Transcript Emily Stevens (PowerPoint) - North Carolina Biofeedback Society

To Fit In Or Not:
Integrating Social & Emotional Communication Interventions
& Software, NF, HRV, & Alpha-stim to Improve
Behavioral Outcomes
North Carolina Biofeedback Society, 2011
Presented by: Emily Stevens, Ph.D., LPC, BCN
[email protected]
TECHNOLOGY IS CHANGING
MENTAL HEALTH TREATMENT
Neuro-Cognitive Enhancement
Model for Success (NEMS)
...Defined as utilizing different techniques and
technology as an adjunct to treatment to help
an individual develop the skills needed to
perform successfully and effectively.
 Interactive brain-based model for treatment.
 Includes a combination of software based interactive
programs, neurofeedback, and non-invasive
stimulation based technology combined with therapy.
To Fit in or Not….
Social Competence
• Increased numbers of children showing behavioral
and social issues….
• Increased numbers of children being diagnosed…
–
–
–
–
Autism/Asperger Spectrum
Severe Mood Dysregulation (Bipolar)
Anxiety
Socially awkward, insecure
• Social Anxiety is key to long-term development of
emotional issues and addiction.
• Goal: Intervention & Prevention
• We have been using brain-based treatment to
improve symptoms associated with ADHD, anxiety,
depression, OCD etc… but we have not spent a lot
of time focusing on what brain research is teaching
us about social communication and how to train it
and/or improve it.
• Research has continued to teach us about the
development of emotional communication starting
at birth and what is happening in the brain when we
interact with others.
What is causing the behaviors that
we are observing?
• Neurological, Social, Genetic, Environmental?
• Or are we all simply a disorder? Westernized medicine &
mental health has attempted to simplify this idea with the
current psychopharmacological approach to treatment.
Ex: Childhood Bipolar?
• Severe Mood Dysregulation, Temper dysregulation
disorder, behavioral disorders
–
–
–
–
–
–
–
–
Sleep
Inability to self-sooth by 18 months of age
Chronic irritability
Carb craving
Temperature dysregulation
Anxiety, separation anxiety
Chronic fight or flight
Poor emotion and social recognition/ communication
• What is causing the behaviors we are seeing?
• Systems…..
– Dysregulation of arousal
– Immature nervous system
– Fight of flight – dysregulated stress response system
Tips for Emotional and Social
Communication
Limbic – Amygdala Support
What have we learned about the
amygdala? Emotion Recognition?
Amygdala
The
Amygdala is
also known
as the
“Hub of
Fear”
Poe’s Heart and The Mountain Climber
The Effects of Nurture impact...
The Early Emotional Recording
• Starting at birth… from 0-2 years of age…
• “Depressed” preschoolers are more tuned in to negative facial
expressions.
• Sadness, Shame and Fear were the ones they responded to
most.
– FACE: Facial Affect Comprehension Evaluation Test
• “Depressed” teenagers and adults tend to interpret happy facial
expressions as neutral and neutral expressions as sad.
» NIMH 5 year study, Washington Univ., 2000
More Research…
• Violent and aggressive teenage girls fail to spot anger or disgust in faces
compared to normal peers.
– Anti-social behavior tends to show in girls in their teen years and not
when they are younger and is on the increase in females 14-18.
– Boys w child onset of CD also have difficulties recognizing anger
and disgust but adolescent males do not according to other studies.
– Biological Psychiatry, 2010
• Fearless 3-4 year olds who demonstrate fearless behavior have less
empathy and more aggression toward peers which is correlated with
genetic/parental influence.
– They do not recognize facial expressions of fear or distress in a
classmate or initiate helping the distressed peer.
– They are described as generally aggressive, take advantage of
friends, emotionally shallow and lack regret or guilt
– The heart rate in children with fearless behavior was slower to
start compared to peers.
– University of Haifa, Faculty of Education, Israel, Nov 13, 2010
• Teenagers antisocial conduct and judgements about
aggressive behaviors influences each other at early, middle
and late adolescence.
• Social decision making and behavior continue to influence each
other over time.
