May 3, 2007.
I am very excited to be in my new office space at Majestic Plaza. If you go to their website you can easily see the location at Building number one. I am on a cozy spot on the first floor next to a Chinese doctor who does Chinese acupuncture, a neorologist and then there also some lawyers on the first floor. It is very quiet and the foyer to this red brick building is elegant.
Two issues have come up in the last several weeks that I am compelled to discuss here:
1. Aggression and biofeedback do not mix. I have two boys who were doing EEG biofeedback who are not only ADHD, but they are aggressive. The issue that is prompted by that is: Can you use biofeedback to address aggression? My answer, "Not so much." The issue here is that there is a long history of research and clinical evidence about what works with aggression and it is behavioral and cognitive behavioral therapy along with family therapy or parent training. So, my new answer when patients who have a child with aggression and ADHD is to say I can help you with the aggression first in individual and family therapy. Only when we get a handle on that we can discuss whether EEG biofeedback makes sense for his ADHD issues. Obviously on the triage model aggression is more emergent than ADHD and must be addressed NOW. So that is what I will do.
2. How to make EEG biofeedback affordable and more of an INVESTMENT? Cost, length of treatment time and the gradual change seen in EEG biofeedback make this a challenging modality. This has been an issue that has been nagging for my attention. The issue is somewhat complex, but demmands attention and sorting. Here is the deal. Nationwide research has shown that for PSYCHOTHERAPY the average number of sessions patients attend are 6 sessions. Now psychotherapy is very different from biofeedback. Biofeedback is substantially dependent upon the patient's typical rate of learning. To accomplish success in treating ADHD a group of differnt studies have found 25-40 sessions as a minimum. Yes, that is a minimum.
Having been traditionally trained as a psychologist, knowing that the typical number of psychotherapy sessions is 6, getting to 25, let alone 40 is difficult for me to endure. I get antsy. I always question the process in which I engage which is simply part of my nature and it was definitely reinforced in my training as a research-scientist. So, I question the process along the way. This complicates things.
However, the issue is that I truly have seen kids make consistent progress, but it really is slow and subtle. It really does take 25 to 40 sessions. Usually is seen more gains on the IVA follow-up test than losses. Most kids are going in a positive direction, but not blazing new paths. Now, since I have done EEG biofeedback for only a little over 2 years this long treatment period is long for me to endure. It is definitely long for the child and the parent to endure and it is clearly costly.
Now obviously on strictly business level it would make sense for me to see all patients in my office for the entire 40 sessions or whatever it turns out to be. Yet, I am not comfortable with either the cost for parents nor the time I spend myself often in training which is repeated over time. Once a good protocol is worked out it is not that complicated to do it at home. What happens is kids lose motivation and don't want to continue. Parents get frustrated at the rate of progress. So the question is: How to address this?
Well, a comment a father made the other day came back to me as I struggled with this issue. He said that this was an investment in his son. When his son expressed frustration with the slowness of the process and the desire to quit his fater looked quite despondent. So what struck me today was doing 10 to 20 sessions in the office and make those agreed upon choice points.
The choices at 10 and then 20 sessions are these: 1. Continue with office sessions. 2. Buy a machine and begin training and I supervise over the phone or through e-mail. 3. Stop altogether if the family just feels that they don't see progress, but the child must take the IVA test to objectively measure progress first. To at least have an objective measure of progress. The reality is that consistently I see progress on the objective computerized test first. Truth is, people are just not that objective. Moms and dad yearn for their child to make leap and bounds of progress even if that has not been the child's history. So when you reach 10 or 20 sessions and you have only seen baby steps there is a tendency to bolt. I hope this approach tempers that tendency.
How does this solution help families: The family limits up front costs and the money spent from there on out is truly an investment. They will own the machine and if their child takes a large number of sessions then they will have the money to do them at home.
Here is how the numbers work "roughly". Without including the initial testing or initial session or the updated testing, right now patients are paying $120 per biofeedback session.
Right now if a patient pays for 40 sessions that is 40 times $120=$4800
So, if, instead we do 10 sessions X 120=$1200
Right now a brainmaster can be purchased for roughly $1500
Add these together and you get $2700.
For supervision you would pay me $240 a month. (This is 2 hours a month.)
The difference between the $4800-2700=$2100 divide this by supervision fees per month and you get 8.75 more months of training. You do 3 sessions a week which is 12 a month. That will give you 105 sessions after the initial 10 for a total of 115.
Now with this number of sessions, I can confidently say that the vast, vast majority of patients with only ADHD are quite done by that time. If there is a learning disability or some other problem then it is a different story. Also, you would then own the machine for the whole family to use. Given that ADHD runs in families it truly has become an investment. I stay on as your consultant supervisor and you chug along with as many sessions as you want. At minimal you get approximately 115 sessions instead of 40. You most definitely would have completely answered whether or not EEG biofeedback would successfully work with ADHD and you can try it with other family members too.
So this is what I will do. I will offer to do 10, 20 or 40 in office sessions and the family can then decide at any choice point what they want to do. However, I will require that they do the IVA test again to 'OBJECTIVELY' check progress.
That is the best I can do for now.
Sincerley,
Charles Shinaver III, Ph.D., HSPP
I hope this was interesting and informative.
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