teaching biofeedback in israel - lynda kirk

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But we don’t have to have a “problem” or symptom to benefit from biofeedback. We can take a “good brain” or “good body” and make it better.

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Using LK’s expertise in this area….

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Integrating Biofeedback, Neurofeedback and Adjunctive Techniques for Optimal Health and Performance Biofeedback Foundation of Europe 14th Annual Conference Rome, Italy April 13, 2010 Lynda Kirk, MA, LPC, BCIA-C, BCIA-EEG, QEEG-D Jennifer Kirk Schriever, MA, LPC, NCC Austin Biofeedback and EEG Neurotherapy Center Copyright 2010 Healthy Life Options, Inc. .

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You Can Take a Good Brain And Make It Better We can increase the number of neurons in our brain by creating a more “enriched” environment, including EEG NFB training, “We got denser brains in an enriched environment”

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Integrating Biofeedback, Neurofeedback and Adjunctive Techniques for Optimal Health and Performance Training your Clients to Move from Dysfunction to Optimal Function (‘The Peak Zone’) Dysfunction Impaired/Inadequate Function Optimal Function Copyright © Lynda Kirk, 2009 Desired Function or ‘The Peak Zone’)

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All Clients and Patients Are Optimal Function and Optimal Performance Seekers Our GOAL is to move clients toward the Optimal Function end of the spectrum (‘The Peak Zone’) Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Our Mission Our primary clinical objective is not just to perform biofeedback therapy successfully, but to empower our patients and clients by helping them to identify and reach their psychophysiological wellness, emotional, behavioral, developmental, & performance goals, and to verify achievement by setting concrete, measurable objectives that are drawn directly from these goals. Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Experience also informs us that because of the complex etiologies of most dysfunction, the best and most durable outcomes are generally achieved by using biofeedback therapy in combination with whatever other case-relevant therapeutic approaches will allow us to address the dysfunction globally, throughout the whole person. Copyright © Lynda Kirk, 2009

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The basic assumption above requires three clinical responses on our part: First, casting a broader net in our information gathering efforts, listening and observing without intent, and being curious about everything the client brings to us as a potential source of relevance. You cannot know too much! Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Second, developing a therapeutic plan that coordinates multi-modal biofeedback and neurofeedback therapy with whatever other adjunctive therapies will increase the positive impact of our efforts on the whole person. Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009 Third, being open and flexible in our efforts because we know that humans are dynamic beings; information gathering never stops, invariably new factors come to light, and therapy must be adjusted.

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SETTING WELL-FORMED GOALS & OUTCOMES: ► “What outcomes do you want?” ► “How will you know you have them?” ► Indicators of change (measurable and concrete): Copyright © Lynda Kirk, 2009

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Peripheral Biofeedback Assessment Baselines (sitting, standing, moving, working, performing home activities & usual activities of daily living, recreational activities , postural habits, general ergonomics) PSP (Psychophysiological Stress Profile) Copyright © Lynda Kirk, 2009

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EEG Assessments Copyright © Lynda Kirk, 2009

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“Mini QEEG” - One or Multi-Site Assessment (under various conditions or states) - Neutral eyes open - Neutral eyes closed - Reading - Listening - Math - Stress conditions or recall - Peak performance recall - Taking continuous performance tests (TOVA, Connors, others) Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Continuous Performance Testing (CPT Testing) Example: TOVA (Test of Variables of Attention) Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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QEEG (Quantitative EEG) - Neutral eyes open - Neutral eyes closed - Challenge states specific to client goals: - Reading - Listening - Math - Stress conditions or recall - Peak performance recall - Taking continuous performance tests Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009 Copyright © Lynda Kirk, 2009

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Other resources Copyright © Lynda Kirk, 2009

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Resource tools, such as ADHD inventories, intelligence tests, depression, anxiety, personality inventories, learning skills evaluation, etc. Copyright © Lynda Kirk, 2009

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Outside referral, when during the intake process or subsequent therapy, case characteristics come to light that suggest evaluation by other specialists. Copyright © Lynda Kirk, 2009

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Working with extended teams: Physical therapists Occupational therapists Audiologists Developmental optometrists Physicians Nutritionists Dentists Chiropractors Accupuncturists Other therapists Copyright © Lynda Kirk, 2009

