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The NeuroDevelopment Center's Approach to Neurofeedback
As in any other area of practice in mental or behavioral health, there are very significant differences among providers of "the same" service: differences in level of training and experience, differences in how the treatment is conducted, differences in how or whether treatment outcome is tracked during the process or carefully measured.
At the NeuroDevelopment Center, we have an approach that is carefully and comprehensively based in the science and research evidence, and guided by ten years of experience working with more than one thousand patients.
The sections below provide the details of how we do neurofeedback.
Systematic and Data Driven
Our approach to neurofeedback training is systematic and data driven. We gather data prior to beginning neurofeedback using scientifically-proven instruments. We use this data to guide the training over time and to document effectiveness. We follow a carefully designed series of steps throughout the training to assure and demonstrate that your goals are met:
1. We begin with a comprehensive initial assessment to guide the neurofeedback. This includes:
• An online report about strengths and weaknesses and individual characteristics in numerous dimensions of behavior, learning, and emotions. This report becomes the basis of a Functional Brain Assessment that allows us to learn a great deal about the brain and about how to conduct the neurofeedback training by carefully evaluating how it functions.
• A quantitative EEG study (QEEG) of brain function is conducted. The recording done is in our Psychophysiology Lab by trained and experienced technicians. The EEG is then analyzed to remove any electrical activity that is picked up by the sensitive electrodes but comes from sources other than the brain’s electrical activity - for example, muscle activity, eye movements, tongue movements, and so on. Then your brain’s unique and complex patterns of brain activation and communication are analyzed using complex mathematical and statistical methods and compared to a database of over 5000 individuals with no known neurological, developmental, or psychiatric disorder.
• Computerized neuropsychological testing of sustained and shifting attention, impulsivity, memory, processing speed, executive function, and cognitive flexibility.
• Well validated, standardized psychological rating scales are used to provide baseline measures of functioning in numerous domains of behavior, thinking, emotion, and learning. These scores also enable us to objectively measure the results of your training when we repeat the very same measures after 15 – 20 sessions of neurofeedback training.
2. After the initial assessment is complete, we will sit down with you, review our findings, and together plan the neurofeedback training. You will be asked to write a list of your goals and objectives for the training and to describe how you will know when they have been achieved: Exactly how will daily life be different when these goals are attained. You will also be asked to prioritize these goals in order of importance. Based on your goals and the results of our assessment, a detailed neurofeedback training plan will be developed.
3. Neurofeedback begins. Each trainee works with one of our highly trained technicians using state of the art EEG biofeedback equipment. We can choose among seven different advanced computerized neurofeedback systems to meet every possible need in every possible circumstance.
4. Each day, after every training session, you will be asked to go online and complete a 40 item checklist detailing any and all changes you observed after the session. This information is immediately available to us and is compiled between sessions, allowing us to fine tune the training parameters over time to achieve the best results possible. We will also talk to you during most visits to clarify any questions we have about your report and give you an opportunity to ask questions of us.
5. Some time between the 15th and 20th session, we repeat the baseline assessment, using the computerized test and all of the rating scales. These results are then carefully studied to show us objectively the results of the training, and the initial training goals are reviewed with you to assess our progress.
6. If further training is indicated by this repeat assessment, training parameters are adjusted based on these results and the training continues. If training goals are met, a schedule of gradually decreasing frequency of training sessions is developed to taper off the training – from twice to once weekly, to every other week to once a month.
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EEG Changes After Neurofeedback in ADHD Child Showing Singificantly Increased Frontal Activation |
Rely on a Nationally Recognized Leader
Our neurofeedback program is directed by Dr. Laurence Hirshberg. Dr. Hirshberg serves on the faculty of the Department of Psychiatry and Human Behavior of the Brown Medical School. He has been practicing for over 17 years and provides professional training and consultation to schools and clinics throughout New England. He has published and presented on many areas of clinical psychology and child development.
Dr. Hirshberg has published on neurofeedback in professional journals and presented at national and international meetings of neurofeedback and behavioral medicine specialists. He recently edited a special issue of Child and Adolescent Psychiatric Clinics of North America devoted to neurofeedback and other brain based interventions. Dr. Hirshberg serves on the executive board of the neurofeeedback division of the Association for Applied Psychophysiology and Biofeedback. He serves as an instructor for the largest neurofeedback training organization in the world, and has also provided instruction in neurofeedback at the American Psychiatric Association annual meetings. Dr, Hirshberg is certified by the Biofeedback Certification Institute of America and has been recognzed as a Fellow of the International Society for Neruofeedback and Research. He is currently conducting research into the efficacy of neurofeedback with several internationally known research experts.