• Efforts to change these behaviors are more effective if
interventions address how adolescents make decisions about
acting aggressively.
• Awareness of what is driving their behavior…
– J. Child Development, Mar/Apr 2008
Assessment
 Face
Test, The Eyes Test
www.autismresearchcentre.com
DANVA : Diagnostic Analysis of Nonverbal Accuracy

http://www.psychology.emory.edu/clinical/interpersonal/danva.htm
http://www.creducation.org/resources/nonverbal_communication/as
sessment_with_danva.html
Interview or Questionnaire
Instruments
• CDI (Child Depression Inventory), RADS-2 (Reynolds
Adolescent Depression Scale)
• Children’s Inventory of Anger, Aggression Questionnaire,
Adolescent Anger Rating Scale, Conduct Disorder Scale
• ARI Adolescent Risk Inventory
• Adjustment Scales Inventory, Reynolds Adol Adjustment
Screening Inv.
• Symptoms Assessment-45 (13 & up)
• Revised Children’s Manifest Anxiety Scale, Multidimensional
Anxiety Scale for Children, Social Phobia & Anxiety Inventory
• Feelings, Attitudes & Behavior Scale for Children
• Jeannie & Jeffrey Illustrated Interview for Children
– (online @ www.jbrf.org)
• www.schoolpsychiatry.org Table of Screening tools &
rating scales
Social & Emotional
Development
• Social Development:
• What are your natural tendencies?
» shy, awkward, defensive, explosive, negative
• How often do you see happy/angry/sad faces?
• What do children observe in the media?
• Do you feel like you belong? Do you have a sense
of belonging?
• Social exclusion changes brain function and can lead to poor decision
making and diminished learning ability.
» Journal of Social Neuroscience, Nov., 2006
• Students who feel “disconnected” from their school environments are
at higher risk for poor and unsafe behavior.
• Key areas identified:
– I feel close to people at school
– I feel like I am part of this school
– I am happy to be at this school
– The teachers at this school treat people fairly
– I feel safe in my school
» J. Pediatrics, 2000, Nov.
Emotion Recognition
Interventions
•
•
•
•
•
What do emotions and feelings look like?
Posters, pictures, magazines, movie clips
Scrap book
Observation Exercises
Mood Adjustment Exercises:
• Changing mood with facial expression and thoughts.
“Re-record the Limbic”
 Step 1: What do they look like?
 Emotion Recognition Exercises
 Step 2: What do they sound like?
 Hearing and Expressing Emotions
 Appropriate Emotional Expression
 Developing a Full Range of Emotional Expression
 Step 3: How do I act?
 Body Language and Physical Expression of Emotions
Emotional Communication
cont.
• Thoughts, Feelings & Actions Graph
• Behavior/Situation, My thoughts, My feelings, My
actions
• Anger Buttons/ Pushing My Buttons Drawing
• Make a list of emotions
• Make the face, Describe a time when I felt…
• Sad, rejected, excited, insecure, silly, hopeful…
• How Would You Feel Activity: Provide a list of scenarios and
have the child describe how they would feel or react
• Draw a picture of a body: Where do I feel my feelings?
Social Communication
• Effective conflict resolution is built on strong communication
skills.
• Keys to support effective social communication and
conflict resolution.
– Have the child describe & discuss their feelings.
– Teach mirroring: listening & paraphrasing.
– Teach empathy, connection/relate to thoughts and feelings of
others, understanding others leads to the ability to compromise.
– Teach compromise.
» What is negotiable and what is non-negotiable.
» How does it relate to your personal values.
– Teach basic rules of conduct: no name calling, the past is the
past…
– Teach active listening, restate, paraphrase, summarize
Social Competence
• The ability to achieve personal goals in social
interaction while at the same time
maintaining positive relationships with others
over time and across situations.