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Getting Into the Peak Zone DISREGULATED REGULATED Inattention Fatigue Social Impairment Sleep Disturbance Depression Limited Creativity Decreased Stamina Slow Processing Speed Focus Calm “Peak Zone” Cognitive Flexibility Intentional Energetic Bright Creative Underfocused Hyperfocused Focused / Calm DISREGULATED Anxious Worried Impulsive Obsessive Stressed Sleep Disturbance Irritability Poor Concentration

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“I don’t ‘do’ depression any more. I don’t react angrily very often any more, and when I do, I get over it real quick. I credit EEG biofeedback for making it possible. I’ve got a new appreciation of life. They say life begins at 40. Well for me it began at 41 because that’s when I finished my biofeedback training.” --Jeff Hammond (with permission)

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Each individual’s starting point on the continuum is different. What defines optimal performance for one will differ from what defines it for another: For a CVA/TBI patient, optimal performance may be the ability to speak again or to walk. For a post-prostatectomy patient, optimal performance may be no more leakage or “Depends.” For an Olympic athlete it may be winning a medal. Copyright © Lynda Kirk, 2009

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Each objective met as a patient moves along the continuum creates new possibilities: Dysfunction/Inadequate Function Adequate Function Optimal Function As a patient acquires new abilities, the possibilities for growth increase. To put it another way…they can keep getting better and better! Copyright © Lynda Kirk, 2009

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"We balance probabilities and choose the most likely. It is the scientific use of the imagination." -Sherlock Holmes, “The Hound of the Baskervilles” (1901-1902) Copyright © Lynda Kirk, 2009

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Comprehensive Therapeutic Solutions: Combining Adjunctive Therapies with Biofeedback Copyright © Lynda Kirk, 2009

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The Decision Tree: Determining When and How to Include Adjunctive Therapies Copyright © Lynda Kirk, 2009

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Common Presenting Problems “More Physiological” Pelvic Floor Dysfunction Chronic Prostatitis Urinary Incontinence Dysfunctional Voiding "Bashful Bladder” Interstitial Cystitis Vulvadynia Vaginismus High Blood Pressure Cardiac Arrhythmia Chronic Pain Headaches Migraines TMJ Syndrome Fibromyalgia Chronic Fatigue Gastrointestinal Problems Acid Reflux/GERD Esophageal Spasm Irritable Bowel Syndrome Chronic Constipation Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009 EMG biofeedback muscle sensors on client’s arms and legs to help him learn to lower excessive muscle tension and to recruit the proper muscles for specific muscle (motor) activities of daily living Cheerleading section! Copyright © Lynda Kirk, 2009

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Common Presenting Problems “More Psychophysiological” ADHD Anxiety Disorders Autism PDD Depression Bipolar Disorder Tourette’s Syndrome Learning Disabilities Conduct Disorder Developmental Delay Explosive Rage Syndrome Obsessive/Compulsive Panic Disorder Seizure Disorder Sleep Disorders Stress Disorders Traumatic Brian Injury Addictions Habit Control PTSD Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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Neurofeedback’s Best Ally Copyright © Lynda Kirk, 2009

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Peripheral Biofeedback Electromyograph (sEMG) Peripheral Temperature (TEMP) Skin Conductance Level (SCL) Breathing/Respiration (RESP) Heart Rate (HR) Heart Rate Variability (HRV) And More... Copyright © Lynda Kirk, 2009

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Peripheral Biofeedback Training Tends to give a more comprehensive picture of levels of sympathetic nervous system arousal Skin conductance/resistance, temperature, and sEMG tend to register changes in anxiety levels more immediately than EEG As such, they can be used in an ongoing diagnostic capability Copyright © Lynda Kirk, 2009

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Peripherals Demonstrate the Mind-Body-Spirit Connection... and the Ability to Control It! Peripheral biofeedback can teach the client how to control their own body states before beginning neurofeedback This is an excellent convincer for skeptics (adolescents and left-brain analyzers) It’s hard to argue with the “scientific data”! Copyright © Lynda Kirk, 2009

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Benefits of Adding Peripheral Biofeedback to Neurofeedback Shortens training time RAPIDLY increases internal locus of control for your client/patient Improves generalization of learned skills and states Allows you to diversify your practice Increases clinical effectiveness Copyright © Lynda Kirk, 2009

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Peripherals Give the “Monkey Mind” Something to Focus On If you train peripheral biofeedback first, it is an excellent distracter for your “analyzer” clients who have to figure everything out It gives them something concrete to do during the neurofeedback portion of their training rather than “Try, Try, Try” Copyright © Lynda Kirk, 2009

