Schummer obtaining positive outcomes

Copyright © 2008 Gary J. Schummer PhD APC., Unauthorized duplication or distribution is illegal.
Maximizing Treatment EfficacyMaximizing Treatment Efficacy
In ADD/ADHDIn ADD/ADHD
Gary J. Schummer, Ph.D.
Neuropsychologist
Clinical Director of the A.D.D. Treatment Center
Torrance, California, U.S.A.

 Skill level of the technician who collects theSkill level of the technician who collects the
EEG, the Data Acquisition Instrument (DAI)EEG, the Data Acquisition Instrument (DAI)
and databases used, the skill level of theand databases used, the skill level of the
interpreter of the data, ability of the doctor tointerpreter of the data, ability of the doctor to
complete, explain, and implement acomplete, explain, and implement a
treatment plantreatment plan
 Frequency of the training – number ofFrequency of the training – number of
sessions per week, length of time for eachsessions per week, length of time for each
session, “spaced” verses “massed” trainingsession, “spaced” verses “massed” training
 Frequently changing the reward and inhibitsFrequently changing the reward and inhibits
or rarely changing theseor rarely changing these
 Therapist as “friend” or on the “pedestal”.Therapist as “friend” or on the “pedestal”.
FactorsFactors ThoughtThought To Impact OutcomeTo Impact Outcome
(But We Have No Data)(But We Have No Data)

 Train amplitude first, then coherence, or trainTrain amplitude first, then coherence, or train
coherence first then amplitude, or somecoherence first then amplitude, or some
combination of the twocombination of the two
 The degree of bonding between the parentThe degree of bonding between the parent
and child and the developmental age of theand child and the developmental age of the
childchild
 Therapy done by the “Doctor” or a technicianTherapy done by the “Doctor” or a technician
closer to patient’s agecloser to patient’s age
 How important is therapist-patient rapport?How important is therapist-patient rapport?
 Are patients better trained in single roomsAre patients better trained in single rooms
(minimizing noise) or multi-station rooms(minimizing noise) or multi-station rooms
(noise level that of a typical classroom).(noise level that of a typical classroom).
FactorsFactors ThoughtThought To Impact OutcomeTo Impact Outcome
(But We Have No Data)(But We Have No Data)

Factors Known To NegativelyFactors Known To Negatively
Impact OutcomeImpact Outcome
 Chaotic or dysfunctional homeChaotic or dysfunctional home
 PTSD – Emotional or physical abusePTSD – Emotional or physical abuse
 ““Stuck” cofactors (addiction, OCD,Stuck” cofactors (addiction, OCD,
Tourette’s Syndrome, ODD)Tourette’s Syndrome, ODD)
 Early Attachment IssuesEarly Attachment Issues
 Bipolar Disorder as a co-occurring conditionBipolar Disorder as a co-occurring condition
 History of head traumaHistory of head trauma
 Physician, Teacher or other authority figurePhysician, Teacher or other authority figure
verbally negative about therapy.verbally negative about therapy.

Factors Known To NegativelyFactors Known To Negatively
Impact OutcomeImpact Outcome
 Separated or divorced parentsSeparated or divorced parents
 Chronic sleep disregulationChronic sleep disregulation
 If behavioral and psychological overlayIf behavioral and psychological overlay
issues are ignoredissues are ignored
 Distance of the commute to the officeDistance of the commute to the office
 Long Term: If you don’t taper patientLong Term: If you don’t taper patient
or educate them as to the possibility ofor educate them as to the possibility of
the condition returning.the condition returning.

Factors Known To Negatively ImpactFactors Known To Negatively Impact
OutcomeOutcome
 Personality of patient is aggressive,Personality of patient is aggressive,
hostile, argumentative, oppositionalhostile, argumentative, oppositional
 Overly narcissistic adolescentsOverly narcissistic adolescents
 Borderline or passive dependent PDBorderline or passive dependent PD
 ““Liberal” non-structured parentingLiberal” non-structured parenting
 On medication at initiation of NFBOn medication at initiation of NFB
 Using illicit drugs while in treatmentUsing illicit drugs while in treatment
 Inaccurate diagnosis.Inaccurate diagnosis.

