1. Whole Brain & Specific Site Z- Score Brain TrainingBy
John Bailey, PhD, BCIA-EEG

2. QEEG Guided Training
“The most important thing about live Z Score training is that it is scientific.  It is based upon published research and a well-documented normative database .  It uses concepts that have been proven in clinical research to lead to beneficial outcomes.  It eliminates guesswork, and reduces the risk or over- or under-training key parameters including coherence , phase , and asymmetry.  These parameters are known to have optimal values, and it is important in neurofeedback training to seek training targets that are beneficial.  Z Score training with 4 channels can address the whole head, and normalize activation, relaxation, concentration, focus, connectivity , control, and communication.  Z Score training can provide a complex task that addresses whole brain function in a single protocol.” Tom Collura
See: Thatcher, R.W.  EEG database guided neurotherapy.  In: J.R. Evans and A. Abarbanel Editors, Introduction to Quantitative EEG and Neurofeedback, Academic Press, San Diego, (N = 577 with many details).
See: POSITION PAPER  Standards for the Use of Quantitative Electroencephalography (QEEG ) in Neurofeedback: A Position Paper of the International Society for Neuronal Regulation Journal of Neurotherapy vol. 8 no. 1 p  

3. Core Concepts Must understand concept of Z scores
Must understand neuroanatomy
Must understand typical EEG metrics
Must understand neuropathologies
Must understand the different Z score targeting options

4. The Critical Training Link
Must be able to Link identified QEEG neuropathologies (the Z scores) with the behavioral correlates (symptoms & complaints) in order to pick target of training
Must be able to explain the link to the person being trained in developmental language they understand

5. Some Training Specifics
Good impedence essential
Can train whole brain
Can pick specific sites
Can use a combination of both methods
The brain will often “pick” the specific Z scores it responds to throughout the training
I typically use a Interval training model

6. “Inhibit” outlyer Z scores
Set parameters to include all Z scores between (–2.0 to + 2.0) for example.
Adjust these parameters to include approximately 98% of the Z scores.
Establish Percent of Chosen Z scores OK level (typical rule is 95% OK) and adjust so individual can achieve this 85% of time.
Success feedback can be Raw %, a game screen, or DVD, etc.

7. Reward / “Pull” In Z scores
Adjust narrow parameters such as (-1.0 to +1.0) which may only include 70% of the Z scores.
Set rule of this % of Z scores to stay above the 60% success level
Success is gradually pulling a higher percentage of the Z scores within that parameter rule.
No need to change type of feedback & you can switch to this “Pull” method from the “Inhibit” method on the fly.

8. Other Combinations of Training
Traditional neurofeedback such as inhibit theta/high beta while rewarding beta at c3 or smr at c4 + meet Z score rules.
Pick Specific Z scores such as low coherence between two sites to inhibit or reward.
Traditional neurofeedback while only monitoring the Z scores.
Train only the coherence Z scores.

9. Brief Assessment with Z Scores
Typical Configurations for ADHD assessment are 3-5min. eyes closed and 6-10 min eyes open with two tasks at Fp1Fp2FzCz & then at F3F4P3P4.
Compare results to Monastra Protocol.
Use TLC or Brownback & Mason subjective questionnaire to determine most relevant sites to measure.
Able to measure 8 sites in 60 min.

10. Tracking Treatment Response
If training only once per week I ask for symptom tracking at 2, 4, & 6 days post session by patient or parents.
Use of Results software by Matthew Fleischman for tracking
Use CTC-1020 Computerized Neurodiagnostic Checklist

11. Case Study: Age 11 Female Problem: Depression & ADHD
Primary Symptoms: Both depression & anxiety; irritability, low motivation, High forgetfulness & disorganization, inattention, poor school performance.
Very sensitive – Could only tolerate DVD feedback of stop/go, but would want to train for 40 min. Yet did not want to stop the neurofeedback training.

12. 3 Case StudyTraining Slides
1st slide- F3FzP3PZ: early in training targeting mood, distractibility, language problem complaint (Inhibit outlyers)
2nd slide - F3Fp1P3PZ: middle training with similar focus, but more on planning and concentration complaint (pull)
3rd slide- F3F4C3C4: last session with focus on mood/concentration & stabilizing (pull)

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16. Case Study: Age 10 male
Pervasive Developmental Delay (6 weeks premature; 3 weeks in neonatal unit) & ADHD symptoms – Inattention; hyperactivity ; Can’t handle transitions; Lack of cooperativeness; problems in school; difficulty with sleep.
Changed Training sites based on QEEG, parental report of symptoms, & subjective response to training

17. Treatment: 19 Z score sessions
Parents tracked improvement on scales for 2 -4 – 6 days post training. Feedback was initially with Planet Earth DVD at stop/go; then Moving Brain Cell game; and from session #7 on I used primarily the numbers and percent OK graph.
Improvement was consistently noticed in 2 days post training and gradually by the end lasted for the full week with very noticeable improvement in positive mood and level of cooperativeness & no reports of problems at school for the last two months of training.

