1997-1998

A Chance To Grow, Inc. New Visions School
EEG Neurofeedback Annual Report 1997 – 1998

INTRODUCTION
The EEG neurofeedback department of A Chance to Grow, Inc. (ACTG) was initially established in 1991 to provide neurofeedback training for students in the Minneapolis Public Schools where the agency was located. The program also served agency staff, their families and a few clients from the community.

ACTG opened New Visions School (NVS) in 1992. NVS is a public charter elementary / middle school serving children in grades 1 through 8. Through its association with A Chance To Grow, New Visions School was the first public school in the U.S. to utilize neurofeedback training for its students. As a leader in the application of new technology in the school setting, NVS has become a training center for education and health professionals who want to apply these innovations to their own programs.

This report presents a summary of the results of neurofeedback training for New Visions School students during the 1997-98 school year. Results are determined using the Test Of Variables of Attention (TOVA-), The Conners- Continuous Performance Test (CPT), client self-reports, teacher evaluations, and parent communications.

The EEG neurofeedback program is designed to help students correct problems in brain function such as ADD (Attention Deficit Disorder), hyperactivity, depression, anxiety and others. This is done through a -feedback- process, which shows moment by moment alterations in brain activity. The student observes these alterations as changes on a computer screen and hears them as changes in audio tones as well. S/he then learns, through practice, to move brain activity in the desired direction. Once accomplished, this learning appears to be maintained by the student and the reported effects seem to permeate many areas of neurological, psychological, and physiological functioning.

EVALUATION
New Visions School uses an ongoing, dynamic evaluation process based upon referrals from classroom teachers, parents, special education staff, and/or other concerned persons in the student-s life. Once a referral has been made, it is reviewed by the Student Services Coordinating Committee, which includes representatives from the child-s educational programs and members of the professional services departments. Professional services include Neurofeedback, Speech/Language and Auditory Therapy, Developmental Optometrics, School Psychologist, Social Worker and Youth Advocate.

This committee recommends evaluations of the student-s strengths and needs by one or more of the professional services. These evaluations are discussed at the next SSCC meeting and a treatment plan is developed to build on those strengths and meet the student-s needs. The student begins the intervention(s) and his or her case is reviewed in 90 days.

Students referred for neurofeedback are evaluated using either the TOVA- or the Conners- Continuous performance tests. Parents fill out a health history form and the classroom teacher completes a brief behavior form. Training protocols are developed from this information.

TRAINING PROGRAM
Students generally receive two 1/2-hour sessions of neurofeedback training per week. Occasionally there are compelling reasons to increase the frequency of sessions, so some students with severe impairments may come to the clinic daily or twice daily for a period of time.

The training becomes a part of the student-s regular curriculum, scheduled around other activities. Training is accomplished using protocols established by the foremost clinicians and researchers in the field of EEG neurofeedback, modified to reflect our experience working within this unique environment. Our protocols generally follow the guidelines established by the staff of EEG Spectrum in Encino CA and are constantly updated to reflect the continuing growth of knowledge in this field. Individual training procedures are developed for each student to address presenting concerns. Training variables included sensor placement, frequency selection, type of visual and auditory feedback, and of course, frequency of sessions. These variables are monitored and adjusted as training proceeds. Forty sessions of training is generally considered to be optimum for effective resolution of the attention, impulsivity and behavior problems that bring students to the neurofeedback clinic.

Generally, students are taught to enhance or increase higher frequency (12 to 20 hz) brainwave activity associated with increased attention and focus. They are concurrently taught to inhibit or reduce lower frequency (4 to 7 hz) brainwave activity associated with decreased attention and focus. Students are also taught to inhibit EMG (muscle activity) to encourage relaxation. The specific range of frequencies encouraged is determined by the initial evaluation. Alterations in training protocols are made based upon an ongoing evaluation process.

PERSONNEL
Staff members have backgrounds in education, psychology, and EEG technology. They are either certified in EEG neurofeedback or are pursuing such certification. Staff members attend regular continuing education programs devoted to EEG neurofeedback, neurophysiology, neuropsychology, assessment, general and educational psychology, and education.