The NeuroDevelopment Center is one of the fastest growing neurofeedback centers in the US.
Case Studies In Neurofeedback
What Case Studies Mean
In the brief case studies presented below, psychological tests were used before and after neurofeedback in order to determine if significant change occurred and to measure the degree of change. We used well established measures that are frequently employed in research and in clinical practice. Whenever possible, we used objective computerized tests to complement subjective rating scales in order to have an unbiased measurement of change. (After all, our clients badly want neurofeedback to work, as do their parents who are serving as the raters. For this reason, these subjective rating scales may be subject to bias.)
In assessing what these results mean, it is important to remember that the results of any one individual's treatment are not necessarily representative of all such cases. Your results may differ. (Our statistical analyses of treatment outcome data for individuals with autism spectrum disorder do show average gains from 20 sessions of neurofeedback.)
However, well controlled research is the best indicator of the efficacy of a treatment method. These studies assess change in a group of individuals and average scores across all participants, and control for other factors that might be resulting in any changes found. For information on this research, click here.
Still, well documented single case studies, using outcome measures that have been found in research to be valid measures of the behavior being studied, are an accepted source of evidence for treatment effectiveness. However, in looking at these examples, please remember that neurofeedback is NOT ALWAYS effective. There are treatment failures for neurofeedback just like every other form of intervention. Our general rate of success varies based on the type of difficulty involved. Overall, we see statistically and clinically significant improvements in the measures we use to assess progress in approximately 70-80% of the individuals we work with.
The measures used to assess treatment outcome vary based on the type of difficulty involved and also have evolved over time. For example, years ago, we used only computerized tests of attention to regularly monitor progress. Some of those cases are presented below. More recently, we use multiple measures with several observers reporting: parents and teachers for children and individual self-reports and spouse reports for adults.
TO DOWNLOAD SIX CASE STUDIES FROM OUR CENTER, CLICK HERE.
TO DOWNLOAD A SUMMARY OF 11 CASE STUDIES FROM OUR CENTER, CLICK HERE.
Treatment Outcome Research
In our neurofeedback program, we conduct regular systematic treatment outcome measurement after every 20 sessions of neurofeedback with each individual patient in order to measure change and improvement.
Our chief goal is to discover with hard data what works for whom, so that we contiually improve our ability to obtain good outcomes. In this way we can see what training approaches work best with which types of problems or disorders.
We also do this to provide data for our treatment outcome agreement: if you do not show statistically signficant improvement on well established measures of functioning in the areas of your goals after 20 sessions, we stop charging and keep training for up to another 20 sessions.
We also conduct formal statistical analyses using these data. The resultant research is called a retrospective pre post study.
As research evidence of the effectiveness of neurofeedback, the results have significant limitations. There is no control group. The raters (parents and teachers for children, self and observer for adults) are not blind to the intervention. We primarily use subjective ratings scales rather than objective tests, although we are now using a brief computerized neuropsychological test as well. The diagnoses were not confirmed using gold standard diagnostic procedures.
Still, these data are also not without value, because they make clear that the results we observe with each individual using our treatment outcome measurement are refelctive of what is happending in general or on average. In addition, research in medical treatment has shown that most of the time, treatment outcome results from uncontrolled observational studies like ours show good agreement with the results of more carefully controlled studies.
Autism Spectrum Disorder
In general, on a case to case basis, we have observed very good results employing neurofeedback with individuals on the autism spectrum. We expect to see statistically significant improvement in social function after 10 weeks (20 sessions) of training. Very few other treatment methods show such rapid and robust results.
In order to look at the results on average, we analyzed the data for all patients diagnsoed with an autiism spectrum disorder, with the diagnosis confirmed by their scores on the parent version of the Social Resposnsiveness Scale. A score of 60 or higher on the "Total" scale indicates the presence of an autism spectrum disorder. This included 46 patients.
The Social Responsiveness Scale is a well established measure of social functioning. This measure has five subscales and a total score. The Social Awareness Scale measures the degree to which an individual remains attuned to or aware of the social environment. Social cognition is a measure of the degree to which the child is able to understand the social environment. Social communication measures the level of communication purely for social purposes, as opposed to getting things done or imparting information. Social motivation indexes the degree of interest in social interaction. Autistic mannerisms measures the repetitive and rigid behavior often seen in the autism spectrum. The Total scale combines all five sub scales. Scores greater than 60 are indicative of an autism spectrum disorder.
