Frequently Asked Questions
Neurofeedback is becoming increasingly popular and with this popularity there are individuals who are not trained in Mental Health and Neuroscience conducting this therapy. It is important for the consumer to be able to evaluate the clinician they are using and to determine whether they possess the knowledge and professional credentials to conduct neurofeedback.
The first most important question is whether the clinician is BOARD CERTIFIED through the only certifying body, the Biofeedback Certification International Alliance (BCIA) as indicated by BCN after their name. If they are NOT BOARD CERTIFIED I strongly caution not receiving services from them.
Below are questions that clients have asked me in the past during our initial (no charge) consult. My intent is not to draw clients into my practice but to provide education as to the process so that you can make an informed decision. The following responses are based solely on my personal professional opinions.
QUESTIONS REGARDING THE EEG AND NEUROFEEDACK
The clinician I contacted wants to do a consult and says I will be charged for this, is that typical?
While it is up to the practitioner, I believe a “no-charge” consult is a better option, so that questions can be answered, the goals of therapy can be discussed, and both parties can determine whether this therapeutic relationship is a good fit. It gives the consumer time to evaluate the clinicians’ knowledge base as well.
What exactly is Neurofeedback and how does it work?
All forms of EEG neurofeedback, even the “basic symptom led” approaches that use one or two electrode placements, are based on the concept of “operant conditioning” meaning that when a behavior is rewarded it increases the likelihood of its occurrence. With respect to neurofeedback, regulation of the EEG within specific parameters results in a “reward” that involves auditory as well as visual feedback. If you would like to read more detailed information on this subject go to the International Society of Neurofeedback Research, ISNR.org.
Can there be any adverse reactions to neurofeedback?
The answer is yes. Systems that use clinical symptoms to guide placement and frequency training of the EEG do not rely upon scientific data and are the result of a symptom guided approach that began in the 1960’s. Training over the sensorimotor strip (C3, C4, CZ) in the past was found to be an area that resulted in generalized improvements in attention and arousal. But it is still guesswork, and it is not evidenced based. You may not be training in a EEG frequency or region of the brain that links your symptoms. In addition, even when using the qEEG inexperienced clinicians might be tempted to look at the “hot spots” in the topographical (colored heads) data and place the electrodes there to either up or down train EEG frequencies. These might be “compensatory” regions of the brain and training at these loctations and frequencies might have the opposite effect of strengthening dysregulated networks leading to adverse reactions or lack of improvement.
What is the most advanced form of EEG neurofeedback?
Currently, LORETA (low resolution electromagnetic tomography) is considered to be the “gold standard” and the most advanced and evidenced based form of neurofeedback available; this form of neurofeedback, in my opinion, should be your first choice when evaluating a practitioner. LORETA neurofeedback is expensive in terms of the equipment, databases, educational training, and requires a full cap of 19 placements. Practitioners who state it lacks credibility are incorrect. It links symptoms to the data obtained from the qEEG and provides information that is specific to that individual’s brain in order to develop training that is unique and targeted to that individual’s brain. It is often faster and due to the individualized nature of training there are no adverse effects.
Can you be more specific about LORETA neurofeedback (low resolution electromagnetic tomography) neurofeedback and how is it different?
First, it is important to note that although the word “electromagnetic” is used, this type of neurofeedback does not involve any application of electricity. Rather, our brain is “electric” (EEG), and this is what is measured in traditional as well as LORETA neurofeedback.
LORETA neurofeedback is considered to be the MOST ADVANCED form of neurofeedback available. Because of its ability to measure deeper brain areas LORETA neurofeedback is a more effective treatment method than classical symptom guided neurofeedback (no qEEG analysis to guide the training) and even surface Z score neurofeedback which uses 2-6 placements for training. LORETA involves the use of a full cap of 19 placements for treatment; if you think about this it makes sense. The brain is highly complex, in order to regulate and make changes in networks of the brain it is imperative to treat the entire brain and not just selected regions where is appears that dysregulation exists. Also, in the hands of an inexperienced clinician, the temptation to treat highly deviant frequencies and regions on the brain (based on the qEEG data) might actually be the wrong areas to train since these could be compensatory in nature (maladaptive). This could potentially result in lack of progress or adverse side effects.