Factors Known To Positively ImpactFactors Known To Positively Impact
OutcomeOutcome
 Higher skill level of the clinicianHigher skill level of the clinician
 Parents either maintain or obtain therapyParents either maintain or obtain therapy
 Therapist maintains frequent contact with aTherapist maintains frequent contact with a
spouse (adult) or school (kids), [CAUTION]spouse (adult) or school (kids), [CAUTION]
 Parent (or spouse’s) willingness to be anParent (or spouse’s) willingness to be an
active part and supporter of the treatment,active part and supporter of the treatment,
(i.e., being diagnosed and treated(i.e., being diagnosed and treated
simultaneously)simultaneously)
 Knowledgeable informed parents regardingKnowledgeable informed parents regarding
the abuses of medication in developingthe abuses of medication in developing
brains.brains.

Factors Predicting SuccessFactors Predicting Success
0 1 2 3 4 5 6 7 8 90 1 2 3 4 5 6 7 8 9
1010
| _ | | | _ | || _ | | | _ | |
Less Likely To Succeed More Likely To Succeed
LifeLife GoalsGoals graduate HS graduate college become a professionalgraduate HS graduate college become a professional
MotivationMotivation Poor OK GoodPoor OK Good
HobbiesHobbies play video games play board games read for recreationplay video games play board games read for recreation
PersonalityPersonality pessimist, introvertpessimist, introvert optimist, extrovertoptimist, extrovert
IllnessIllness malingering, secondary gainsmalingering, secondary gains patient dislike illnesspatient dislike illness
Therapist interactsTherapist interacts
with clientwith client Constantly Often RarelyConstantly Often Rarely
AgeAge Young children Adults AdolescentsYoung children Adults Adolescents
TreatmentTreatment done in the home done at clinicdone in the home done at clinic
GenderGender male (male ( tolerant of boredom)tolerant of boredom) female (female ( pleasing adults)pleasing adults)
RelationshipsRelationships Many positive Few positiveMany positive Few positive

Factors Impacting OutcomeFactors Impacting Outcome
0 1 2 3 4 5 6 7 8 90 1 2 3 4 5 6 7 8 9
1010
| _ | | | _ | || _ | | | _ | |
MuMu a lot some very little nonea lot some very little none
TeacherTeacher poor relationship good relationship superior relationshippoor relationship good relationship superior relationship
ClassroomClassroom disorganized & lacks structure organized & structureddisorganized & lacks structure organized & structured
SchoolSchool Low or high expectations Realistic expectationsLow or high expectations Realistic expectations
IQIQ Very low <60 Average ~100 Above average >130Very low <60 Average ~100 Above average >130
FinancialFinancial low income,low income, insurance higher income,insurance higher income, insuranceinsurance
ExerciseExercise No exercise Some exercise Aerobic exerciseNo exercise Some exercise Aerobic exercise
SleepSleep Poor sleep hygiene, variable onset times Good sleep, regular hoursPoor sleep hygiene, variable onset times Good sleep, regular hours
IssuesIssues Neglect Adopted Parentified Indulged Handles responsibilityNeglect Adopted Parentified Indulged Handles responsibility
Friend/FamilyFriend/Family
NFB ExperienceNFB Experience Poor OK GoodPoor OK Good
Same sex parentSame sex parent Negative to therapy Positive to therapyNegative to therapy Positive to therapy

Factors Impacting OutcomeFactors Impacting Outcome
0 1 2 3 4 5 6 7 8 90 1 2 3 4 5 6 7 8 9
1010
| _ | | | _ | || _ | | | _ | |
ADD/ADHD TypeADD/ADHD Type Inattentive Impulsive HyperactiveInattentive Impulsive Hyperactive
Self-ConsciousnessSelf-Consciousness Don’t want to be seen at the Center Oblivious to thisDon’t want to be seen at the Center Oblivious to this
Parent who brings kid hasParent who brings kid has Severe ADD Moderate-Mild ADD No ADDSevere ADD Moderate-Mild ADD No ADD
Parent starts NFBParent starts NFB No In the future SimultaneouslyNo In the future Simultaneously
PersonalityPersonality Passive Assertive Aggressive ExplosivePassive Assertive Aggressive Explosive
Same sex parentSame sex parent Is out of the home a lot Is a participative parentIs out of the home a lot Is a participative parent
CommitmentsCommitments Overcommitted Makes NFB a priorityOvercommitted Makes NFB a priority
Pain LevelsPain Levels Low Moderate HighLow Moderate High
Disregulated siblingsDisregulated siblings 2 or more 1 None2 or more 1 None
ExpectationsExpectations High or unreasonable Moderate AppropriateHigh or unreasonable Moderate Appropriate
InitialInitial  reactivityreactivity None SomeNone Some