18. Case Study Training Sites
1-3 trained C3C4CzF4 for frontal slowing & most abnormal at F4
4-8 trained F3F4FzC4 ( 1st slide is of session 8)
9-12 trained T3T4F4C4
13-15 trained FzFp1F3C3 & FzFp1T5F3
16-17 trained FzF4P3P4 & Fp1F3T3Fz
18-19 trainedFp1F3T3Fz (2nd slide)

21. Case Study: Age 12 male
Symptoms: Depression & ADHD with Hair pulling on left side at C3; Complete shut downs at school with oppositional refusal to do work; not doing any homework.
Medication had been ineffective & he was at risk of being sent to residential program
Positive response noted after session has lasted – parents & teachers rate it at 75% improvement / no need for residential placement which was alternative

22. Single session Positive Response
Lack QEEG – Previous assessment session showed frontal slowing at F3
Trained Percent Z Ok – Inhibit outlyers & added specific low alpha coherence reward sound & visual F3F4 & C3C4
Then added specific low beta coherence reward sound & visual for F3C3
He normalized F3 Beta1/Gamma by first normalizing the low coherences shown in series of slides

26. Case Study: Age 14 male
ADHD: Wanted to be off medication. Wanted to train his brain just likes he trains his muscles for sports; Wanted to get better at sports. Problem from parents point of view is poor school performance, not doing chores, and rather irritable & argumentative.
Full QEEG planned, but agreed to start training while waiting for this result

27. Trained 5 sessions
Slide 1 showed snapshot of eyes closed assessment only
Slide 2 showed snapshot of eyes open assessment with task
Slide 3 shows initial training with my rewarding percent Z ok – inhibit outlyers & I also gave a added reward for normalizing the beta coherence between F3F4

31. Early Training Results
Following slide is after 5 Z score training sessions. He reports 50% improvement in: his homework completion & in his doing chores without any parental prompting. He reports 75% improvement in his sports performance and 75% improvement with better sleep, with his being less irritable, frustrated, and prone to anger or oppositional in responses to parents

33. Combined Neurofeedback Case Study: Age 17 male
Aspergers with Severe Depression/Anxiety
QEEG showed high frontal T/B ratios & greatest abnormalities at T5T6 – excess fast activity and excess coherence.
23 sessions from to 9-08
Traditional Neurofeedback 1-6 Bipolar Training: t5-t6; t5-f3; t6-f4
Z score training F3F4T5T6 for 7-13
Both Traditional Neurofeedback plus added Low Frequency Othmer training for t4-p4 (0-.2) reward
Complete symptom relief with both depression & anxiety low at end of training and sustained as of last check in one year later. Went from failing # of classes to high grades & graduation. Reported significantly improved social relations compared to feeling a social outcast at beginning of treatment.

34. Case Study: Age 10 male
ADHD; Lower IQ in 70s; Distractible; Doesn’t finish tasks; poor memory; Impulsive; Emotional outbursts; Easily frustrated; misses social cues; problems with reading slow & having poor comprehension
QEEG: Diminished beta activity; Localized in the left lateral parietal & occipital areas responsible for language processing; more pronounced abnormlities in EEG under task
Recommended training at sites T5,F3,Fz,T3, C3,C4, T4 & alpha coherence Fp1-Fp2,T5-C4

35. Training Sequence 1-2 Trained C3C4P3P4 percent Z OK
3-4 Trained C3F3FzC4 percent Z OK
5-9 Trained C3C4T5Fz + C hz
10-13 Trained Fp1Fp2F3F4
14-17 Trained C3C4T5Fz & then did min bipolar training at T3-Fp1 & T4-P4
He used AVE & Captains Log at home

36. Z Score training choices & Choice of AVE / Bipolar Training
Slide 1: With consistently noticing low alpha absolute power I recommended home use of AVE with David Pal and put on a Alpha Enhancement Protocol. This appeared to assist in the z score training.
Slide 2: After elevated Beta absolute power normalized more, yet Z scores still showed some low Alpha and low alpha coherence patterns I added some Bipolar Training in “Optimizing” method used by Sue Othmer / Optimal ended up being in alpha range which corresponded partially with low alpha coherence z score values.
Side 3: Snapshot of one of the last training sessions showing more normalized numbers.

40. Overall Training Results
Used Results Training Sheet with average of 85 % parent reported improvement on these top 9 symptom concerns: Less distractible; Able to finish tasks; Better working memory; Able to sit still; Able to handle frustration emotions; Better at reading social cues; Reading with increased speed and independence & having better comprehension of material read.
At the beginning of treatment 7/9 of the inattention and 2/9 of the hyperactivity- impulsivity symptoms were in the very problematic range.  At the end of treatment only 1/9 of the inattention and 0 of the hyperactivity - impulsivity symptoms were identified in the problematic range. 
Most meaningful to parents was the high level of improvement in frustration tolerance skills with his being less easily annoyed or touchy. 

41. Some Z score Cautions identified by Tom Collura
EEG deviations should be consistent with clinical presentation
Consider coping, compensatory traits
Consider “peak performance” traits
Consider phenotypes & general recommendations
Monitor subjective experience & clinical changes always

42. Some Tom Collura Identified Training Modules
1. Fz Cz T3 T4 – Memory / Planning
2. F3 F4 O1 O2 – Seeing / Planning
3. C3 C4 F7 F8 – Doing / Expressing
4. P3 P4 T5 T6 – Perception / Understanding
5. Fp1 Fp2 Pz Oz – Attention / Perception
5a. T3 T4 Pz Oz – Memory / Perception
6. O1 O2 C3 C4 – Seeing / Doing
7. F7 F8 F3 F4 – Planning / Expressing
8. T5 T6 Fz Cz – Understanding / Doing