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Peripherals Give The Client a Way to Change States at Will Having them practice their peripheral biofeedback during EEG neurofeedback “anchors” the states together Having them practice “out there in the real world” helps speed and generalize training When you have them practice their “Quick Mental & Physical Cool Downs” they also access the EEG state you have been training Copyright © Lynda Kirk, 2009

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Peripherals Give Us More Clues to the Client’s State Clients who are completely disconnected from their feelings and are relatively unsophisticated may have trouble describing what they are experiencing They may describe all uncomfortable feelings as “depression” or “I feel bad” Peripheral BFB may help in this regard Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009 “No more migraines, way less stress. I wish the doctor had made the suggestion [biofeedback] earlier instead of wasting time and money on pills that don’t work.”

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Amanda’s Story 37 y.o. female complaining of depression Always started each session c/o how depressed she felt, even though she appeared more anxious than depressed During Neurofeedback, her TEMP and SCL measures gave more clues to her affect than she could describe (TEMP while SCL as anxiety decreases) Copyright © Lynda Kirk, 2009

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Peripheral Biofeedback Is One of the Most Immediate Ways to Measure the State of the Mind-Body-Spirit It is a very powerful and convincing thing for your clients to see/hear/feel the effects of their thoughts on their mind-body-spirit Skin Conductance Level (SCL), sEMG or Applied Kinesiology (AK) are excellent ways to demonstrate the immediacy of this It is an excellent convincer/motivator strategy Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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The Power of sEMG Quickly gives the client a sense of “control” Allows the client to “see” that where they proprioceptively feel is “normal” may actually be clinically very tense or hyper-vigilant Makes a nice metaphor for the “stuck but familiar” theory when you do NFB Can do wonderful ergonomic training Don’t train sEMG in a recliner! Copyright © Lynda Kirk, 2009

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Peripherals Give Your Clients Some of the Most Valuable Tools They’ll Ever Own Practicing state control gives your clients a conscious “control tool” at the same time as they increase body-mind flexibility and learn to “park” in a more optimal, healthy place Copyright © Lynda Kirk, 2009

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Let Us Play! Copyright © Lynda Kirk, 2009

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The Quick Mental & Physical Cool Down Scan your body for muscle tension, thought content, and breathing style (“just notice”) Take a slow diaphragmatic breath and as you exhale, relax your face, jaws, shoulders, abdomen, and pelvic floor Choose to change your thoughts if they are not helping/healing you “Change the channel” to something pleasant Copyright © Lynda Kirk, 2009

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Thought Changing Every thought is a “prayer” or intention The body-mind-spirit cannot differentiate between a thought and “reality” The body-mind-spirit has no sense of time-space-distance The body-mind-spirit has no sense of past-present-future It experiences everything in the present moment - RIGHT NOW! Copyright © Lynda Kirk, 2009

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Thought Changing Observe your most recent thoughts If they aren’t healthy, happy, or healing (“Triple H”) thoughts, change the channel Negative, or worry, or judgmental thoughts about yourself or anything/anyone else have a negative effect on your mind-body-spirit Copyright © Lynda Kirk, 2009

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“The Greatest Thing, Then, Is to Make the Nervous System Our Ally Instead of Our Enemy.” ---William James Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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From Dysfunction… To Function... To Optimal Function Learning to differentiate and shift states is the name of the game When we can do this, our nervous system is our ally rather than our enemy Copyright © Lynda Kirk, 2009

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Adding in other Adjunctive Therapies Copyright © Lynda Kirk, 2009

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Potential Concurrent Therapies Medical and Surgical Physical Therapy and Occupational Therapy Dental Chiropractic Family and Relationship Counseling Ophthalmology and Audiology Substance Abuse or other Support Groups And many more, depending on need Copyright © Lynda Kirk, 2009

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What Are Adjunctive Techniques? Adjunctive techniques are basically any other non-biofeedback therapies or techniques you include with peripheral biofeedback and/or neurofeedback training to increase overall effectiveness. Copyright © Lynda Kirk, 2009

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Some Adjunctive Techniques “Energy” Therapies - EMDR, TFT, EFT Hypnosis Neurolinguistic Programming (NLP) Coaching & Counseling Psychotherapy Imagery Applied Kinesiology (AK) Others per need & availability Copyright © Lynda Kirk, 2009