Recommendations (Therapist)Recommendations (Therapist)
Bring your skill level up to incorporate the latestBring your skill level up to incorporate the latest
PROVEN technologies and therapy delivery systemsPROVEN technologies and therapy delivery systems
Don’t assume other professional’s diagnosis isDon’t assume other professional’s diagnosis is
accurate (positive treatment outcome is based onaccurate (positive treatment outcome is based on
accurate diagnosis)accurate diagnosis)
Use proven (valid and reliable) assessment toolsUse proven (valid and reliable) assessment tools
Consider the value of utilizing “professional” powerConsider the value of utilizing “professional” power
dynamics as an aid to treatment with NFB clienteledynamics as an aid to treatment with NFB clientele
Keep in mind that NFB is a unique interventionKeep in mind that NFB is a unique intervention
Consider possibly focusing your practice moreConsider possibly focusing your practice more
exclusively on quality implementation of NFB training.exclusively on quality implementation of NFB training.

If you’re considering implementing QEEG into your practice,If you’re considering implementing QEEG into your practice,
plan a budget of at least $5,000 if you’re going to lease the dataplan a budget of at least $5,000 if you’re going to lease the data
acquisition instrument (DAI) and ~$12,000 to purchase itacquisition instrument (DAI) and ~$12,000 to purchase it
Budget continuing education time in the range of ~40 hours toBudget continuing education time in the range of ~40 hours to
bring your skill level up (assuming you’ve mastered basic NFBbring your skill level up (assuming you’ve mastered basic NFB
information and have an average NFB clinician’s level ofinformation and have an average NFB clinician’s level of
knowledge regarding EEG)knowledge regarding EEG)
Money will be spent on DAI, QEEG courses, to replace incomeMoney will be spent on DAI, QEEG courses, to replace income
lost from studying and not working, professional supervisionlost from studying and not working, professional supervision
and on-going consultation with an expert, and other “start-up”and on-going consultation with an expert, and other “start-up”
costs (caps, electrodes, paying EEG technician, costscosts (caps, electrodes, paying EEG technician, costs
associated with the inevitable hardware and software issuesassociated with the inevitable hardware and software issues
you’ll likely have to repeat data collection sessions, etc.).you’ll likely have to repeat data collection sessions, etc.).

For risk management purposes, if not proficient in doing NFB,For risk management purposes, if not proficient in doing NFB,
disclose in signed paperwork your level of expertise especially ifdisclose in signed paperwork your level of expertise especially if
you are treating a disorder that is outside the scope of youryou are treating a disorder that is outside the scope of your
typical clientele. Also, identify who is supervising you and gettypical clientele. Also, identify who is supervising you and get
signed releases to do so. Since there are no clearly identifiedsigned releases to do so. Since there are no clearly identified
“Standards of Care” for NFB outside of BCIA certification, these“Standards of Care” for NFB outside of BCIA certification, these
are individually determined but certification as a NFB providerare individually determined but certification as a NFB provider
by BCIA should be a minimal requirement.by BCIA should be a minimal requirement.
At first, limit the scope of your practice to treating thoseAt first, limit the scope of your practice to treating those
disorders that you have successfully treated in your clinicaldisorders that you have successfully treated in your clinical
practice and branch out when appropriately supervisedpractice and branch out when appropriately supervised
In CA (check in your state) you need a license to charge a feeIn CA (check in your state) you need a license to charge a fee
to the public and certification should not be confused withto the public and certification should not be confused with
licensure.licensure.

General RecommendationsGeneral Recommendations
Turn off the feedback when patient isn’t payingTurn off the feedback when patient isn’t paying
attention to it or you need to speak to the patient (thisattention to it or you need to speak to the patient (this
sends a message to the patient that the A/V feedbacksends a message to the patient that the A/V feedback
is important)is important)
Stress the importance of consistency in training, don’tStress the importance of consistency in training, don’t
treat new patients in one session per week (usetreat new patients in one session per week (use
practical models to explain this)practical models to explain this)
Make sure to meet with both parents (child) or theMake sure to meet with both parents (child) or the
spouse (adult) to assess their perspective (desire andspouse (adult) to assess their perspective (desire and
support for, agreement with, etc.) on this treatmentsupport for, agreement with, etc.) on this treatment
Meet at regular intervals with the parent (child) andMeet at regular intervals with the parent (child) and
occasionally with the spouse (adult).occasionally with the spouse (adult).