PROGRAM EVALUATION

TOVA- and Conners- (CPT)
Student improvement is often demonstrated by changes in attitude, behavior and academic performance. These changes are somewhat difficult to measure due to the inherent variability of rating scales filled out by teachers and parents. Therefore, for purposes of this report, student progress is primarily expressed in terms of changes in student scores on computerized continuous performance tests. These tests are objective, easy to administer and have been nationally validated for screening attention disorders.

The TOVA and the Conners- CPT are continuous performance tests which evaluate four basic measures of arousal and alertness. These functions are attention, impulsivity, response time and variability. Attention refers to the ability to remain on task during the entire test. Impulsivity represents the tendency to respond to the incorrect stimulus (the non-target symbol), and/or the inability to inhibit such a response to the incorrect stimulus. Response time measures how long the student takes to process and respond to the signal. And finally, variability measures the student-s ability to maintain a reasonably steady focus (as determined by fluctuations in response time) during the entire test. The two tests measure and report this information in different ways, but the concepts are similar. The tests have been compared to other methods of screening and evaluating children and adults with attentional problems and have been found to be essentially consistent and valid. Normative data was gathered from -typical- individuals matched for age and gender.

The following graph indicates the number of sessions per student. Other graphs later in this report detail the results from pre and post testing. Testing is administered prior to the start of training and is repeated every 20 to 40 sessions to monitor progress. There is a clear correlation between the number of sessions and improvements in test scores among those students with similar abilities. New Visions School accepts students without regard to physical, mental or emotional limitations. Many students are highly impaired and qualify for a diagnosis of MMMI (mild to moderately mentally impaired). Others experience less severe but still serious physiological and neurological impediments to learning. Many of these students are seen in the neurofeedback program with excellent results. Anecdotal reports confirm that neurofeedback training, sometimes on a daily basis, often makes the difference between such students being able to remain in a mainstream classroom as opposed to being in a more restrictive setting. Most of these students are not able to take continuous performance tests and are therefore not reflected in the graphs in the following sections. Others are able to take the tests and their scores have been included.

Testing Results
Seventy-five New Visions School students received neurofeedback services during the 1997-98 school year. The TOVA or Conners- CPT was administered to most students prior to training. As mentioned above, a significant number of students did not possess the minimum skill level needed to take either test and therefore were not tested.

Forty students (53 %) were given repeat tests after a minimum of 20 neurofeedback sessions. Some students began neurofeedback training late in the school year and did not receive the minimum 20 sessions required for re-testing. Other students either left the school or left the program for various reasons. A few students were not re-tested at the end of the year due to absence, schedule conflicts or other difficulties. Of the 40 students who received pre and post-testing, 8 received the TOVA and 32 received the Conners- CPT.

Conners- Continuous Performance Test (CPT) Results
Seventy-five New Visions School students received neurofeedback services during the 1997-98 school year. The TOVA or Conners- CPT was administered to most students prior to training. As mentioned above, a significant number of students did not possess the minimum skill level needed to take either test and therefore were not tested.

Thirty-two students received the Conners- CPT before and after training. Their results indicate improvement in many of the most important scales of this test. The following graphs show changes in all Conners- CPT scales. The first graph shows the percentage of students improving by the number of scales improved. Improvement on one scale may represent a significant change in a student-s performance, particularly if the other scales for that student were essentially normal. Also, an individual scale may represent an important area of improvement for a student, which would then indicate a global change in that student-s life. Students with difficulty in more areas of functioning would be expected to show improved scores on more scales.

The second graph represents the percentage of students improving on each individual scale of the Conners- CPT. Some scales, such as the response time scale (scale 2), often show less improvement because students slow down and become more deliberate in their responses. The names of the scales in the second graph have been simplified to reflect the four characteristics being measured, i.e., attention, impulsivity, response time and variability.

It is important to note that some measures are more reliable indicators of student progress and reflect more significant changes than others. The Conners- Continuous Performance Test User-s Manual (Conners, 1995) states -The reaction time variability (scale) is often a better measure than speed of how consistently the respondent can focus his or her attention, and is much less affected by response sets or expectations than speed. Variability, and not just the average level of speed, is a useful measure of attention.

There are various levels of significance in continuous performance test results. The graphs above reflect improvements of .5 standard deviations (SD) from the original test scores, which generally indicates a change that would not normally occur without some intervention. A more definite improvement is represented by changes of 1 SD (a 10 point change in T-Score) which represent highly significant changes in the student-s ability to focus, pay attention and remain on task in the classroom setting. The following graph shows the percentage of students improving by 10 points or more by the number of scales improved.