In order to do LORETA neurofeedback a qEEG of 19 placements must be used and within this qEEG analysis there MUST be information on deep brain data (similar to a fMRI). Please note, that if a practitioner is not going to use LORETA to train there is NO reason to do a LORETA analysis in the qEEG. If it is done and an additional charge is expected then, in my opinion, it is being done to increase billing revenues.
My doctoral research utilized LORETA neurofeedback in a pilot study for children with ADHD and severe sleep disturbances. The abstract for this study and the results are available upon request.
Where does the EEG come from?
Your clinician should be able to explain to you in detail how the EEG is generated, and the regions and networks of the brain that correlate with the symptoms identified in the qEEG. The EEG is generated from a summation of post-synaptic potentials; ask your clinician to explain this process to you in detail.
How important is it for a provider to be Board Certified in EEG Neurofeedback?
It is critically important for your provider to be Board Certified through the Biofeedback Certification International Alliance (BCIA) because it ensures a “minimum” level of competency in the field. It is similar to a physician who finished his medical training and is give a MD after completing medical school, but he/she is not Board Certified in their field of practice until they complete the necessary training (residency) and take their boards. Once Board Certified the neurofeedback practitioner is now able to advance their level of training based on their own professional goals. In order to be Board Certified the practitioner has to meet certain educational standards such as having a Master’s degree or higher in an accepted field of practice. See BCIA.org for more information.
The neurofeedback practitioner that I contacted said they are “certified” because they went to a week long course, is that true?
That is not true, the 4-5 day course which introduces practitioners to neurofeedback is only designed for training on the system (equipment) they will be using. Attendance at these training courses is open to anyone including those who do not have an accepted degree that would allow them to pursue Board Certification (educator, general college degree such as a BA or BS or no college degree). You can check if the clinician is Board Certified in EEG Neurofeedback by going to BCIA.org. If the clinician is certified they will have a BCN after their name in the BCIA database under their state of practice. If BCB is listed after their name it means they are certified in biofeedback or peripheral training such as heart rate variability; pelvic floor biofeedback is only within the scope of practice for nurses, physical or occupational therapists.
You should also check your clinician’s professional credentials by going to IDPR (Illinois Department of Professional Regulation) to confirm what type of health professional they are and if they are licensed in the state of Illinois to practice.
Should a clinician leave a child alone in the room during training?
The answer is NO. During training, especially with children, it is important to insure that the data being recorded and the operant conditioning occurring during training is accurate. Doing neurofeedback is MORE than just “hooking” someone up and running the system. Shaping of the EEG should occur in order to ensure that training is being performed competently. If a child moves, loses an ear clip, loses good connectivity with the EEG placements (impedance), then no training is taking place. I have had clients who have told me that the clinician has “left the room for a break” and when ear clips have fallen off that it “really isn’t important”.
Is it true that children with ADHD, anxiety, depression, OCD and other behavioral and mental health conditions might also have underlying sensory processing concerns?
Yes, because sensory processing reflects your autonomic nervous system and your individual ability to process daily sensations such as tactile, taste, sound, and movement. This can contribute to the conditions listed above and it is useful to understand the unique sensory capabilities we have in order to support the nervous system and provide a foundation for neurofeedback process. As a Doctoral Occupational Therapist, certified in Sensory Integration, I think it is important to include the results of a standardized Sensory Profile in the qEEG report and analysis. Suggestions can then be made to support sensory capabilities. If you are already working with an Occupational Therapist I would be more than happy to consult with them, if requested, about the results of the qEEG and the neurofeedback training and how this might correlate with any Sensory or Motor difficulties the child is experiencing. Referral to experienced clinicians is also available.
