neurofeedback for the autism spectrum and for adhd: an integrative perspective and a clinical...

Neurofeedback for the Autism Spectrum and for ADHD:

An Integrative Perspectiveand a Clinical Approach

US Autism and Asperger’s Association

Annual Conference, August, 2006

Siegfried Othmer, Ph.D.

Chief Scientist, The EEG Institute at the Brian Othmer Foundation

www.eeginstitute.com

Agenda

• A Framework for the Discussion

• The Changing Face of Autism

• From Behavioral to Biomedical Models

• The Missing Integrative Perspective:

The Regulation Regime

• Neurofeedback:

Treating Brain Behavior Directly

• Clinical findings

• Model confirmation

A personal perspective

• I approach this topic both as a parent and as a scientist/practitioner– Parent of a child who would now, thirty years

later, be labeled Asperger’s– Physical scientist– Husband of Susan Othmer: neurophysiologist

The rocky past:

• Personal experience with what parents encounter:– Clinical complexity– Bafflement on the part of the professionals– Compartmentalization of thinking– Piecemeal approach– Blaming of the parents

• But now there’s hope from many quarters...

“An integrative perspective is missing”

• Ironically, the condition of the child is mirrored in the system that treats the child!

• Our historical approach to autism has had autistic features!

• Integration Deficit Disorder

The fragmentation of mental health disciplines makes an integrative perspective difficult:

Child Psychiatry

NeurologyPsychology

Speech andLanguage Therapy

Everything else

EducationalTherapy

Pediatrics

A quick march through history:

• Autism was historically viewed as a behavioral disorder

• One for which there was no remedy

• Not treated as a medical condition

• Biochemical models are relatively recent

• Or at least the attention of the medical field has been relatively recent

This plot contradicts the primacy of both genetic and of behavioral models of autism

Classes of remediation:

• Remediation falls either under the behavioral or the biomedical umbrella

• There is something missing:• What connects the realm of behavior to the

biomedical realm?• How is behavior mediated in the CNS?• This may be the nexus where primary

attention is needed for both understanding and relief

A “new” approach:

• Neurofeedback is a behavioral technique whose immediate target is the behavior of the brain, not of the child

• In neurofeedback, the CNS is treated as the behaving entity

Biochemical Deficits

Brain Dysfunction

The Martha Herbert Model

Biochemical Deficit

Brain Dysfunction

Brain dysfunction in turn acts back on biochemical regulation!

Structure versus Function

Biochemical Deficit

Functional Implications

Are biochemical deficits a large part of the story?

Structure versus Function

Biochemical Deficit

Functional Implications

Or are the biochemical deficits only a small part of the story?

Biochemical Deficit

Brain Dysfunction

What happens to brain dysfunction when biochemical deficitsare remediated…

Brain Dysfunction

Learning may have occurred, so dysfunction lingers

Brain Dysfunction

Alternatively, learning has not occurred; the relevant developmental stages were missed…

What is missing from the discussion?

An integrative perspective is missing…

• The systems perspective

• The cross-disciplinary perspective

• We must talk about:

The Regulation Regime

How is our regulatory regime organized?

• Integration of function is a matter of communication

• Communication in the brain is largely neurochemical, but also bioelectrical

• We have to talk about frequency and timing

• Why?

Because that regime may be the most vulnerable to dysfunction. (Hypothesis)

The domain of timing and frequency may be the most vulnerable to functional

disturbance

• Why?

• Because it has the tightest constraints under which it operates:

Good brain regulation requires large-scaleorganization in the timing domain down to the level of 10 milliseconds!

How do we understand our regulation regime?

• As a network!

• Even beyond the neural network, it can be understood in a network model

• Fortunately, network models are the latest hot issue in the biological sciences

What are salient features of this network?