Looking at scores on this measure before and immediately after 20 sessions of neurofeedback, we found statistically and clinically signifcant improvement on all subscales and on the total score. These results show averages from 46 patients who met criteria.
These data are shown in the table below:
These data show that on average our patients on the autism spectrum show a very signficant degree of improvement in social and executive function after only 10 weeks or treatment. Cohen's d is a statistic that shows the size or amount of a chnage. For Cohen's d an effect size of .2 to .4 is considered a small effect, .4-.8 a "moderate" effect and .8 and higher a "large" effect. For social functioning, in all but two areas, the amount of change is considered large.
A graphic representation of these results is given below:
Self-regulation Deficits
The area of functioning that seems most consistently to respond favorably to neurofeedback is behavioral and emotional self-regulation. Again, here, we expect to see significant improvements in emotional and behavioral self-control ad flexibility within 20 sessions or ten weeks, based on our case by case treatment outcome data.
The Behavior Rating Inventory of Executive Function is a well established measure that includes four measures of behavioral and emotional self-regulation: Inhibit, which measures behavioral self control and the capacity to inhibit impulses, Shift, which measures flexibility in behavior and thinking, Emotional Control, and BRI or Behavior Regulation Index which is a summary measure of the previous three areas. In interpreting this measure, scores equal to or greater than 65 are considered abnormal.
In order to look at the results of our neurofeedback training on average with children with difficulties with self-regulation, we analyzed all cases from our files in which there was a score in the abnormal range in one or more of these measures. This included 103 children.
The results are presented in the table and charts below. Looking at these scores before and after 20 sessions of neurofeedback, we found statistically significant improvement on all four scales, with the average score changing from the abnormal to the normal range for each measure.
Post Traumatic Stress Disorder
Early published research shows preliminary evidence of the efficacy of neurofeedback for the symptoms of Post Traumatic Stress Disorder (PTSD). This research was conducted with Vietnam war veterans. At the NeuroDevelopment Center, we have worked with a new generation of veterans, som eof whom who have returned from the combat in Iraq and Afghanistan with PTSD.
To date we have worked with four vets. Although the number is too small to allow for statistical analysis, we have measured improvement in several areas of functioning after 20 sessions of neurofeedback. Using the Hopkins Symptom Checklist, a well established measure fro adults, levels of difficulty have been cut approximately in half for most of the scales. The results are presented in the graph below:
Our Clients Speak...
about Neurofeedback for PDD/Autistic Spectrum Disorder:
“My son was a normal baby who, around 15 months old, stopped talking, more or less stopped smiling, started screaming a lot, and became very obsessive….By the time he was 3.5 years old, he was very non-compliant, obsessive, and aggressive toward his younger brother. He spent much of the day screaming or smashing his head into the wall or floor. His obsessions were so strong they ran our lives. I had difficulty bathing him, getting him dressed, and especially, keeping him from hurting his brother. Everything was a struggle. He was diagnosed with autism (PDD-NOS) around this time. A few months later my son started EEG biofeedback with Dr. Laurence Hirshberg. He is now a nice little boy. He gives me kisses when I am sad. He is no more aggressive with his brother than any normal kid. In fact, he is very tolerant. His obsessions have decreased markedly. He plays cooperatively with his brother and shows concern for him...I am extremely grateful to have my child back. I am convinced that it is this treatment (EEG biofeedback) that has changed him.”
R. H. , N. Attleboro, MA
about Neurofeedback for ADHD:
"My husband and I first became aware of neurofeedback from attending a seminar conducted by Dr. Hirshberg at our local high school. Our son was diagnosed with ADD eleven years ago, and since then has been on either Ritalin or Adderol. Although he has willingly taken his medication when it is put out for him, he doesn’t think to take it on his own. I was getting desperate. He is heading off to college next year, and I had visions of him becoming angry, frustrated, and discouraged, as well as missing classes, assignment deadlines, and even meals due to his lack of time awareness. Even though neurofeedback sounded very promising, it seemed almost a little too “woo-woo” (you know, Twilight Zone theme song playing in the background). However, I was at the point where I was willing to give anything a chance!