Assess improvements from a wider range of individuals thanAssess improvements from a wider range of individuals than
only a parent or spouse, if feasible, due to reliability issues withonly a parent or spouse, if feasible, due to reliability issues with
these sources of informationthese sources of information
Consider training sessions of less than 30 minutes duration orConsider training sessions of less than 30 minutes duration or
less frequent training for more severely impacted disorders (ex.less frequent training for more severely impacted disorders (ex.
Autistic Spectrum Disorder, Head Injury) – reason is unknownAutistic Spectrum Disorder, Head Injury) – reason is unknown
but probably related to diminished integration capacity.but probably related to diminished integration capacity.
Depending on level of intensity, duration, and frequency,Depending on level of intensity, duration, and frequency,
negative effects should be tolerated when initiating treatment ornegative effects should be tolerated when initiating treatment or
sometimes after changing protocols. The most common is ansometimes after changing protocols. The most common is an
increase in reactivity in boys in the first 6-10 sessions. It shouldincrease in reactivity in boys in the first 6-10 sessions. It should
be minimal and controllable. This is an indication that the childbe minimal and controllable. This is an indication that the child
is coming out of the “fog” of ADD/ADHD. It may also be seen inis coming out of the “fog” of ADD/ADHD. It may also be seen in
remediating low-frequency coherence issues.remediating low-frequency coherence issues.

HOW TO DETERMINE WHEN TO END TRAINING?HOW TO DETERMINE WHEN TO END TRAINING?
Attention Deficit Disorder is NOT a deficit of attention,Attention Deficit Disorder is NOT a deficit of attention,
in fact, individuals with ADD have superior attentionin fact, individuals with ADD have superior attention
when engaged in tasks they enjoy (“Hyperfocus”) orwhen engaged in tasks they enjoy (“Hyperfocus”) or
that capture their interest because it is novelthat capture their interest because it is novel
If you carefully examine the readings of an ADDIf you carefully examine the readings of an ADD
patientpatient during the first 20 sessionsduring the first 20 sessions of NFB it willof NFB it will
appear they are getting worse (especially in theappear they are getting worse (especially in the
problematic low frequency). This is because they areproblematic low frequency). This is because they are
doing the exact same thing they typically do in alldoing the exact same thing they typically do in all
tasks involving sustained mental effort that aretasks involving sustained mental effort that are
ordinary in your office. I call this sinking into the “fog”ordinary in your office. I call this sinking into the “fog”
of ADD.of ADD.

The first session of NFB is inherently the ADDThe first session of NFB is inherently the ADD
patient’s most interesting, and therefore, by definition,patient’s most interesting, and therefore, by definition,
most novel experience of NFBmost novel experience of NFB
It yields a reasonable and physiologically attainableIt yields a reasonable and physiologically attainable
set of scores that become the criteria I urge them toset of scores that become the criteria I urge them to
work toward as their subjective experience of NFBwork toward as their subjective experience of NFB
morphs from an extraordinary experience (movingmorphs from an extraordinary experience (moving
something on the screen using only their brain) to ansomething on the screen using only their brain) to an
ordinary experience (after 30 sessions, making “Pac-ordinary experience (after 30 sessions, making “Pac-
Man” move is about as much fun as completing aMan” move is about as much fun as completing a
sheet of math problems or writing an essay).sheet of math problems or writing an essay).

You’ll note that an ADD patient typically has theirYou’ll note that an ADD patient typically has their
lowest Standard Deviation [SD] readings, and highestlowest Standard Deviation [SD] readings, and highest
amplitude [mV] reading on reward and lowestamplitude [mV] reading on reward and lowest
amplitude readings on the inhibitsamplitude readings on the inhibits during their firstduring their first
session of NFBsession of NFB
These are reasonable to use as goals, and if the ADDThese are reasonable to use as goals, and if the ADD
patient is able to attain them (or even close to them)patient is able to attain them (or even close to them)
the patient’s ADD will likely no longer be the problem itthe patient’s ADD will likely no longer be the problem it
waswas
This works well assuming the patient isn’t too young,This works well assuming the patient isn’t too young,
immature, or oppositional.immature, or oppositional.