• A high level of inter-connectivity, and even of functional integration, particularly at the brain level

• Feedback operation

• Redundancy(minimum of single-point failure modes)

• Highly hierarchical character of organization

Network characteristics

• The network is a web, not a chain

• If a link breaks, we still survive…

• Breaking or degrading links in the network degrades function, but does not necessarily disable function completely

• “Soft” failures rather than “hard” failures

• But these may not be small in number

Implications for autism

• Miracle cures will always be relevant only to the few

• For most, a whole host of deficits will need to be addressed

• Standard research methods (focusing on techniques in isolation) will therefore always undervalue each particular partial remedy

“Take me to your leader”

• The hierarchical nature of our regulatory regime makes it advisable to appeal to the top of the regulatory hierarchy:

Our neuronal networks:

Their organization in the timing and frequency domains

• A “top-down” approach to complement “bottom-up” biochemical remedies

Neurofeedback

• Neurofeedback is a behavioral technique that targets brain behavior directly

• It bypasses the child’s behavior

• We utilize measures of brain activity:

1) The Electroencephalogram (EEG)

2) Cerebral perfusion

3) Oxygenation of the blood

The Electroencephalogram

• The EEG bears witness to the brain’s continuing attempt to regulate its own affairs

• It reveals dysfunction at the neuronal network level

• It reveals dysfunction in communication networks

• It reveals dysfunction below the level where it becomes behaviorally obtrusive

Exemplar of a dysregulated EEG

Can we train brain function?

• Explicitly?• Directly?• Having only data about brain function

to work with?• In a child who does not seem to be

quite with us? This is the question, and the promise,

posed by neurofeedback

EEG Neurofeedback

• By implementing a reinforcement paradigm on frequency-based EEG parameters, we train the whole regulatory network

• Bias is toward the more basic regulatory functions– I.e., arousal regulation

How do we understand autism in this model?

In terms of “soft” failures of key regulatory systems affecting primary regulatory functions:

1) Arousal regulation

2) Attentional regulation

3) Affect regulation

4) Sensory systems excitability

5) Autonomic nervous system regulation

6) Motor control

7) Cognitive function, executive function, and working memory

And how do we understand ADD/ADHD in this perspective?

In the same terms (although the particulars differ):The “soft” failure of key regulatory systems affecting primary

regulatory functions:

1) Arousal regulation

2) Attentional regulation

3) Affect regulation

4) Sensory systems excitability

5) Autonomic nervous system regulation

6) Motor control

7) Cognitive function, executive function, and working memory

What is autism, from the perspective of Neurofeedback?

• Autism is a spectrum disorder, with a variety of organic causes

• The functional deficits that follow from such organic flaws affect the whole brain, the whole CNS, and the entire regulatory domain

• They can be understood in terms of a disregulation or breakdown of the brain’s internal communication, of functional connectivity

• Such disregulations are accessible to us in NF

Key features of the autistic spectrum

• Profound over-arousal

• Lack of emotional connectedness

• Sense of self versus sense of the “other”

• Sense of body in space

• Global “communication” deficit

• Specific language deficits

• Sensory hyper-excitability

• Autonomic dysregulation

The key issue isOverarousal:

Laterality issues in autism

• Left Hemisphere

• Sequencing deficits

• Specific language deficits

• Perseverative behavior

• Hyperfocus

• Constricted behavioral responding

• Right Hemisphere

• Emotional connectedness

• “Communication deficit”

• Sense of self

• Sense of the “other”

• Sense of body in space

• Constricted “narrative of life”

Integration Deficit Disorder

• The most salient issues in autism suggest a generalized deficit in regulatory functions that are integrative in character– Non-localizable– Across rather than within regulatory systems

• Suggests a remedy that addresses itself to that issue

The general and the specific:

General regulatory function

• Sub-cortical regulation– Arousal

– Attention

– Affect regulation

– Sensory system excitability

– Motor function

– Autonomic setpoint

– Interoception

Specific regulatory function

• Cortical involvement• Localization of function

– Specific learning disorders

– Dyslexia

– Primary auditory processing disorder

– Speech, articulation

Autism: A disorder of Attachment

• The core, defining issue in autism is that of emotional regulation

• --the engagement and appropriate modulation of our emotional responses in interaction with “the other”

• We are dealing with a disorder of attachment• Attachment is our primary learning task in the first

18 months of life

Autism: A disorder of Attachment

• The consequences of a failure to learn to establish and maintain attachment bonds are so dire, and the subsequent prospects of improvement so dim, that one is tempted to refer to the first 18 months of life as a critical period for attachment.

Attachment Disorders--

• If the “mother” is not available for attachment, we get “Reactive Attachment Disorder” (RAD)

• If the child’s nervous system is not available for the learning of attachment, we get the autistic spectrum

Is there a critical period for the learning of attachment?