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Benefits of Using Adjunctive Techniques Allow you to help your clients break old body-mind habits and “stuck states” more quickly Help the therapy/training move along more quickly and effectively Can address blocks and resistance to progress during biofeedback/neurofeedback Can address and heal core issues Can quickly resolve abreactions Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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When To Use Specific Adjunctive Techniques: Coaching I consider myself a “coach” and in that context, I am coaching all the time Good coaches establish exquisite rapport and learn to “read” their clients well Good coaches are caring teachers Good coaches are “with” their clients Copyright © Lynda Kirk, 2009

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When To Use Specific Adjunctive Techniques: Counseling Coaches can also “counsel” as needed How you define “counseling” may depend on your professional credentials Often my clients come in with a specific problem or issue that needs to be dealt with in order to move the NFB/BFB training along and counseling is appropriate in that particular session Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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When To Use Specific Adjunctive Techniques: Psychotherapy If your credentials & training allow it, adjunctive psychotherapy can be very helpful with biofeedback & neurofeedback For example, with anxiety or depression clients, you may help them even more by using any number of psychotherapeutic techniques (CBT, RET, desensitization, etc) Copyright © Lynda Kirk, 2009

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When To Use Specific Adjunctive Techniques: NLP (Neurolinguistic Programming) I have found NLP to be invaluable in all the work that I do. NLP can help: Rapport skills Communication skills State change skills Rapid change skills Belief system change Trauma…and much more Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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When To Use Specific Adjunctive Techniques: Hypnosis Sleight of mouth is an excellent tool to use to bypass the client’s logical left brain “Formal” Hypnosis may be very helpful to some clients Some clients are afraid of hypnosis (Stephen’s case) GET GOOD TRAINING! Copyright © Lynda Kirk, 2009

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When To Use Specific Adjunctive Techniques: Imagery & Therapeutic Metaphor Similar to hypnosis but not as threatening to some clients Significant research shows that the body-mind-spirit is greatly affected by imagery We use outcome imagery with virtually all our clients Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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When To Use Specific Adjunctive Techniques: “Energy Therapies” TFT (Thought Field Therapy) or EFT (Emotional Freedom Technique) are especially useful with anxiety, panic, phobias, trauma, and fears Helpful with abreactions if they occur Copyright © Lynda Kirk, 2009

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Copyright © Lynda Kirk, 2009

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More on EEG Neurofeedback Protocols for ADHD The 3 “Tried & True Trio” supported by published, peer-reviewed studies 7 EEG NFB Protocols from SPECT and QEEG neuro-imaging Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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The 3 “Tried and True Trio” The “Tried and True Trio” protocols for neurofeedback training for ADHD subtypes described on the following 3 slides have been supported by published controlled, group studies: Rossiter & LaVaque, 1995 Linden, Habib, & Radojevic, 1996 Monastra, Monastra, & George, 2002 Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003 Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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“Tried and True #1” Hyperactive/Impulsive Type ADHD Protocol (Hypo-aroused) Electrode Placement: C3 or C4 active with linked ear reference Reward Frequency: 12-15 Hz Inhibit Frequency: 4-7 Hz Behavioral Duration: Minimum 0.5 second (1/2 second) to obtain reward Sampling Rate: Minimum of 128 per second per Rossiter & LaVaque Rate of Reward: Settings for Reward EEG and Inhibit EEG: approximately 15-20 auditory/visual rewards per minute Feedback Delivery: Depending on neurofeedback system: auditory tones or music; visual counter displays; animations; video games; movie DVDs; tactile vibrating pillows or stuffed animals; vibrating video game controllers Clinical Outcome: Reduce behavioral symptoms of hyperactivity and impulsivity

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“Tried and True #2” Hyperactive/Impulsive Type ADHD Protocol (Hyper-aroused) Electrode Placement*: C4 active with linked ear reference Reward Frequency: 12-15 Hz Inhibit Frequency: 22-30 Hz Behavioral Duration: Minimum 0.5 second (1/2 second) to obtain Reward Sampling Rate: Minimum of 128 per second per Rossiter & LaVaque Rate of Reward: Settings for Reward EEG and Inhibit EEG: approximately 15-20 auditory/visual rewards per minute Feedback Delivery: Depending on neurofeedback system: auditory tones or music; visual counter displays; animations; video games; movie DVDs; tactile vibrating pillows or stuffed animals; vibrating video game controllers Clinical Outcome: Reduce behavioral symptoms of hyperactivity and impulsivity *1st Half of Fuchs Inattentive Split Protocol for Combined ADHD

