Whole Brain & Specific Site Z- Score Brain Training

1. Whole Brain & Specific Site Z- Score Brain Training By John Bailey, PhD, BCIA-EEG

2. QEEG Guided Training • “The most important thing about live Z Score training is that it is scientific.  It is based upon published research and a well-documented normative database .  It uses concepts that have been proven in clinical research to lead to beneficial outcomes.  It eliminates guesswork, and reduces the risk or over- or under-training key parameters including coherence , phase , and asymmetry.  These parameters are known to have optimal values, and it is important in neurofeedback training to seek training targets that are beneficial.  Z Score training with 4 channels can address the whole head, and normalize activation, relaxation, concentration, focus, connectivity , control, and communication.  Z Score training can provide a complex task that addresses whole brain function in a single protocol.” Tom Collura • See: Thatcher, R.W.  EEG database guided neurotherapy.  In: J.R. Evans and A. Abarbanel Editors, Introduction to Quantitative EEG and Neurofeedback, Academic Press, San Diego, 1999. (N = 577 with many details). • See: POSITION PAPER  Standards for the Use of Quantitative Electroencephalography (QEEG ) in Neurofeedback: A Position Paper of the International Society for Neuronal Regulation Journal of Neurotherapy vol. 8 no. 1 p. 5-27 2004 

3. Core Concepts • Must understand concept of Z scores • Must understand neuroanatomy • Must understand typical EEG metrics • Must understand neuropathologies • Must understand the different Z score targeting options

4. The Critical Training Link • Must be able to Link identified QEEG neuropathologies (the Z scores) with the behavioral correlates (symptoms & complaints) in order to pick target of training • Must be able to explain the link to the person being trained in developmental language they understand

5. Some Training Specifics • Good impedence essential • Can train whole brain • Can pick specific sites • Can use a combination of both methods • The brain will often “pick” the specific Z scores it responds to throughout the training • I typically use a Interval training model

6. “Inhibit” outlyer Z scores • Set parameters to include all Z scores between (–2.0 to + 2.0) for example. • Adjust these parameters to include approximately 98% of the Z scores. • Establish Percent of Chosen Z scores OK level (typical rule is 95% OK) and adjust so individual can achieve this 85% of time. • Success feedback can be Raw %, a game screen, or DVD, etc.

7. Reward / “Pull” In Z scores • Adjust narrow parameters such as (-1.0 to +1.0) which may only include 70% of the Z scores. • Set rule of this % of Z scores to stay above the 60% success level • Success is gradually pulling a higher percentage of the Z scores within that parameter rule. • No need to change type of feedback & you can switch to this “Pull” method from the “Inhibit” method on the fly.

8. Other Combinations of Training • Traditional neurofeedback such as inhibit theta/high beta while rewarding beta at c3 or smr at c4 + meet Z score rules. • Pick Specific Z scores such as low coherence between two sites to inhibit or reward. • Traditional neurofeedback while only monitoring the Z scores. • Train only the coherence Z scores.

9. Brief Assessment with Z Scores • Typical Configurations for ADHD assessment are 3-5min. eyes closed and 6-10 min eyes open with two tasks at Fp1Fp2FzCz & then at F3F4P3P4. • Compare results to Monastra Protocol. • Use TLC or Brownback & Mason subjective questionnaire to determine most relevant sites to measure. • Able to measure 8 sites in 60 min.

10. Tracking Treatment Response • If training only once per week I ask for symptom tracking at 2, 4, & 6 days post session by patient or parents. • Use of Results software by Matthew Fleischman for tracking • Use CTC-1020 Computerized Neurodiagnostic Checklist

11. Case Study: Age 11 Female • Problem: Depression & ADHD • Primary Symptoms: Both depression & anxiety; irritability, low motivation, High forgetfulness & disorganization, inattention, poor school performance. • Very sensitive – Could only tolerate DVD feedback of stop/go, but would want to train for 40 min. Yet did not want to stop the neurofeedback training.

12. 3 Case StudyTraining Slides • 1st slide- F3FzP3PZ: early in training targeting mood, distractibility, language problem complaint (Inhibit outlyers) • 2nd slide - F3Fp1P3PZ: middle training with similar focus, but more on planning and concentration complaint (pull) • 3rdslide- F3F4C3C4: last session with focus on mood/concentration & stabilizing (pull)

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16. Case Study: Age 10 male • Pervasive Developmental Delay (6 weeks premature; 3 weeks in neonatal unit) & ADHD symptoms – Inattention; hyperactivity ; Can’t handle transitions; Lack of cooperativeness; problems in school; difficulty with sleep. • Changed Training sites based on QEEG, parental report of symptoms, & subjective response to training

17. Treatment: 19 Z score sessions • Parents tracked improvement on scales for 2 -4 – 6 days post training. Feedback was initially with Planet Earth DVD at stop/go; then Moving Brain Cell game; and from session #7 on I used primarily the numbers and percent OK graph. • Improvement was consistently noticed in 2 days post training and gradually by the end lasted for the full week with very noticeable improvement in positive mood and level of cooperativeness & no reports of problems at school for the last two months of training.