Social Skills Software
• Social Skill & Emotion Recognition Software
– www.socialskillbuilder.com (4-18 years)
• Teach social cues
• Teach appropriate responses
• Teach physical boundaries
• www.autismcoach.com
» Fun with Feelings (6-11 yrs)
» Smart Alex (5-15 yrs)
» MindReading (5 – adult)
• FaceSay Social Skill Program
» www.facesay.com (school age)
Studies to Support the use of
Software:
• Social Skill Software: School Rules & My School
Day
– Pilot Study 2004 Virginia Public Schools: On average, students who
used My School Day software gained 10 percent in every category of
the Vineland Adaptive Behavior Scales, compared to a 3 percent gain
when using traditional methods alone.
– Areas of Improvement w Technology Based Intervention:
– Daily Living Skills
– Socialization:
– Adaptive Behavior
– Communication
For Example: School Rules
• Complex peer relationships
• Subtle social cues
• Appropriate Social
Interactions
Cognitive age: 8-18
Over 350 Video Scenarios
Percent of Test Sample
Demonstrating Positive Gains in
VABS Subtests
80%
Daily Living Skills
40%
60%
Socialization
20%
60%
Adaptive Behavior
40%
60%
Communication
20%
0
20
40
Traditional Therapy Group
60
80
Experimental Group
100
• Social skills are the basis for all of our relationships
throughout life…it impacts school, work, family and
all our social interactions.
• Charts & tools for monitoring social and behavioral
progress:
– Book: Skills Training for Children w/ Behavior Disorders
by: M. Blookquist
Managing the Stress Response
System
Role in Emotion Recognition and Social
Communication
CES & HRV biofeedback
Altered PituitaryAdrenal Axis (Heim et al., 2001)
• Early adverse life situations – induce persistent
changes in corticotropin-releasing factor –
• Multiple studies - Progressive sensitization to
stress in children as well as early maternal
stress sensitizes infants causing a stressresponse system (HPA) that breaks down.
• (J. Psychiatry, 2002; Biological Psychiatry, 2002)
• Penza et al., 2003
– Neurobiological effects of childhood abuse: Early life
traumatic events appear to permanently render
neuroendocrine stress response systems
supersensitive. Childhood abuse increases
vulnerability to depression and anxiety especially in
females.
Conclusions…
Trauma creates a stress
hormone response that
impacts the endocrine
system and has a long
term impact on the
pituitary and normal
hormone functioning
when not treated
properly.
There are no conflicts of interest to report
New hope for anxiety, depression & aggression?
Cranial Electrostimulation (CES)
Electrotherapy, Electromedicine & Alpha-Stim
Technology
Cranial Electro-Stimulation (CES)
• Cranial electrotherapy stimulation (CES) is the application of
low-level, pulsed electrical currents (usually not exceeding
one milliampere), applied to the head for medical and/or
psychological purposes.
• It is primarily used to treat both state (situational) and trait
(chronic) anxiety, depression, insomnia, stress
related and drug addiction disorders, but it is
also proving indispensable for treating pain
patients.
(Lichtbroun, Raicer & Smith, 2001; Kirsch & Smith, 2000; Thuile & Kirsch, 2000)
How do you use it?
• Cranial electrotherapy stimulation is a simple treatment that can
easily be administered at any time.
– The current is applied by easy-to-use clip electrodes that attach on
the ear lobes, or by stethoscope-type electrodes placed behind the
ears.
• Patients experience the effects immediately and experience
continued improvement overtime.
– The ideal treatment time is 20 to 60 minutes, but some patients may
achieve the full benefits of a CES treatment within 10 minutes.
• Following CES, most people feel better, less distressed, and more
focused on mental tasks. They generally sleep better and report
improved concentration, increased learning abilities, enhanced recall,
and a heightened state of well-being.
• The Alpha-Stim unit is FDA approved for anxiety & depression.
• www.alpha-stim.com
Studies
• At present, there are over 100 research studies on CES in humans and 20
experimental animal studies (Kirsch, 1999).
• CES reduces aggression in violent in-patient population.
» J. Neuropsychiatry Clin Neurosci. 17:4, Fall, 2005.
• 3 month course of CES
– 59% decrease in aggressive episodes from baseline
– 72% decrease in seclusions
– 58% decrease in restraints
– 53% decrease in PRN’s
• CES reduces aggression in violent neuropsychiatric patients.