• The behavioral model would suggest that attachment has to be learned the old-fashioned way—through behavioral methods

• From the perspective of neurofeedback:It’s a software problem!Attachment can be learned through

brain-based methods

What about late onset autism?

• Reveals the disturbance of emotional regulation through biochemically-mediated processes

• Motivates a natural pessimism of the biochemical researcher that a learning-based model should succeed in restoring function

• After all, the learning had already occurred…

• Nevertheless, attachment bonds can be restored through appropriate reinforcement of relevant brain mechanisms

• We need to look to the data…

Training brain function through EEG Neurofeedback

• An introduction to the process and a demonstration

Methodology of EEG Neurofeedback

• The EEG is monitored in terms of its temporal and frequency properties

• At certain particularly relevant sites

• Frequency-based parameters are extracted and subjected to reinforcement techniques

• Visual, auditory, and tactile feedback is involved

How we look at the EEG: A Demonstration

EEG activity as monitored in neurofeedback: choosing how to train…

Case Example – Relative Power

Data furnished by Rob Coben, Ph.D.

Case example - Connectivities

Correlation data

With thanks to Rob Coben, Ph.D.

• Neurofeedback places two sites on the scalp into communication

• Inherently addresses deficits in functional integration

• The relevant pathways involve the whole brain…

Placing the EEG in a Feedback loop:

A Demonstration

• xy full training demo

Initial response of the behavioral camp might be:

Neurofeedback is difficult to do:

• Tactile defensiveness; electrode intolerance

• Lack of engagement with the training task

• Inability to communicate the objective to the child and get buy-in

• Lack of confirmation from the child that the right training is being done

• This is hopeless!

The response of the Biomedical Camp might be:

• Once you know that the biochemical deficits exist, isn’t it our obligation to address them as the first order of business?

• Normalizing the physiology should be attempted before resources are devoted to behavioral techniques

• Medical practitioners tend to lump neurofeedback into the behavioral camp

• We must look to the actual data to see how neurofeedback should fit into a comprehensive strategy of remediation

• First a review of the early history of neurofeedback for autism

Early work in neurofeedback:

• Seizure disorder

• Attention Deficit Hyperactivity Disorder

• Both relevant to the autism spectrum

Improvement in Seizure Incidence 18 studies over 25 years

% improving incidence: % improving EEG:

82%68%

Rossiter2004

Neurofeedback for Seizure Disorder and ADHD

• Neurofeedback substantially improves on medication response for seizure disorder

• Neurofeedback matches stimulant response in ADHD

• But this does not necessarily translate to the autism spectrum…

Targeting the Autism Spectrum

• The primary focus of EEG neurofeedback is the the regulation of arousal, along with sensory excitability

• Autistic children manifest as profoundly over-aroused

• The secondary focus is that of affect regulation

• Standard ADHD protocols did not work…

Historical development of NF for Autism

• Early attempts were misguided (<1990)

• First success reported: Kenneth Kangh in Singapore (circa 1995)

• First replication, Joy Lunt (Chicago)

• Four-year remote training of autistic child

• Training the famous “autiste”

• Doris Karras study

• Michael and Lynda Thompson compilation

Preliminary Results, Doris Karras study (unpublished)

• All 12 made significant gains

• All developed speech

• IQ improvements 10-13 points

• Improvements in cognitive, emotional and social function

Outcome Study, Michael and Lynda Thompson

Autistic spectrum disorder clients have primary deficits in their ability to interpret social communications (innuendo, abstract meaning), appropriately initiate and maintain social interactions, handle anxiety, shift mental set, and sustain external attention span and response control. These deficiencies correspond to patterns observed on the EEG that can include slowing at Pz, P4, T6, F4 and PF1 and differences in coherence and comodulation from normal data bases. High theta activity at Cz is also observed in association with the problems with attention span. This presentation will list symptoms of PDD (Autism) and Asperger's syndrome; describe typical cases; outline assessment and intervention; and give an overview of results of neurofeedback training with >60 cases, ages 5-51 including some with long-term follow-up.