Is there any electricity being put into my head during the qEEG or neurofeedback session?
No, your brain is “electric”. The EEG is generated by pyramidal neurons that are in the cortex (outer lining) of your brain. The summation of these neurons is amplified many times and the amplifier is able to show you a recording of your EEG on the computer screen. Your EEG dictates your state of arousal, and when measured against a normative data base for your age and sex allows for a comparison to determine the networks/regions and frequencies of the brain implicated in your symptoms.
Can I just rent the equipment from the clinician and do home training?
In my opinion, NO. There is more to a neurofeedback session than putting a few electrodes on the head and pushing a button. First it is better to have a full cap of training rather two to four placements; this cannot be done at home competently by the client. Second, if you do not have a good connection recording of the EEG and impedance) your training is placebo. Third, it is critical during neurofeedback that the clinician is able to evaluate how you are doing throughout the session and “shape” the training in terms of rewards to the brain so that the brain can learn to function more optimally. Giving a reward or reinforcement to the brain on the computer screen (auditory and visual) that is too easy results in the brain not learning and when neurofeedback stops the improvements will be extinguished meaning they will go away. If the rewards are too hard the brain will not learn. This is based on the concept of “Operant Conditioning”. Neurofeedback should never be a “cookbook” process, it should be individualized to the client, and the session should result in shaping or changing the integrity of the brain (based on the concept of operant conditioning) and the brain’s ability to learn and self-regulate.
QUESTIONS REGARDING THE QUANTITATIVE EEG (qEEG)
Is a quantitative EEG (qEEG) and a brain map the same thing?
A quantitative EEG always means there are 19 channels of recording against a normative data based that is used for interpretation of the eyes open and closed recordings. A brain map can be four or more placements and an independent normative data base is not used, it is often associated with the training platform and can be biased as to the results.
I called a clinician who stated they perform a qEEG and was told I could have one for $45.00; does that sound right?
In my opinion, this is an attempt to “bait” you into receiving neurofeedback services, but often at a much higher rate. Often the clinician will will state this is a brain map. A brain map is different than a qEEG. A mini brain map does not use an independent normative data base, but rather uses the data base that is part of that clinician’s training platform which means that it will be biased towards performing neurofeedback in a very basic format. The qEEG always involves 19 channel of electrode placements and is referred to as a full cap. In addition, if the clinician hand applies the sensors/electrodes that in itself is a concern because these placements should be specifically applied in very precise locations on the skull according to the Internationa10/20 system.
Who can do a qEEG?
An experienced EEG neurofeedback clinician can do it but there are many steps in the process to insure that the data is good. If done incorrectly, “bad data” results in inaccurate findings. For example, in order to insure that the data is high quality “impedance” or electrical resistance should be reduced to under 10 ohms. Your provider should be able to show that the data they have recorded is of high quality. If the recording is sent to a second party to analyze it is especially crucial that the data be high in quality because the second party did not do the recording. Ideally, if a practitioner is going to do qEEG led neurofeedback they should be able to administer and interpret the qEEG and fully understand the neurological principles associated with training. An additional question is whether or not the clinician is able to “hand edit” the raw EEG and understand the difference between the EEG and artifact (muscle activity or movement which appears to be EEG). Some clinicians just use the automatic edit feature of the normative data base and that in itself should not be a stand-alone method of choosing EEG data to put against the normative data base in order to develop the training guidelines.
I had a qEEG done but all I received was a few pages of a report with colored heads and no real explanation for what it meant.
The practitioner who did the qEEG must be able to meet with you and explain the results in detail, and this means more than vague inferences as to the results. The practitioner should be able to specifically explain the brain regions, networks, and frequencies of the EEG and how they correlate to the symptoms that prompted the analysis. If a practitioner is unable to explain in detail to you how the EEG is generated, how this relates to arousal in the brain, and the specific brain regions and networks identified in the qEEG analysis then, in my professional opinion, it is not in your best interest to receive neurofeedback from this individual.