In cases where you have very young children or oppositionalIn cases where you have very young children or oppositional
children this first session may not be all that reliable of achildren this first session may not be all that reliable of a
measure of progress.measure of progress.
Another way involves examining their best score during oneAnother way involves examining their best score during one
period of the 30-minute session. Typically, even very youngperiod of the 30-minute session. Typically, even very young
children or oppositional children will have one good period.children or oppositional children will have one good period.
Criteria for knowing when to stop a protocol or change to a newCriteria for knowing when to stop a protocol or change to a new
protocol is not agreed upon by experts in this field; so it remainsprotocol is not agreed upon by experts in this field; so it remains
a bit of an art. One day we will have norms for each age baseda bit of an art. One day we will have norms for each age based
upon initial level of severity. Lacking these, we currently needupon initial level of severity. Lacking these, we currently need
to base this decision on multiple factors which typically don’tto base this decision on multiple factors which typically don’t
involve the opinion or evaluation of the child (if under 10 or 11)involve the opinion or evaluation of the child (if under 10 or 11)
I look at multiple factors, the most important of which are:I look at multiple factors, the most important of which are:

1) The Standard Deviation (SD) – this measure should1) The Standard Deviation (SD) – this measure should
decrease as the patient reaches the point of maximumdecrease as the patient reaches the point of maximum
benefit (PMB) and be consistent in all bands (<3.0 in 3benefit (PMB) and be consistent in all bands (<3.0 in 3
Hz wide bands, and larger but proportional in widerHz wide bands, and larger but proportional in wider
bands)bands)
2) Amplitude microvoltage readings hit a ceiling2) Amplitude microvoltage readings hit a ceiling
(reward band) and floor (inhibit bands) for ~3 sessions(reward band) and floor (inhibit bands) for ~3 sessions
3) parent and teacher rating scales have improved3) parent and teacher rating scales have improved
4) the goals agreed to at the start of treatment have4) the goals agreed to at the start of treatment have
been realized.been realized.

If co-occurring conditions are present we may work onIf co-occurring conditions are present we may work on
them in a second phase of treatment. For example, ifthem in a second phase of treatment. For example, if
the QEEG indicated the presence of a Learningthe QEEG indicated the presence of a Learning
Disorder, we may begin to focus on that. Also, Alpha-Disorder, we may begin to focus on that. Also, Alpha-
Theta training can be helpful in patient’s who remainTheta training can be helpful in patient’s who remain
anxious after treatmentanxious after treatment
Parents or adult patients should taper their NFB, notParents or adult patients should taper their NFB, not
just stop. I have 3 levels of tapering one average,just stop. I have 3 levels of tapering one average,
another more conservative for younger children oranother more conservative for younger children or
those in puberty, and a fairly liberal one for thosethose in puberty, and a fairly liberal one for those
patients that are older and have shown consistencypatients that are older and have shown consistency
through the training period.through the training period.

Referral to an ADD coach or educationalReferral to an ADD coach or educational
specialist is often made as NFB is windingspecialist is often made as NFB is winding
down. This is to help “fill in the gaps” of thingsdown. This is to help “fill in the gaps” of things
the child or adult missed when ADD wasthe child or adult missed when ADD was
prevalent in their lifeprevalent in their life
I often recommend continuing to focus on thoseI often recommend continuing to focus on those
skills that impede a child’s progress the mostskills that impede a child’s progress the most
and that the child be given a course in “how toand that the child be given a course in “how to
be a successful student” most often calledbe a successful student” most often called
“Study Skills”.“Study Skills”.

Remember, organization and study skills are notRemember, organization and study skills are not
something we’re born knowing. After NFB the patientsomething we’re born knowing. After NFB the patient
is now more likely than ever to be able to changeis now more likely than ever to be able to change
behavior patterns that are dysfunctional. Oftenbehavior patterns that are dysfunctional. Often
parents have given up and they need to beparents have given up and they need to be
encouraged and told to raise the bar of theirencouraged and told to raise the bar of their
expectationsexpectations
I assume that, during the treatment, the clinician hasI assume that, during the treatment, the clinician has
worked with a prescribing physician to titrate orworked with a prescribing physician to titrate or
eliminate use of medication, as necessary, if not, aeliminate use of medication, as necessary, if not, a
treatment summary should be sent to the prescribingtreatment summary should be sent to the prescribing
physician recommending a re-evaluation.physician recommending a re-evaluation.

Sometimes the best effect of NFB comes in theSometimes the best effect of NFB comes in the
year or so after the treatment ends. This isyear or so after the treatment ends. This is
because, during that year, the gaps get filled inbecause, during that year, the gaps get filled in
(information doesn’t just show up in the brain(information doesn’t just show up in the brain
when one does NFB)when one does NFB)
So, in subjects where mastery of pastSo, in subjects where mastery of past
information is necessary (Math, for example)information is necessary (Math, for example)
additional time may be necessary and tutoring,additional time may be necessary and tutoring,
if available, is the best method to accomplishif available, is the best method to accomplish
this.this.

Thank You!Thank You!
Time for questions?Time for questions?

Schummer obtaining positive outcomes

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