• ISNR, Feb 2003

•Percent Improvement: 26% in 30 sessions

•Nearly 1% improvement per half-hour training

•No saturation of training effects yet seen

Summary of first published study, by Betty Jarusiewicz

Parent Ratings of Behavioral EffectsPreliminary Results with ATEC Rating Scale -

3 44

Worse noneNo effect 3Better 44Number of cases 47Better : worse 44 : 0

Assessment Guided Neurofeedback for Autistic

Spectrum Disorder

Robert Coben, PhD, BCIA-EEG, D-qEEGNeuropsychologist

Massapequa Park, New York

Patient Sample

• Patient sample included 20 males, 4 females.• Mean age = 105.46 (8.8 yrs), SD = 34.78, range

58 (4.83 yrs) – 176 (14.78 yrs) months.• 23 Caucasian, 1 Asian American.• 18 RH (75%), 3 LH, 3 Mixed.• 15 No Meds, 5-1 Med, 3-2 Meds, 1-3 Meds. • ATEC = 53.05 (30 – 39TH %ile)

Control Sample

• 12 subjects in wait list control group.• Matched for gender, age, race, handedness,

other treatments, ATEC score.• No new treatment during study design.• Pre-post testing showed no significant

change for Parental Judgment, Parent Ratings, Neuropsychological tests, Infrared Imaging.

Results: Parental Judgment

Improved No Change Worse

22 2 0

91.67% 8.33% 0%

Results: Parent Ratings

ATEC GADS BRIEF PIC-2

p<.0001 p<.001 p<.002 p<.003

53.05 – 31.00 81.35 – 71.00 71.42 – 64.21 71.60 – 65.75

41.57% 33.00% 33.66% 27.08%

Results: Neuropsychological Testing

Attention Visual-Perceptual

Executive Functioning

p<.0003 p<.07 p<.003

36.32% 20.82% 49.64%

Sample Infrared Images pre and post NF session.

91.0°F

99.0°F

95

91.0°F

99.0°F

95

Discussion

• Enhanced efficacy compared to previous work. 63% increase in efficacy in half the time.

• 26% vs. 42% in shorter time period (mean of 36 vs. 20 sessions).

• Possible reasons: – More mild sample (65 vs. 53 on ATEC)

– Assessment guided NF vs. Clinical protocols

– Bipolar protocols vs. mainly unipolar.

0

5

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15

20

25

30

35

40

45

0 10 20 30 40

Number of Sessions

Percentage of ImprovementJarusiewicz (2002)

Coben (2005)

0.7%/session

2.1%/session

Hendrickson2.8%/session

0

5

10

15

20

25

30

35

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45

0 10 20 30 40

Number of Sessions

Percentage of ImprovementJarusiewicz (2002)

Coben (2005)

0.7%/session

2.1%/session

Hendrickson2.8%/session

Neurofeedback and Hyperbaric Oxygen Treatment

• Hyperbaric oxygen treatment supports the claims of neurofeedback

• Separates the issues:– Is it all just activation?– Is neurofeedback more specific than hyperbaric

oxygen treatment?

• Issues must be resolved through research…

Feedback using blood oxygenation measure (“Hemoencephalography”): A study in Thailand

• By Penkhae Limsila M.D., M.Sc. et al. • Largest HEG study done to date: studied 180

autistic children in Thailand. • Of the 81 subjects who were studying in

public school, 86% increased their GPA by more than 0.5 (mean = 0.94) points on a 4-point scale.

• Only 4% decreased their GPA by more than 0.5 points (mean = 0.57).

Data Courtesy of Hershel Toomim, Ph.D., BioComp Research

Two case histories

Autism, 7-year-old boy(case furnished by Leslie Hendrickson)