The next graph shows the percentage of students improving a significant amount in the variability scales. Those that are most important in terms of variability are scales 3, 4, 7, 8, 9 & 10. Changes in the variability scales are shown as the percentage of students improving in on 1, 2, 3 and 4 scales out of the 6 variability scales. Eighty-four percent of the students improved on at least one of the variability scales, 78% on 2 scales, 47% on 3 scales and 34% of students improved on 4 of 6 scales.

The following graph shows one student-s improved test results. Decreases in T-Scores usually indicate improvement. These scores were converted so positive numbers show improvement. A change of 5 points equals .5 standard deviations, 10 points is 1 SD, 15 points is 1.5 SD and so on. The large change in scale 6 (Risk Taking or confidence) reflects a child who went from a score of 96.51 (normal is between 40 and 60) to a score of 55.24. In behavioral terms, this student was initially extremely cautious and afraid of making a mistake. At the end of training, he had developed more self-confidence and self esteem, which was reflected in a greater tendency to trust his own judgement as he took the test.

TOVA RESULTS
Initial TOVA results indicated that 6 of the 8 students receiving the TOVA were below the typical range in at least one scale on the pre-test. The other two had been in the neurofeedback program for some time and were continuing for reasons not related to characteristics measured by the TOVA. All 8 students improved at least 0.5 standard deviations (SD) in one or more scales upon re-test. Generally 0.5 standard deviations from the mean is considered a significant change. The TOVA Interpretation Manual (-1991 by Lawrence M. Greenberg) states under:

Significance
-In general a change of more than 0.5 standard deviations (in either direction) is significant.-

Attention was not a problem for most of these students so little change was noted. More of these students had impulsive symptoms and 5 of them (63 %) showed improvement in this measure. Response time scores were mixed as some impulsive students slowed down and became more careful in their responses. All 8 students improved in the variability scale and 5 (63 %) improved a full standard deviation on this scale. These improvements indicate that most of those students who were tested experienced significantly fewer problems from factors that may interfere with learning. These factors include such things as impulsive behavior and lack of consistency in skills, abilities, and achievement.

Attention
It is clear that the ability to sit still and pay attention for age appropriate periods of time is an essential skill for any student. Simply being able to attend to information being presented, in whatever form, is required before the student can make use of that information to pass a test or write a report or respond in class. Being able to spend time studying also depends to a large degree on the student-s ability to keep his or her attention on the task long enough to learn the information or complete the assignment. This is why measuring attention skills can provide useful information for predicting a student-s academic performance.

Impulsivity
The ability to resist impulsive actions may be even more important than attention as a general life skill. It can translate into the ability to resist the temptation to respond to teasing or provocation from another student, to resist peer pressure to use drugs or impulsively engage in dangerous or self-defeating behaviors. It can represent the ability to think through an action rather than responding with the first impulsive response. Impulsive students often respond with words and actions that are inappropriate to the task or situation because they lack the ability to -stop and think-. Careful consideration of choices is generally not within the realm of possibility for most impulsive students. They require specific brainwave training to correct this tendency, not punishment or lectures.

Response Time
Response time improvements are actually thought to be improvements in the processing ability of the brain. Generally a faster response time, in the presence of stable attention and reduced impulsivity, indicates improvement in the student-s ability to receive, process, and respond to information. If a student is a -slow processor-, s/he is either not processing the data as fast as his or her peers or is responding cautiously because of a desire to make fewer mistakes.

Variability
Finally, the ability to maintain steady attention for longer and longer periods of time is important for progressing through the ever increasing demands of school, and eventually work. According to the TOVA Interpretation Manual:

-Variability is the single most important variable in correlating TOVA response and attention deficit disorders. It is clearly the most powerful variable and, in older subjects, may be the only variable that is deviant from the norm. We have begun to view variability as the hallmark of attention deficit disorders. It-s as though the average response time and error rates are not as meaningful as the extreme swings in performance. We know clinically that an individual with attention deficit disorder can, at times, attend to tasks and respond appropriately. However, this level of performance cannot be sustained, and their performance often deteriorates within any given period of time.- (emphasis added.)