18. Case Study Training Sites • 1-3 trained C3C4CzF4 for frontal slowing & most abnormal at F4 • 4-8 trained F3F4FzC4 ( 1st slide is of session 8) • 9-12 trained T3T4F4C4 • 13-15 trained FzFp1F3C3 & FzFp1T5F3 • 16-17 trained FzF4P3P4 & Fp1F3T3Fz • 18-19 trainedFp1F3T3Fz (2nd slide)

21. Case Study: Age 12 male • Symptoms: Depression & ADHD with Hair pulling on left side at C3; Complete shut downs at school with oppositional refusal to do work; not doing any homework. • Medication had been ineffective & he was at risk of being sent to residential program • Positive response noted after session has lasted – parents & teachers rate it at 75% improvement / no need for residential placement which was alternative

22. Single session Positive Response • Lack QEEG – Previous assessment session showed frontal slowing at F3 • Trained Percent Z Ok – Inhibit outlyers & added specific low alpha coherence reward sound & visual F3F4 & C3C4 • Then added specific low beta coherence reward sound & visual for F3C3 • He normalized F3 Beta1/Gamma by first normalizing the low coherences shown in series of slides

26. Case Study: Age 14 male • ADHD: Wanted to be off medication. Wanted to train his brain just likes he trains his muscles for sports; Wanted to get better at sports. Problem from parents point of view is poor school performance, not doing chores, and rather irritable & argumentative. • Full QEEG planned, but agreed to start training while waiting for this result

27. Trained 5 sessions • Slide 1 showed snapshot of eyes closed assessment only • Slide 2 showed snapshot of eyes open assessment with task • Slide 3 shows initial training with my rewarding percent Z ok – inhibit outlyers & I also gave a added reward for normalizing the beta coherence between F3F4

31. Early Training Results • Following slide is after 5 Z score training sessions. He reports 50% improvement in: his homework completion & in his doing chores without any parental prompting. He reports 75% improvement in his sports performance and 75% improvement with better sleep, with his being less irritable, frustrated, and prone to anger or oppositional in responses to parents

33. Combined Neurofeedback Case Study: Age 17 male • Aspergers with Severe Depression/Anxiety • QEEG showed high frontal T/B ratios & greatest abnormalities at T5T6 – excess fast activity and excess coherence. • 23 sessions from 11-07 to 9-08 • Traditional Neurofeedback 1-6 Bipolar Training: t5-t6; t5-f3; t6-f4 • Z score training F3F4T5T6 for 7-13 • Both Traditional Neurofeedback plus added Low Frequency Othmer training for 14-23 t4-p4 (0-.2) reward • Complete symptom relief with both depression & anxiety low at end of training and sustained as of last check in one year later. Went from failing # of classes to high grades & graduation. Reported significantly improved social relations compared to feeling a social outcast at beginning of treatment.

34. Case Study: Age 10 male • ADHD; Lower IQ in 70s; Distractible; Doesn’t finish tasks; poor memory; Impulsive; Emotional outbursts; Easily frustrated; misses social cues; problems with reading slow & having poor comprehension • QEEG: Diminished beta activity; Localized in the left lateral parietal & occipital areas responsible for language processing; more pronounced abnormlities in EEG under task • Recommended training at sites T5,F3,Fz,T3, C3,C4, T4 & alpha coherence Fp1-Fp2,T5-C4

35. Training Sequence • 1-2 Trained C3C4P3P4 percent Z OK • 3-4 Trained C3F3FzC4 percent Z OK • 5-9 Trained C3C4T5Fz + C4 11-13hz • 10-13 Trained Fp1Fp2F3F4 • 14-17 Trained C3C4T5Fz & then did 18-20 min bipolar training at T3-Fp1 & T4-P4 • He used AVE & Captains Log at home

36. Z Score training choices & Choice of AVE / Bipolar Training • Slide 1: With consistently noticing low alpha absolute power I recommended home use of AVE with David Pal and put on a Alpha Enhancement Protocol. This appeared to assist in the z score training. • Slide 2: After elevated Beta absolute power normalized more, yet Z scores still showed some low Alpha and low alpha coherence patterns I added some Bipolar Training in “Optimizing” method used by Sue Othmer / Optimal ended up being in alpha range which corresponded partially with low alpha coherence z score values. • Side 3: Snapshot of one of the last training sessions showing more normalized numbers.

40. Overall Training Results • Used Results Training Sheet with average of 85 % parent reported improvement on these top 9 symptom concerns: Less distractible; Able to finish tasks; Better working memory; Able to sit still; Able to handle frustration emotions; Better at reading social cues; Reading with increased speed and independence & having better comprehension of material read. • At the beginning of treatment 7/9 of the inattention and 2/9 of the hyperactivity- impulsivity symptoms were in the very problematic range.  At the end of treatment only 1/9 of the inattention and 0 of the hyperactivity - impulsivity symptoms were identified in the problematic range.  • Most meaningful to parents was the high level of improvement in frustration tolerance skills with his being less easily annoyed or touchy. 

41. Some Z score Cautions identified by Tom Collura • EEG deviations should be consistent with clinical presentation • Consider coping, compensatory traits • Consider “peak performance” traits • Consider phenotypes & general recommendations • Monitor subjective experience & clinical changes always

42. Some Tom Collura Identified Training Modules • 1. Fz Cz T3 T4 – Memory / Planning • 2. F3 F4 O1 O2 – Seeing / Planning • 3. C3 C4 F7 F8 – Doing / Expressing • 4. P3 P4 T5 T6 – Perception / Understanding • 5. Fp1 Fp2 Pz Oz – Attention / Perception • 5a. T3 T4 Pz Oz – Memory / Perception • 6. O1 O2 C3 C4 – Seeing / Doing • 7. F7 F8 F3 F4 – Planning / Expressing • 8. T5 T6 Fz Cz – Understanding / Doing