortical potential

training.

– Large ES for inattention and impulsivity and a medium ES for hyperactivity

Theta Beta SMR

Alpha

VADPRS CALIS

CLIENT A

GENDER Female

AGE 8

ADHD subtypes combined

CALIS Anxious when outside from home

• Restless and fidgety

• Talks excessively and blurted out answers

• Interrupt or intrude on others

• Loses temper and impatient

• Argues with adults and refused to comply

• Poor attention span, easily distracted and avoid tasks that require sustained mental effort

• Forgetful and often loses things necessary for tasks or activities

Month Sessions Protocols

January S1 F3 Beta + F4 SMRP3-P4 SMRFebruary S2 – 3

March S4 – 7

April S8 – 10

May S11 – 13

June -

July S14

Total 14

0

5

10

15

20

25

30

35

40

04

/02

/20

16

25

/02

/20

16

03

/03

/20

16

10

/03

/20

16

24

/03

/20

16

31

/03

/20

16

07

/04

/20

16

21

/04

/20

16

28

/04

/20

16

05

/05

/20

16

12

/05

/20

16

19

/05

/20

16

14

/07

/20

16

S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12 S13 S14

P3-P4 SMR

Delta Theta SMR Hi-Beta Alpha

Presenting Symptoms Improvements

• Restless and fidgety • Able to sit still for longer period of time

• Talks excessively and blurted out answers

• Able to control, talk lesser during session

• Interrupt or intrude on others • Will still interrupt but will wait for her turns when guided

• Loses temper and impatient • More patient and tantrum reduce

• Argues with adults and refused to comply

• Obey to instructions better

• Poor attention span, easily distractedand avoid tasks that require sustained mental effort

• Attention span prolonged, putting effort during session e.g. neurofeedback session

• Forgetful and often loses things necessary for tasks or activities

• Memory improved

CLIENT B

GENDER Male

AGE 9

ADHD subtypes combined

CALIS Parents reported anxiety, self-reported non-anxious

• Restless and fidgety

• Talks excessively and blurted out answers

• Interrupt or intrude on others

• Loses temper and impatient

• Argues with adults and refused to comply

• Poor attention span, easily distracted and has difficulty sustaining attention

• Often loses things necessary for tasks or activities

• Blame others for his mistakes or misbehaviors

• Tell lies to get what he wants or to avoid punishment

• Purposely annoyed others as well as being touchy and easily annoyed by others

Month Sessions Protocols

December S1 – 3 F3 B + C3 SMRPz alpha2

February S4 F3 + C3 SMRC4-P4 SMRS5 – 7

March S8 – 9

April S10 – 12

May S13

Total 13

0

10

20

30

40

50

60

70

80

90

05

/12

/20

15

18

/12

/20

15

31

/12

/20

15

06

/02

/20

16

12

/02

/20

16

20

/02

/20

16

27

/02

/20

16

05

/03

/20

16

19

/03

/20

16

02

/04

/20

16

09

/04

/20

16

16

/04

/20

16

07

/05

/20

16

18

/06

/20

16

S1 com S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12 S13

F3 Beta

Delta Theta SMR Hi-Beta Alpha

0

10

20

30

40

50

60

70

80

18/12/2015 31/12/2015 06/02/2016 12/02/2016 20/02/2016 27/02/2016 05/03/2016 19/03/2016 02/04/2016 09/04/2016 16/04/2016 07/05/2016

com S2 S3 S4 S5 S6 S7 S8 S9 S10 S11 S12

C3 SMR

Delta Theta SMR Hi-Beta Alpha

0

5

10

15

20

25

30

20/02/2016 27/02/2016 05/03/2016 19/03/2016 02/04/2016 09/04/2016 16/04/2016 07/05/2016 18/06/2016

s5 s6 s7 s8 s9 s10 s11 s12 s13

C4-P4 SMR

Delta Theta SMR Hi-Beta Alpha

Presenting Symptoms Improvements

• Restless and fidgety • Can sit still during session for longer time

• Talks excessively and blurted out answers • Able to control and talk lesser during sessions

• Interrupt or intrude on others • Slight improvement

• Loses temper and impatient • Tantrums reduced and able to wait during setup

• Argues with adults and refused to comply • Still required training

• Poor attention span, easily distracted • Attention span prolonged, parents reported to sit longer while watching movie at home