Tic Behavior

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3040

5060

7080

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1 2 3 4

Assessment Milestones

Severity

Self-injury

Tics

Compulsions

Balance

Attention

Anxiety

Anger

Agitation

Aggressiveness

Autistic Behaviors

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1 2 3 4

Assessment Milestones

Severity

Speech Output

Restless Sleep

Social Interact

Self-Stim Beh

Impulsiveness

Hyperactivity

Repetitious Beh

Temper Tantrums

Body Tension

Other Behaviors

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1 2 3 4

Assessment Milestones

Severity

Losing Things

Demanding Beh

Irritability

Crying Beh

Self-Esteem

Blaming Beh

Neg Self-Talk

Compliance

Academic Measures

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1 2 3 4

Assessment Milestones

Severity

Writing

Reading

Memory

Math

Learning Dis

Articulation

Concept Underst

Slow Responding Behaviors

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1 2 3 4

Assessment Milestones

Severity

Writing

Task Completion

Tics

Speech Output

Reading

Repetitious Beh

Balance

Fast Responding Symptoms

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1 2 3 4

Assessment Milestones

Severity

Worry

Sleep Quality

Nausea

Blaming Beh

Depression

Temper Tantrums

Compliance

Aggressiveness

Data Summary Chart

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1 2 3 4

Assessment Milestones

Cumulative Severity

Other Beh

Academic Perf

Autistic Markers

Tic Beh

Progress per Session

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Number of Sessions

Percent Change per

Session

Incremental

Cumulative

Residual Problem Areas

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1 2 3 4

Assessment Interval

Count

Score 6+

Score 5+

Score 4+

Residual Problem Areas

• Six or more– Balance

– Repetitive Behaviors

• Five– Irritability

– Reading

– Speech output

– Tics

– Task completion

– Writing

• Four– Attention

– Compulsions

– Math

– Short term memory

– Losing things

Medication History:

• At start of training:– Tenex 3mg– Risperdal 6 mg– Haldol 75 mg

• At session 71– Off all meds

JS - A Case History

Autism Spectrum plus Birth Injury

Overview, JS, age 6

• Basically a bright kid who was doing poorly socially; severe visual deficits

• “Last year he was the worst case in the system – Orange County public education

• “Next year he will likely need no special services”

Initial presentation: Dx Autism

• Vision problems traceable to post-birth events

• Poor spatial awareness

• Poor coordination

• Easily over-stimulated

• Auditory sensitivity

• Emotionally immature and unaware

Developmental History

• Premature birth at 28 weeks• O2 in ICU >> retinal damage• Retinopathy of prematurity• Laser surgery on both eyes • Vision was 20-400 uncorrected; • 24-40 corrected• Febrile seizure at 2.5 yrs.• Talked early and well

QEEG Findings

• Focus of spike activity in right occiput which triggers paroxysmal generalized spike-wave activity

• Increased inter-hemispheric coherence

• L>R asymmetry

• Impact on visual processing expected

Milestones of progress

#6 with new (occipital) protocols:

• Cooperative and courteous

• “perfect behavior” – Mom’s report

• Considerate of others– very unusual

Milestones of progress

#12: (still training only at occiput)

• Started doing sight words

• Identifying letters with sound

• Drawing “like crazy” – – 20 pictures at a time

Milestones of progress

#18:

• Has drawn more pictures in last 3 weeks than in previous 3 years

• Back to school: “Justin must have been taking some art classes over the summer”

• Writing on his own, an improvement over 2 months prior

Milestones of progress• #18, continued:

• New teacher: “He’s a wonderful little boy; the classroom helper; so easy to redirect. I don’t understand why there were so many issues last year….”

• Last year’s aide: “I have never seen anyone mature so much in only nine weeks.”– No hitting, pushing, poking (in recess), which

were all issues last year. – Full time aide required previous year.

Milestones of progress

A month later:

• JS chosen as one of five first-graders out of a class of 120 to be given “leader of the pack” award

• Criteria: – Success in academic and social arenas– Enthusiasm, cooperation, participation, and

respect for others

Milestones of progress

Mother: (Jan 04)

• Less procrastination

• No issue anymore with auditory sensitivity

• Showing empathy

• School is going well

• Now he is one of the better-behaved children in class

• Hand-writing has improved dramatically

Milestones of progress

May 04:

• Mother estimates that JS is “85% to the goal”

• Teacher says he is a different child:

• “I have never seen anything like this before.”