E was given the QEEG in February of this year [2003], and subsequently began his sessions at the end of March. During his first IVA, his ability to focus was two standard deviations below normal. After just 17 sessions, when given another IVA, he tested in the normal range. If I had to rely on just a test result, I wouldn’t be impressed, but my husband and I see it first-hand in day to day situations! E’s “stick-to-itness” has improved tremendously. He’s actually able to finish tasks he begins without getting side-tracked ten times! He functions on a much more even keel, and his outlook is much more positive. Incidents which would have angered or frustrated him before neurofeedback, now seem to have very little negative effect. His whole personality has “lightened up,” and he is actually able to laugh at himself!
In looking at his report card for the last marking period I was truly amazed; all his grades were good, but in two courses he liked the least, he went from a 70 to an 80, and a 75 to a 95! I very rarely feel the need to give him his medication any more, so I feel much more secure about sending him to college this September. "
M.P., Attleboro, MA
about Neurofeedback for Adult ADHD and Dyslexia:
"I arrived desperate. The medications for attentional deficit disorder made me more anxious, not more effective. They worsened my reading comprehension and my test taking skills. They made me sweat, and my sweat was not paying off.
Four times I had failed Step 1 of the United States Medical Licensing Exam, the exam that students take after completing the first two years of medical school. While my mentors both in the classroom and on the hospital floors reassured me that I knew enough to pass, I kept failing.
Though steadfast in my desire to become a medical doctor, I was running out of options to help me prepare for this 8 hour, basic science, multiple choice examination.
A trusted friend and nationally recognized neuroscientist recommended neurofeedback, saying he had seen Dr. Hirshberg speak at Brown University and was impressed.
After navigating a complex web of insurance information, I had an introductory meeting at Dr. Hirshberg’s Neuro Development center in Providence. I was struck by the warmth of the office staff and the welcoming environment. Dr. Hirschberg listened intently to my story. His bright eyes conveyed sincere interest and a genuine desire to help.
A few days later I began training at the center. The effects were not immediate. Within 5 sessions, however, I began noticing subtle differences in the way I approached test questions. My ability to remain focused on the question at hand changed for the better. I began to read faster and discriminate more effectively between more and less important information, as presented in the often lengthy test questions. I also noticed a greater ease with which I approached my daily test preparation.
Soon my practice test scores started to improve. This further bolstered my confidence and convinced me that the neurofeedback was in fact working. Throughout the 6 week therapy, Dr. Hirshberg made adjustments in the treatment protocol based on my personal reports and continually honed the training to maximize my ability to learn, and convey what I had learned, effectively.
Curiously enough, the afternoon I found out by telephone that I had passed the exam, I was at the neurodevelopment center undergoing training. With electrodes attached to my head, the same ones I found so strange to put on for the first time, I got the good news. Two and a half years of effort had come to an end. The sounds and colors from the Dr. Hirshberg’s training terminals had taught my brain about itself. My effort had paid off, but it had also been sharpened by a very special type of therapy, one that is not yet part of medical curricula.
Thanks to the neurodevelopment center I am now free to move ahead in my professional, and personal, development.
As tears streamed down my face, and I tried to verbalize my joy to those in the room, Dr. Hirshberg detached the electrodes: “That will be enough training for today.”
J.K., Providence, RI
about Neurofeedback for ADHD and Depression:
"My son P had been having difficulty at home and school managing throughout the day, struggling with social interactions, and staying focused at school. We had tried many things including 5-6 different medications, none of which helped. Most made him more agitated, aggressive, angry and less able to focus. The last straw was when he asked me to kill him because his life was way too hard. He is only 7. This brought me to seek alternate routes of treatment, thus The NeuroDevelopment Center.
He began feedback in April 03 2x/wk. The results have been amazing. He now looks at the world in a totally different perspective. The glass is now half full, not empty. He is able to handle frustrations and challenges without getting angry and aggressive. His social situations have also become much easier for him to negotiate. He no longer feels the need to be in control of everything the group is doing. He is now willing to put his ideas on hold, and follow through with what others want to do. His laughter is one of the most beautiful sounds and something we rarely heard. We and he discovered he has a good sense of humor.
To all parents who are lost and torn and feel like they’re on a merry-go-round that doesn’t stop, please take a look at the alternatives. Neurofeedback has certainly had a huge impact on our family and hopefully on the outlook he has for his future. The fears/anxieties that he still has at least now he can verbalize, and we can discuss them openly. We now have some idea as to what he is thinking/feeling."