• Often loses things necessary for tasks or activities

• Still required training

• Blame others for his mistakes or misbehaviors

• Still required training

• Tell lies to get what he wants or to avoid punishment

• Still required training

• Purposely annoyed others as well as being touchy and easily annoyed by others

• Slight improvement

CLIENT C

GENDER Male

AGE 7

ADHD subtypes Hyperactive – impulsive with Oppositional defiant behaviour

CALIS Parent report and self reported to have anxiousness

• Restless and fidgety

• Talks excessively and blurted out answers

• Interrupt or intrude on others

• Loses temper and impatient

• Argues with adults and refused to comply

• Poor attention span, easily distracted and has difficulty sustaining attention

• Often loses things necessary for tasks or activities

• Blame others for his mistakes or misbehaviors

• Tell lies to get what he wants or to avoid punishment

• Purposely annoyed others as well as being touchy and easily annoyed by others

• Unable to follow instruction or complete schoolwork although he understand

Month Sessions Protocols

June S1 – 4 F3 Beta + F4 BetaC3 HiBeta + C4 SMRJuly S5 – 7

Total 6

Presenting Symptoms Improvements

• Restless and fidgety • Able to stay in seat longer

• Talks excessively and blurted out answers • Still required training

• Interrupt or intrude on others • Will stay away as per told

• Loses temper and impatient • Still required training

• Argues with adults and refused to comply • Obey to instructions better

• Poor attention span, easily distracted and has difficulty sustaining attention

• Improved attention span, still required further training

• Often loses things necessary for tasks or activities • Comply better and listen to others

• Blame others for his mistakes or misbehaviors • Still required training

• Tell lies to get what he wants or to avoid punishment

• Still required training

• Purposely annoyed others as well as being touchy and easily annoyed by others

• Still required training

• Unable to follow instruction or complete schoolwork although he understand

• Able to put in effort to read and understand the instruction

CLIENT D

GENDER Female

AGE 5

ADHD subtypes Combined with anxiety symptoms

CALIS Both reported anxiety

• Restless and fidgety

• Did not want to talk/ speak very softly

• Finger biting

• Loses temper and impatient

• Longer adaptation time required

• Poor attention span, easily distracted and has difficulty sustaining attention

• Accompaniment of transitional objects or toys are required

• Accompaniment of parents are requested during sessions

• Keep mentioning she felt scared

• Refuses to follow instructions although she understands

• Refuses to comply with adults’ request

Month Sessions Protocols

January S1 – 9 F3 Beta + F4 alpha1C4-Pz SMRFebruary S10 – 14

S15 F3 Beta + C3 BetaT4-P4 SMRMarch S16 – 19

April S20 – 22 F3 Beta + F4 SMRT4-P4 SMRMay S23 – 24

S25 – 26 F3 Beta + C3 BetaF4 + P4 SMRJune S27 – 29

July S30

Total 30

0

10

20

30

40

50

60

70

80

90

100

13

/02

/20

16

19

/02

/20

16

27

/02

/20

16

05

/03

/20

16

12

/03

/20

16

19

/03

/20

16

26

/03

/20

16

09

/04

/20

16

16

/04

/20

16

23

/04

/20

16

07

/05

/20

16

14

/05

/20

16

20

/05

/20

16

28

/05

/20

16

03

/06

/20

16

18

/06

/20

16

24

/06

/20

16

02

/07

/20

16

S13 S14 S15 S16 S17 S18 S19 S20 S21 S22 S23 S24 S25 S26 S27 S28 S29 S30

F3 Beta

Delta Theta Beta Hi-Beta Alpha

0

10

20

30

40

50

60

70

80

90

05/03/2016 12/03/2016 19/03/2016 26/03/2016 09/04/2016 20/05/2016 28/05/2016 03/06/2016 18/06/2016 24/06/2016 02/07/2016

S16 S17 S18 S19 S20 S25 S26 S27 S28 S29 S30

C3 Beta

Delta Theta Beta Hi-Beta Alpha

0

10

20

30

40

50

60

27/02/2016 05/03/2016 12/03/2016 19/03/2016 26/03/2016 09/04/2016 16/04/2016 23/04/2016 07/05/2016 14/05/2016

S15 S16 S17 S18 S19 S20 S21 S22 S23 S24

T4-P4 SMR

Delta Theta SMR Hi-Beta Alpha

0

10

20

30

40

50

60

16/04/2016 23/04/2016 07/05/2016 14/05/2016 20/05/2016 28/05/2016 03/06/2016 18/06/2016 24/06/2016 02/07/2016