Milestones of progress

• August 04:

• After a few sessions at T5-T6:

• JS showing increasing social interest

• Remembering people’s names

• Able to recognize people

Milestones of progress

• September 04:

• Annual eye exam at UCI:

• Head ophthalmologist could not believe the visual improvement: “Miraculous”

• Such improvement is unheard of in cases of Retinopathy of Prematurity

Pre-post comparison

Integrating NF into a comprehensive program of remediation

• Initial in-clinic training for twenty to forty sessions

• Clinically-supervised remote training with– EEG Neurofeedback– HEG Neurofeedback

• Web-based symptom-tracking

Three Current Cases Illustrating the New Clinical Model

• In-clinic training followed by remote use under supervision

Conlan; age 6; Autism

Pre-training:

• Echolalia

• Frequent tantrums

• Sleep problems

• Anxiety in new settings

• Easily frustrated

• Unable to fit in socially

• Inattentive, easily distracted, disorganized in school

Post-training (20 sessions):• Talking in full, descriptive sentences • Sleep very much improved• Tantrums greatly decreased

– in number, severity, and duration

• Teachers report: able to keep up with classmates

• Teachers amazed at profound improvement • Aides report he no longer needs their

assistance • Organizes and leads neighborhood

basketball games

Conlan, October 05 status:

• Doing home training on a near daily basis. Mother reports he continues to make gains with language, social interactions, and in school. Tantrums are becoming rarer and rarer. Sleep problems are no longer an issue.

Conlon, March 06 status

• Has completed first phase of “The Listening Program”;

• Currently in one month hiatus prior to a repeat of TLP

• He loved the program

• Doing NF 4-5 times/week at home

Conlon, March 06 status

His mother wrote in an e-mail:

• “I was unable to train him for a week, which is the longest he has gone without training. By the time I restarted the training his mood was awful. What a grump.

• “I trained him and wow, what a change. His attitude was so much better and his personality was back.

• “He is also really missing TLP.”

Conlon, March 06 status

• Mother brought child in for a TOVA test– (Continuous Performance Test)

• He scored above norms, after not having been able to take it at all before

• When he came in to the office, he hugged the clinician he had not seen in many months

Clinician’s report:

• I just got a call from Conlan’s mother:• She called to tell me that the switch from inter-

hemispheric to lateralized bipolar training is a blazing success.

• According to her his speech has improved so much "he's blowing people away."

• His teachers are reporting that he's very focused in class, is acing his end of year exams, and is asking his aides not to interfere with his work as he prefers to do it himself.

• His mom also said that his interactions with other kids on the playground are, again, "blowing people's minds."

• She and her husband are “over the moon happy” with all the progress he's made doing NFB. – Madge Desmond

• This argues for the specificity of NF

Implications:

• The last results argue for the specificity of neurofeedback protocols

• Continuing training is needed to maintain gains—in the face of ambient biochemical deficits.

• Other modalities such as TLP are clearly additive.

• Mother has a sense of what each technique is contributing.

Peter, age 6; AutismPre:• Severe, frequent emotional meltdowns• Obsessional fear of toilets• Frequent soiling accidents, bedwetting• Night terrors (screaming, running)• Hits, kicks others. Bites self.• Auditory processing problems• Unable to relate appropriately to other

children (sniffs them, chins them)• Disorganized, easily distracted and

inattentive at school

Peter, age 6; AutismPost-20 sessions:• Tantrums are rare and minor in severity and

duration. • Doesn’t hit self or others.• Toilet obsession close to eradicated• Wetting and soiling accidents only when

under tremendous stress• Night terrors greatly diminished• Social awareness and empathy increased• Attending school full time. Good reports

from teachers.

Peter; October 05 status

• Doing home training 4-6 per week.

• Mother reports that potty obsession is a thing of the past.

• Sleeping through night.

• Tantrums extremely infrequent.

• Top of his class in spelling.

• (Mother and sister currently doing NFB training.) 

Peter, March 06 status

Mother recently wrote that she’d been unable to train him for weeks and finally restarted:

• “Petey is doing great. It was almost like magic. And I had only just started training him again.”

Marc, age 4, autistic

Pre-training:

• No conversational speech.

• Echolalia

• Tics. Picks at self.

• Overly cautious

• Poor fine motor coordination

• Defiant, uncooperative

• Constantly zones out

Marc, age 4, autistic

Post-20 sessions:• Using full sentences• No tantrums; Cooperative• Ever present. Does not zone out• Able to identify and name objects

consistently and with great accuracy• Gaining fine motor skills• Loves going to school. • Doing well academically and socially 

Final Thoughts

• Asperger’s

• The Mirror Neuron Model– (Specificity versus Generality in autism, and in

neurofeedback)

• The path forward for researchers, clinicians, and parents

• Resources for further information:

www.eeginfo.com