» Primary Psychiatry. March 2007.
• 3 month course of CES (48 patients: 83% responded positively to CES)
– 41% decrease in violent episodes, 48% decrease in patients w/ sudden
assault syndrome.
– 40% reduction in restraints
– 42% reduction in PRN’s
Alpha-Stim Data:
T-Scores
Alpha-Stim Averages (ages 6-12)
54.00
52.00
50.00
48.00
46.00
44.00
42.00
TA
O
T
L
Pre-Test
Post-Test
RE
CO
S
TU
R
F
ST
R
O
SC
T
E
S
Y
PH
CO
S
T-
RE
R
E
PE
CO
S
T-
RE
TH
U
A
R
O
SC
T
Pre and Post 20 sessions over 4-5 weeks
Test: Childrens Inventory of Anger
E
Alpha-Stim Data Cont.
Alpha-Stim Averages (All Units
Combined)
E
TSC
O
R
E
R
TH
TSC
A
U
R
EE
P
YS
H
P
29 Residents
O
O
TSC
TS
T
U
S
FR
R
O
R
C
O
R
C
TS
L
TA
TO
E
E
Pre-Test
Post-Test
E
T-Scores
54.00
52.00
50.00
48.00
46.00
44.00
42.00
40.00
Ages: 6-18 years
Incidents on All Units
140
# Of Incidents
120
100
Total
80
On Alpha-Stim
60
Off Alpha-Stim
40
20
0
Incidents
Total number of incidents decreased using Alpha-stim technology
Heartmath HRV Training
• HRV = Heart Rate Variability
Training
• Stress & Anxiety Management
• Anxiety, aggression
• Focus Techniques –
– “The Zone”
• EM Wave PC
• www.heartmath.com
4. Auditory Visual Stimulation
(AVS)
Also called Auditory Visual Entrainment
(AVE)
Auditory Visual Stimulation
• AVS allows the brain to be entrained at specific
brainwave frequencies during the session.
• It has been described as “exercising the brain”
• Research has shown that:
– Decreases stress-related chemicals
– Reduces muscle tension, blood pressure and heart
rate, psychological symptoms.
– Increases, IQ, performance, memory, attention
AVS...
• AVS has been used to treat:
• Depression and Seasonal Affective
Disorder
• Headaches and Migraines
• PMS, Hypertension
• ADHD, LD and poor performance
• Stress
• What are other reported effects of AVS?
• Improved reading and achievement
AVS Clinical Overview
• LD/ADHD: Russell and Carter, 1993, conducted a study on a
group of learning disabled boys between 8 and 12 years of age.
The boys were given 40 sessions of AVE stimulation at 10 Hz and
18 Hz and showed an average IQ increase of 8 points on the
Raven IQ test and significant improvement (<. 01) in memory,
reading and spelling.
• PMS:76% experienced a greater than 50% reduction in their PMS
symptoms (Anderson, Medical College, London)
New Visions School Project
• New Visions School NeuroTechnology Replication Project 2000 2001, Michael Joyce
– This hallmark study is the largest, most convincing study showing the
effectiveness of the DAVID Paradise driving a multiple system to treat
children with attentional disorders. The data generated in the NeuroTechnology (NT) replication project are the result of the efforts of
seven Minnesota public schools (five elementary, one middle and one
K-12).
– Data was gathered for a total of 204 students from seven different
school districts that participated in the NeuroTechnology Program
statewide. The average student completed nearly 30 twenty-minute
sessions over a period of three months, and gained eight months in
grade-equivalent oral reading scores.
Brain Response, Brain Changes or Placebo?