S21 S22 S23 S24 S25 S26 S27 S28 S29 S30

F4 SMR

Delta Theta SMR Hi-Beta Alpha

0

5

10

15

20

25

30

35

40

20/05/2016 28/05/2016 03/06/2016 18/06/2016 24/06/2016 02/07/2016

S25 S26 S27 S28 S29 S30

P4 SMR

Delta Theta SMR Hi-Beta Alpha

Presenting Symptoms Improvements

• Restless and fidgety • Less fidgety and able to sit still longer during session

• Did not want to talk/ speak very softly • Speaks louder and clearer now

• Finger biting • Totally weaned off

• Loses temper and impatient • Tantrums reduced and more patient

• Longer adaptation time required • Able to adapt in shorter time

• Poor attention span, easily distracted and has difficulty sustaining attention

• Attention approved a lot, even feedback from school teacher

• Accompaniment of transitional objects or toys are required

• No TOs or toys are seen

• Accompaniment of parents are requested during sessions

• Able to attend session alone

• Keep mentioning she felt scared • No longer mentioning

• Refuses to follow instructions although she understands

• Able to listen and follow instructions better

• Refuses to comply with adults’ request • Comply with adults more

ReferencesAmerican Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D. C.: American Psychiatric

Publishing Fifth edition.

American Psychological Association. (n.d.). Anxiety. Retrieved on November 30, 2013 from http://www.apa.org/topics/anxiety/

Appendix S2: Evidence-based child and adolescent psychosocial interventions. (2010) Pediatrics, 125(3), S128. doi: 10.1542/peds.2010-0788HArns, M., Heinrich, H., & Strehl, U. (2014). Evaluation of neurofeedback in ADHD: the long and winding

road. Biological Psychology, 95, 108 – 115. doi: 10.1016/j.biopsycho.2013.11.013Arns. M., de Ridder, S., Strehl, U., Breteler, M., & Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD: the effects on inattention,

impulsivity and hyperactivity: a meta-analysis. Clinical EEG and Neuroscience, 40(3), 180 – 189. doi: 10.1177/155005940904000311Brain waves 1 [Online image]. (2014). Retrieved June 5, 2016 from

http://3yo5rd3wte5n2qyjm315n8zl.wpengine.netdna-cdn.com/wp-content/uploads/2014/04/brain-waves-1.jpgCormier, E. (2008). Attention deficit/hyperactivity disorder: a review and update. Journal of Pediatric Nursing, 23(5), 345 – 357.

doi: 10.1016/j.pedn.2008.01.003Freepik [Online image]. (2015). Retrieved June 5, 2016 from http://www.freepik.com/free-vector/keep-it-working_797987.htm

Gomez, R., & Hafetz, N. DSM-IV ADHD: Prevalence based on parent and teacher ratings of Malaysian primary school children. Asian Journal of

Psychiatry, 4(1), 41 – 44. doi: 10.1016/j.ajp.2010.12.003

Lubar, J. F., & Shouse, M. N. (1976). EEG and behavioral changes in a hyperkinetic child concurrent with training of the sensorimotor rhythm (SMR): a

preliminary report. Biofeedback Self Regulation, 1(3), 293-306. Retrieved September 30, 2015 from

http://www.neurofeedbackclinic.ca/journals/ADHD_ADD/adhd05.pdf

Polanczyk, G., de Lima, M. S., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The worldwide prevalence of ADHD: a systematic review and

metaregression analysis. American Journal of Psychiatry, 164(6), 942 – 948. doi: 10.1176/appi.ajp.164.6.942

Shouse, M. N., & Lubar, J. F. (1978). Physiological basis of hyperkinesis treated with Methylphenidate. Pediatrics, 62(3), 343 – 351.

Shouse, M. N., & Lubar, J. F. (1979). Operant conditioning of EEG ryhthms and Ritalin in the treat of hyperkinesis. Biofeedback and Self-regulation,

4(4), 299 – 312. doi:10.1007/BF00998960

United Nations Children’s Fund (2014). Statistical data from the Ministry of Health. Children with Disabilities in Malaysia. Kuala Lumpur: UNICEF

Malaysia.

Wehmeier, P. M., Schacht, A., & Barkley, R. A. (2010). Social and emotional impairment in children and adolescents with ADHD and the impact on

quality of life. Journal of Adolescent Health, 46(3), 209 – 217. doi: 10.1016/j.jadohealth.2009.09.009

Questions?