Working with Behaviorally Difficult Children

by Sue Othmer | June 28th, 2006

We are seeing increasing numbers of very difficult children. They may come diagnosed as Conduct Disorder, Oppositional Defiant Disorder, Bipolar Disorder, Reactive Attachment Disorder, Tourette’s, severe ADHD, or some combination of the above. The presenting symptoms might include unstable mood, physical agitation and hyperactivity, obsessive fears, emotional reactivity and over-reaction to perceived threats, need for complete control, rages, aggressive behavior, tics, impulsivity and attention deficits.

As we explore the benefits of inter-hemispheric versus left and right side training separately, we are rethinking the behavioral categories and how they respond to these different training approaches. We have also expanded our reach with our recent lower frequency training, which is proving very useful with this population. These behaviorally difficult children are generally very sensitive to the effects of neurofeedback. That is positive in that we are likely to significantly help them, but it also means that we need to be very careful in adjusting the reward frequency and in selecting training sites. These are kids we do not want to make worse.

The key placements that we are finding most useful for these children include both inter-hemispheric and single hemisphere training as described below. We are starting with T3-T4 for emotional stabilization or with T4-P4 for physical calming. After optimizing the reward frequency at the starting training site, we then gradually add other placements as needed for other symptoms. We want to move carefully, judging the effect of each new placement before assessing the need for additional sites. We might use one or two or all of these sites in combination for an individual client.

This is our most stabilizing training. Inter-hemispheric training is most effective in stabilizing mood swings as well as headaches, asthma and temporal lobe seizures. A useful indicator for T3-T4 is a good effect from anticonvulsant medications (mood stabilizers).

Right temporal-parietal training is physically calming. Difficult children are usually physically agitated and often hyperactive. This training calms their bodies and also brings them into appropriate awareness of their bodies. It improves awareness of appetite and heat and cold, plus awareness of others. This is also effective in reducing sensory hypersensitivities while improving spatial awareness and coordination. Good effects with more sedating medications for anxiety, depression or hyperactivity might indicate the usefulness of T4-P4 training.

Prefrontal training improves behavioral control, which is somewhat different from stability. Instability might result in mood swings. Lack of control leads to disinhibited and immature behaviors. Left prefrontal-temporal training is our strongest piece for behavioral impulse control and ADD symptoms. It is also the most effective piece for compulsive behaviors and tics. And it is effective for the severe obsessive fears that torment some of these children. Medication indicators include stimulants and antidepressants.

Right prefrontal-temporal training improves emotional control. This is the piece that is most dramatically helpful with the emotionally reactive, aggressive, controlling and raging children. It has a strong effect and needs to be handled carefully. We like to optimize the right-side reward frequency first at T4-P4, where the effects on physical calming are more easily observed and reported. T4-Fp2 can then be added with the same reward frequency with an expectation of good results. Medications that indicate right-prefrontal training include the antipsychotics.

Reward frequencies
Behaviorally difficult children are generally very high arousal and benefit from low reward frequencies. Our expectation is that left-side reward frequencies will generally be 2 Hz higher than right-side reward frequencies. As we have more experience mixing interhemispheric with left and right side training, we are having good results training T3-T4 with a frequency the same as, or close to, the right-side reward frequency. We often need a more calming effect with these kids than is possible even with 0-3Hz. So we lower the center frequency by bringing down the top end of the band. We are currently training a few clients as low as 0-0.3Hz with the Neuroamp and BioExplorer. It is not yet clear how the left and right side reward frequencies should relate at these very low frequencies. In the meantime, we are keeping the left reward slightly higher than the right. So we might train 0-1.0 on the left and 0-0.5 on the right, or 0-2 on the left and 0-1 on the right.

Other challenges:
Other factors can strongly impact the success of neurofeedback with these children. The families are often very stressed and may have great difficulty managing the children and even getting them to their sessions. There is often blaming and confusion about the nature of the problem. This is where we find a SPECT report from the Amen Clinics useful. There is something very tangible and compelling about those pictures of a child’s brain on fire.

Diet and food sensitivities may have a strong effect on the behavior of these children. Environmental allergies sometimes complicate the process as well. Consistent and reliable communication with family members is critical. We need good feedback from client and family in order to sort out the specific effects of shifts in reward frequency and placement as we optimize the training for each individual child.

3 Responses to “Working with Behaviorally Difficult Children”

  1. Children Anxiety Disorder says:

    antidepressants may be prescribed for social anxiety disorder children

  2. ADHD Signs says:

    Well writen article, I’ve bookmarked your site.

  3. Hi. You have a really great blog which I enjoyed reading. Thanks! I have found a good website about depression and bipolar disorder which may help ( Cheers.

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