QEEG Correlates of
Auditory Visual
Entrainment
Efficacy in
Treatment Resistant
Depression
Study:
Phase I
Journal of
Neurotherapy, Vol
13, April 2009
Cantor & Stevens
Initial results of :
The effects of 14hz AVE on symptoms of depression and
relative frontal alpha
Key Components
• Cognitive Software:
– Working Memory, Attention, Focus, Following Directions, Impulse
Control, and Staying w/ Task
• Captains Log: Next Generation & Working Memory
• Happy Neuron
• Earobics
– Emotion Recognition and Social Skill Training
• Smart Alex
• Fun w/ Feelings
• School Rules
•
•
•
•
Neurofeedback (Cz & F3)
HRV
AVS
Alpha-Stim CES
Producing Measurable Outcomes…
Case Review 1: 14 yr Male
11 Neuro, 4 AVS, 2 Earobics (A little goes a long
way)
140
124
120
103
100
95
85
75
80
113
109
83
Pre
Post
60
40
35
20
0
0
0
0
Aud
Impulse
Vis
Aud Cons Vis Cons Aud Stam Vis Stam
Impulse
IVA Continuous Performance Test ( 85 and above are w/in normal limits)
Case Review 2: 11 Yr Female
11 Neuro, 6 Captains Log
140
123
122
120
106
100
91
74
80
114
112
111
115
93
96
85
75
70
Pre
Post
60
40
20
0
Full Scale
Attn
Aud
Impulse
Vis Impulse
Aud Cons
Vis Cons
Aud Focus
Vis Focus
IVA Continuous Performance Test ( 85 and above are w/in normal limits)
Case Review 3: 16 Yr Male
8 Neuro, 1 Captains Log
100
90
80
70
60
50
40
30
20
10
0
87
93
92
80
75
56
81
50
37
Aud
Impulse
88
83
Vis
Aud Cons Vis Cons
Impulse
Pre
Post
43
Aud
Focus
Vis Focus
IVA CPT
Case Review 4: 13 Yr Male
16 Neuro, 11 Captains Log
More Sessions = More Improvement
132
140
120
101
100
80
86
107
94
94
98
81
80
68
Pre
Post
60
40
IVA CPT
20
0
Full Scale Attn
Aud Impulse
Vis Impulse
Aud Cons
Vis Cons
Plus: Depression Score on TSCC Pre: 71 and Post: 61
Case Review 5:
13 Yr Male
24 Neuro, 6 Captains Log, 3 Earobics
120
101
100
89
78
80
70
60
40
36
77
38
83
83
Pre
Post
44
IVA CPT
20
0
Full Scale
Attn
Aud Attn
Vis Attn
Aud
Impulse
Vis Impulse
Case Review 6: 13 yr Male
21 Neuro, 10 Captains Log, 6 AVS
120
109
98
100
89
88
75
80
63
Pre
Post
60
40
24
20
0
0
IVA CPT
0
0
Full Scale
Attn
Aud Attn
Vis Attn
Aud
Impulse
Vis Impulse
More Sessions =
More Improvement
120
111
74
80
60
96
95
100
96
78
75
70
Pre
Post
50
40
20
0
0
0
0
Vis Cons Aud Cons Vis Speed
Aud
Speed
Vis Focus
Aud
Focus
Case Review 6 cont.
Global Attention Scales
160
160
150
150
140
140
130
130
120
120
110
110
100
100
90
90
80
80
70
70
60
60
50
50
40
40
03/31/07
Solid Line (*) = Full Scale Dashed Line (+) = Auditory
05/30/07
Dotted Line (X) = Visual
Areas of Improvement:
Attention, Impulse Control, Consistency, Speed of Processing
Hyperactivity
160
160
150
150
140
140
130
130
120
120
110
110
100
100
90
90
80
80
70
70
60
60
50
50
40
40
03/31/07
05/30/07
57
85 and above is within normal range
94
Lab Case Reviews Support:
Measurable Outcomes in using
NEMS
• Areas of Improvement:
 Attention, Impulse Control, Consistency, Stamina (staying
with the task)
• Other areas of Improvement Include:
 Anxiety, Depression, Thought Problems, Social Problems,
Internalization, and Externalization (Achenbach Self-Report)
 Anxiety, Depression, Anger, PTSD, and Dissociation
(TSCC – Trauma Symptom Checklist)
Conclusion of Technology Review:
Mental Health becomes Cutting-Edge
There are many tools available to include in the mental health
“tool box” of treatment.
It is time for mental health to reference the current research and
implement effective change in treatment approach!