All 8 students tested improved 0.5 standard deviations from their original test scores on at least one scale and 75 % improved 1 standard deviation. A gain of one standard deviation is highly significant and indicates a change in that student which is unlikely to be due to random factors.

The following graph represents the percentage of students improving on 1, 2 or 3 scales of the TOVA. None of the students improved on all scales.

The following graph shows a student who was initially quite variable and impulsive in his responses to the TOVA. He showed 1 SD improvement the impulsivity and variability scales and behaviorally he became much more focused, less distractable and less impulsive. Teachers reported that he was able to remain on task longer, that he enjoyed school more and began to participate in more activities. The student reported that reading and math were easier for him. He said that he had been -kind of down- on himself before and that his mood had improved -a lot-. TOVA results are shown as standard scores with a change of 15 points equaling 1 standard deviation; 7.5 is .5 standard deviations. His initial score on the impulsivity scale was 104 (within normal range) but he showed marked improvement in this scale upon retest with a final score of 121 (higher scores are better).

SUMMARY
These results represent some of the gains made by students served during the 1997-98 school year at New Visions School. We noticed a significant difference in scores with increased numbers of sessions. Students receiving only 20 to 30 sessions often did not show as much improvement as those students receiving 40 sessions or more. Many researchers recommend 40 to 60 sessions of neurofeedback training to assure that training goals are met and that improvements are maintained following the cessation of training. The population served by this program often experiences more severe impairments than the typical ADD/ADHD participants included in most research studies. Some of our students have received more than 200 sessions over the course of several years as part of a comprehensive program developed by A Chance To Grow to help them maintain a higher level of functioning than would normally be expected of them.

Forty-two students were served during the 1994-95 school year, fifty-three during the 1995-96 school year and sixty-five students received EEG neurofeedback services during the 1996-97 school year. The 1997-98 school year saw 75 students receiving services from the EEG neurofeedback department. Projections for future years include a further increase in number of students served and an increase in total sessions for those students.

Promising gains by students and modest increases in the numbers of students receiving neurofeedback only serve to highlight the need for greater capacity and newer technology to enable the neurofeedback program to provide this service to more students with greater effectiveness. Nearly half of New Visions School students were able to make use of neurofeedback training this past year, but many students who had been identified as needing this service were not seen.

The entire ACTG program including New Visions School will move into a new facility in the fall of this year. Larger space and more staff will increase our ability to serve the students who need neurofeedback training. Our next goal is to move out into the community into other public schools so that this intervention becomes available to all who need it.

Future Programs / Research Initiatives
A Chance To Grow and the EEG neurofeedback department conducted a State of Minnesota funded demonstration project during the 1997-98 school year. A separate report on this project is available from ACTG.

The neurofeedback department began using Audio Visual Stimulation Devices (AVS) this year. After careful research we determined that the DAVID Paradise units (Comptronic Devices Limited, 2nd Floor, 9876A – 33rd Avenue, Edmonton, AB, Canada T6N 1C6, 800-661-6463 ) were the best choice and we purchased a multi-user system which allowed us to offer AVS services to 10 students at a time. We conducted some preliminary trials with students who either had high levels of anxiety or were exhibiting difficult behavior problems. These trials will continue next year and we will report on our results in our 1998 – 99 annual summary. We are also using individual AVS devices with students and will continue and expand this program next year. We have found in our preliminary work with AVS that it provides an intervention that is easy to use, is enjoyed by the students, and appears to have results that are quite immediate and powerful.

Our associate Michael Joyce, in Perham, MN conducted a well designed trial of AVS with students from two schools in his area. He demonstrated excellent results and has produced a report describing this project. Contact him directly at mjoyce@perham.k12.mn.us for a copy of his report.

We are constantly exploring other methods for helping our clients develop their skills and abilities to the highest levels possible. We hope to continue these efforts and expand into other arenas where our programs can be of benefit to many more children.