S.F., Foxboro, MA
about Neurofeedback for Non-Verbal Learning Disability:
“My son is 10 years old and has been diagnosed with non-verbal learning disorder. He was challenged every day to control his emotions and manage his frustrations with everyday situations. He would become very upset when he perceived situations as unfair or negative...He would become overly aggressive, (showed) ragelike behavior, and (was) extremely defiant to everyone. ….After approximately 10 sessions of neurofeedback, we began to see a difference. He is now handling the same situations with grace. He is handling the loss of football games and recess at school without incident. He is a better friend and is in better control of his emotions.”
C.L., Lincoln, RI
about Neurofeedback for Non-Verbal Learning Disability:
“My son has attention issues as well as social pragmatic deficits and sensory integration dysfunction. We had pursued vision therapy and...occupational therapy and had made gains...but we were still struggling with the attentional deficits, impulsivity, and social pragmatic issues. Neurofeedback has helped NZ make incredible progress in his ability to organize himself. He is now able to get himself dressed with little or no management. He is coping successfully in a regular education classroom setting. He is exercising judgment and is not as easily led into disruptive or confrontational situations. He is calmer and has even been known to sit through an entire dinner with little movement. We are very pleased with his progress and plan to continue the therapy.”
C.Z., Barrington, RI
about Neurofeedback for Anxiety:
“It is hard to believe that a year ago my family was living in Hell. My daughter was so scared of everything in life and my husband and I didn't know what else to do for her. The level of stress, fear, and sadness was unbearable. Her anxieties and panics were becoming mine. It is unbelievable the change which has occurred. The confidence she has built in herself and in facing her fears is remarkable.”
F.P., East Providence, RI
Our Agreement on Treatment Outcome
We make a formal agreement with every neurofeedback patient. We used well established psychologiical tests to measure treatment outcome. If you do not obtain significant improvements in fucntioning after 20 neurofeedback sessions, as measured by these tests, we will continue the treatment without charge for another 20 sessions.
This agreement is detailed in our Neurofeedback outcome agreement.
We make this agreement for a simple reason: neurofeedback takes time, like the learning of any other complex skill. Yet we understand that if you have not seen improvement in 20 sessions, you may not be inclined to continue to invest your time and money. This agreement gives us the time to make neurofeebqck work for you.
Informed Consent for Neurofeedback
It is very important to us that you have all the information you need to make a well informed decision about whether neurofeedback is right for you.
We have gone to considerable lengths to provide you with the information you need. Some is available here onthe website. Several scientific papers are available here by download.
In addition, we invite you to attend a 90 minute public presentation that Dr. Hirshberg gives monthly, both in Cambridge and Providence. This talk is designed to give you the iformation you need to make an informed decision.
Finally, we have available a number of scientific papers for you to read or take with you in each of our centers. We can alos provide you with copies of additional research should you be interested.
Before we begin, we will ask that you read carefully and sign an Informed Consent for Neurofeedback. This document confirms that you have made a careful and considered decision to undertake neurofeedback.
Home Based Training
Intensive home based training after training in our office
After an initial period of assessment and training at the Center, participants can lease a neurofeedback system from the Center or buy a home training system and conduct training sessions at home under close supervision from the Center. All of the important parameters of the home training sessions - the number of sessions, length of sessions, sites for training, and frequencies to train - are determined by Dr. Hirshberg initially and will be modified as indicated by the results of the training over time.
Home trainees will use a specially designed web application to complete the post-session checklists and can send us the actual EEG recording by email when we need to review it.
We also have an electronic helpdesk online for careful and prompt support for any technical or clinical issues that may arise during the course of home training.
With these tools, we are able to oversee the details of the training from home much like in the office. Regular monthly half-hour long phone consults with Dr. Hirshberg are scheduled by Home Trainers. Additional office visits may be scheduled as needed at the usual charge.
All home trainers should call at any time with urgent issues or concerns.
Training at home can be done as often as is well tolerated by the trainee. Ideally it would be done no less than four times weekly. Our experience is that more frequent and regular training results in a more even, predictable outcome and faster progress.
Internship for Providers
The NeuroDevelopment Center is offering a practicum or internship for neurofeedback providers interested in developing or sharpening their skills. The internship includes supervised experience at all levels of the neurofeedback process including:
A minimum commitment is required of six months for at least one afternoon weekly. A shorter period with a more intensive time commitment is also possible, as in two months, for three days per week.
For more information, call 401 351-7779.