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“Tried and True #3” Inattentive ADHD Protocol (Hypo-aroused) Increase Beta 1 / Decrease Theta *2nd Half of Fuchs Inattentive Split Protocol for Combined ADHD Electrode Placement*: -Cz or C3* active with linked ear reference -FCz-PCz w/ ear reference -Cz-Pz w/ ear reference a Reward Frequency: 16-20 Hz Inhibit Frequency: 4-8 Hz Behavioral Duration: Minimum 0.5 second (1/2 second) to obtain reward Sampling Rate: Minimum of 128 per second per Rossiter & LaVaque Rate of Reward: Settings for Reward EEG and Inhibit EEG: approximately 15-20 auditory/visual rewards per minute Feedback Delivery: Depending on neurofeedback system: auditory tones or music; visual counter displays; animations; video games; movie DVDs; tactile vibrating pillows or stuffed animals; vibrating video game controllers Clinical Outcome: Reduce behavioral symptoms of inattention and hypo-arousal

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7 EEG NFB Protocols from SPECT and QEEG neuro-imaging Amen et al (1993) identified 6 subtypes of ADHD using SPECT (single proton emission cerebral tomography). SPECT measures cerebral blood flow and thereby provides information regarding brain metabolism. Amen (2001) uses SPECT plus his clinical experience to determine neurotransmitter abnormalities and specific medications for the 6 ADHD subtypes. Amen also suggests NFB protocols for 5 of the 6 identified subtypes may be useful. Amen later added a 7th ADHD subtype: “Trauma-induced ADHD.”

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ADHD – “Classic” or Combined Type Per Amen, neurofeedback for this subtype consists of rewarding pre-frontal beta and decreasing theta (Amen, 2001). At Austin Biofeedback and EEG Neurotherapy Center, we use a combination of DSM-IV behavioral assessment plus mini-QEEG or full-QEEG with challenge states to determine NFB protocols. Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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Inattentive ADHD Per Amen, neurofeedback for this subtype consists of rewarding prefrontal beta and decreasing theta (Amen, 2001). At Austin Biofeedback and EEG Neurotherapy Center, we use a combination of DSM-IV behavioral assessment plus mini-QEEG or full-QEEG with challenge states to determine NFB protocols. Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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Over-Focused ADHD Per Amen, neurofeedback for this subtype consists of rewarding high alpha over the anterior cingulate gyrus (Amen, 2001). At Austin Biofeedback and EEG Neurotherapy Center, we use a combination of DSM-IV behavioral assessment plus mini-QEEG or full-QEEG with challenge states to determine NFB protocols. Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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Temporal Lobe ADHD Per Amen, neurofeedback for this subtype consists of rewarding SMR and inhibiting theta over the affected temporal lobe(s) (Amen, 2001). At Austin Biofeedback and EEG Neurotherapy Center, we use a combination of DSM-IV behavioral assessment plus mini-QEEG or full-QEEG with challenge states to determine NFB protocols. Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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Limbic ADHD Per Amen, neurofeedback for this subtype consists of rewarding beta and inhibiting theta over the left prefrontal cortex (Amen, 2001). At Austin Biofeedback and EEG Neurotherapy Center, we use a combination of DSM-IV behavioral assessment plus mini-QEEG or full-QEEG with challenge states to determine NFB protocols. Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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“Ring of Fire” ADHD Amen (2001) cites no NFB protocols for this subtype. At Austin Biofeedback and EEG Neurotherapy Center, we tailor NFB to fit both the specific behavioral symptoms & the QEEG-defined abnormalities to > psychophysiological calm and to < impulsivity & oppositional, manipulative behavior in this subtype. We view this subtype as either Bipolar or Bipolar co-morbid with ADHD. Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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Trauma-Induced ADHD Amen identifies this subtype as one that comes on or intensifies in the year following a head injury. Amen uses psychostimulant and/or anticonvulsant meds, but suggests no NFB protocols. At Austin Biofeedback and EEG Neurotherapy Center, we see this “subtype” as part of the sequelae to Traumatic Brain Injury and we rely on clues in the patient’s specific presenting symptoms and the QEEG to tailor specific outcome-based NFB protocols. Copyright 2006, Lynda Kirk - Healthy Life Options, Inc.

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