APPENDIX
Equipment
Neurofeedback training was conducted using two Neurocybernetics EEG biofeedback systems (Neurocybernetics, 16340 Roscoe Blvd, Suite 120 * Van Nuys, California 91406-1201 818-891-6789 ) and two PHL EEG biofeedback systems (Biocom Technologies, P.O. Box 2729, Poulsbo, WA 98370, [206]- 853-5090). The Neurocybernetics systems use a two-computer configuration with an isolated EEG signal amplifier. The feedback display is in the form of a -Mazes- game similar to pacman and -Islands- or -Highways- games which represent the signals as three boxes which change size as EEG (brainwave activity) and EMG (muscle tension) signals change in amplitude. This information is displayed against an interesting and changing visual background. The PHL systems use a single computer configuration, also with an isolated EEG signal amplifier manufactured by J&J Engineering. Physiological information is presented in a wide variety of graph, picture, and game displays. In addition to EEG, the Neurodata systems display other physiological data such as EMG, EDR (sweat gland response) and thermal (peripheral vasodilatation). This information is quite useful in evaluating students who are anxious. These modalities also help such students learn anxiety response control.

TOVA
The TOVA is a continuous performance test, which evaluates four basic measures of arousal and alertness. These functions are attention, impulsivity, response time and variability. Attention refers to the ability to remain on task during the entire twenty-two minute test. The impulsivity scale represents the tendency to respond to the incorrect signal, and/or the inability to inhibit such a response to the incorrect signal. Response time measures how long the student takes to process and respond to the signal. And finally, variability measures the student-s ability to maintain a reasonably steady focus (as determined by fluctuations in response time) during the entire test. The test has been compared to other methods of screening and evaluating children and adults for attentional problems and has been found to be essentially consistent and valid. Normative data was gathered from -typical- individuals matched for age and gender.

Conners- Continuous Performance Test (CPT)
The CPT is similar to the TOVA in design and purpose. It does however introduce several other variables, which have proven interesting when evaluating students in the EEG neurofeedback program. The TOVA presents the images at a fixed interval while the CPT presents the images at intervals from 1 to 4 seconds. This change in inter-stimulus interval (isi) elicits differing responses in students depending upon the specific difficulties they experience in the learning environment.

Students with classic attention problems may be able to respond correctly to stimuli presented moderately fast (2 second intervals) but may have problems processing the stimuli accurately when they are presented quickly (1 second intervals). Some clients may also experience some -drift- or fall off in their ability to stay with the task when the stimuli occurs less frequently (4 second intervals). The results of this variability in the frequency of stimulation are reported as changes in response speed and consistency when the interval changes. The CPT also uses letters as its stimuli and this introduces the factor of discriminating between stimuli which appear similar (the x and y for example). This variable is reported as perceptual sensitivity.

Like the TOVA, the CPT also reports specific response time (RT) data and then evaluates variations in this data over the course of the test to determine several different measures of variability. One variability measure is the hit response time standard error (SE) taken from all the individual responses. Another is the variability of standard errors, which is the standard deviation of the 18 standard error values calculated from each sub-block of responses within the test. Hit standard block change measures indicate whether the individual-s reaction times became more or less consistent as the test progressed. Hit response time inter-stimulus interval change registers a slowing or speeding of reaction time as the time between targets increased. Finally, the hit standard error inter-stimulus interval change records the level of increased or decreased consistency in response time as the time between targets increased.

Another measure of alertness in the CPT is that of attentiveness, which is measured by how well the individual discriminated between targets and non-targets (stimuli). Further measures of variability, attention, and impulsivity involve analysis of the student-s response to the test in general. Was the student cautious and responding slowly to avoid mistakes, or did the student favor quicker response times at the expense of accuracy? Also did the student-s responses slow down, speed up, or remain the same from the beginning of the test to the end? Did the student slow down his or her responses as the interval between letters increased or decreased and did he or she have more errors of omission or commission compared to the response time and variability scales.

The complexity and level of detail in the Conners- CPT appear to make it an effective tool for evaluating students both prior to and following EEG neurofeedback training. Our experience with the Conners- CPT indicates that it may generate more of a negative practice effect than the TOVA. This means that student scores may decline during subsequent test administrations due to the inherently boring nature of the test. This is a common factor for all continuous performance tests. Some of them, however seem to be more sensitive to this effect than others. The results of the CPT seemed to reflect the actual improvement in student-s performance on other measures, so we are hopeful that it will continue to provide us with useful data. This was our first year using the Conners- CPT and we will continue to assess its effectiveness as an evaluation tool.

New Visions School
Michael Joyce, MA NLP

3820 Emerson Ave.
Minneapolis, MN 55412
(612) 521-2266 F-9647


Email: mjoyce@mail.actg.org

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