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McReynolds et al.NeuroRegulationpopulations. Neurofeedback can be conceptualizedas utilizing the brain’s inherent capability ofneuroplasticity that allows individuals to becomeaware of the faint cues of their EEG neural activity.By attending to the feedback provided, individualslearn to control and direct their brain activity in orderto cultivate a more harmonious and balanced mentalstate (Budzynski, 1999; Demos, 2005; Nunez, 1981;Othmer & Othmer, 2009; Speckmann & Elger, 1987;White & Richards, 2009). The changes resultingfrom neurofeedback have been found to result inlong-termchangesandpositiveoutcomes(Budzynski, 1999; Demos, 2005; Othmer & Othmer,2009).The training process involves placing EEG sensorsover selected brain regions on the scalp and ears tomeasure the amplitude of the electrical activity of thebrain’s neuronal network.The individual’sbrainwave patterns are quantified and thendisplayed on a computer screen in a meaningfulmanner using both visual and auditory feedback.The therapist develops a treatment plan, which canconsist of 20 to 40 training sessions lasting aboutthirty minutes each, and establishes therapeuticgoals that are specific for each person’s needs.Both visual and auditory game-like feedback isutilized to reinforce the achievement of traininggoals.The purpose of this retroactive study was toevaluate the clinical effectiveness of theneurofeedback treatment for the 20 veterans whopresented with a variety of PTSD symptomsincluding anxiety, panic attacks, concentrationdifficulties, sleep disorders, depression, and memoryconcerns. It was hypothesized that the IntegratedVisual and Auditory Continuous Performance Test –Version 2 (IVA-2 CPT) global measures of visualand auditory attention (VAQ and AAQ scale scores,respectively) would show a significant improvementafter both 20 and 40 sessions of treatment. Asecond hypothesis was that the ratings of well-beingmeasured by the General Well-Being Scale (GWBS)would significantly increase after 40 sessions werecompleted. Since five statistical tests were plannedand neurofeedback training was expected based onpast studies to positively affect attention and wellbeing, a one-tail alpha level was set to p .02 basedon the Bonferroni correction with adjustments for theinitial mean correlation between all test scales.Additional analyses were planned to examine therelationship between improvements in IVA-2measures of attention and the GWBS ratings of wellbeing in order to explore in detail the specificaspects of attentional functioning that changed after116 www.neuroregulation.orgveterans completed 20 and 40 neurofeedbacksessions and whether or not improvements inattention led to increases in veterans’ feelings ofwell-being.MethodsParticipantsNeurofeedback treatment was provided for 20 U.S.military veterans (16 males, 4 females).Theaverage age of the veterans at the time of testingwas 46 years old ( 1 SD 17.7). The self-reportedprimary diagnoses of these veterans included PTSD(65%), ADHD (15%), Major Depression (10%),Generalized Anxiety (5%), and Learning Disability(5%). The participants for this study were randomlydrawn from an archival database of a sample ining.Individualizedneurofeedback training was provided within auniversity-based clinic setting. Veterans were notcompensated to participate in the neurofeedbacktraining. The funding agency provided support forneurofeedback services to be delivered as a clinicalintervention rather than as a study of a specificneurofeedback protocol. This study was approvedby the California State University San BernardinoInternal Review Board. Participants were providedwith an informed consent process.MeasurementsThe IVA-2 CPT has been found to be a valid andreliable measure of both visual and auditoryattention functioning in both children and adults andprovides both global and primary measures ofattentional functioning. The normative sample, withapproximately equal numbers of males and females,included 1,700 individuals ages 6 to 96 (Maddux,2010). The scales on the IVA-2 have a mean of 100and a standard deviation of 15. The IVA-2 globalmeasures of attention used in this study are theVisual Attention Quotient (VAQ) and the AuditoryAttention Quotient (AAQ). The VAQ is a globalmeasure of attention that is comprised of threeprimary visual scales: Vigilance, Speed, and Focus.Vigilance measures errors of omission, and Speedprovides a measure response time to visual testtargets. Focus is a measure of the variability ofresponse time to visual test targets. The AAQ hasthe exact same components and differs in that itassesses auditory test responses to the sameprimary measures of attention (Sandford & Sandford2015). Moreover, the IVA-2 has been demonstratedto be valid for adults with neurological insults suchas traumatic brain injury (TBI; Tinius, 2003).Vol. 4(3–4):114–124 2017doi:10.15540/nr.4.3-4.114

McReynolds et al.NeuroRegulationThe GWBS is an 18-item questionnaire that is a selfreport rating scale that measures a person’s generalsense of well-being. It incorporates six subscales ofwell-being including measures of anxiety, positivewell-being, depression, vitality, general health, andself-control. The GWBS has been found to be botha valid and reliable measure of well-being for severalethnic minority groups including young Caucasianmales (Fazio, 1977) along with Japanese(Nakayama, Toyoda, Ohno, Yoshiike, & Futagami,2000), Mexican-American (Poston et al., 1998), andAfrican-American populations (Taylor et al., 2003).Test ProcedureEvery veteran was administered and completed theIVA-2 CPT and the GWBS before beginning theirfirst neurofeedback session.Testing wasindividually administered and scored in accordancewith test procedures. There were a few individualswho were not able to validly respond to either visualor auditory IVA-2 test stimuli due to their extremedeficits in attentional functioning. In these cases,their “invalid scores” for IVA-2 were scored as zeroin accordance with the test interpretive procedures(Sandford & Sandford, 2015). After the completionof 20 and again after 40 neurofeedback sessions,the IVA-2 test was readministered. Twenty veteranscompleted 20 neurofeedback sessions and 19completed an additional 20 sessions. One individualdropped out due to scheduling conflicts aftercompleting 20 sessions.Following the lastneurofeedback session, the GWBS rating scale wasadministered for the second time. IVA-2 data wasanalyzed comparing baseline test scores and thescores obtained after both 20 and 40 sessions werecompleted. The GWBS rating scale score analysiscompared pretraining baseline scores to scoresobtained after 40 sessions of treatment.Neurofeedback Treatment ProtocolsAn individualized neurofeedback training plan wasdeveloped for each participant and clinicallymodified as necessary. Therapeutic goals focusedon improving attentional functioning and reducingany identified mental stress related to the symptomsof depression and anxiety. Training was completedusing the SmartMind 3 artifact correctedneurofeedback system with a two-channel EEGstation (BrainTrain, Inc., North Chesterfield, VA)which continuously filters out frequently occurring,very brief EMG artifacts in real time withoutinterrupting the training program. Neurofeedback117 www.neuroregulation.orgexercises were provided in game-like format thatutilized both visual and auditory reinforcement, aswell as graphs and numerical scores to providepositive reinforcement. The first step in the trainingsession was to collect an individual’s baseline EEGdata in order to determine Z-Score feedback goalsfor each individual. Based on each individual’sperformance, they were provided clinically relevantfeedback and adjustments were made to the trainingprotocol to optimize their performance. All EEG datawas automatically recorded.ResultsSince five main tests were required to answer thehypotheses of this study, the alpha level wasdetermined to be .02 using a Bonferroni correctionadjusted for the pretreatment correlation of themeasures used (r .46). All t-tests were one-tailmeasures given that it was expected based on pastresearch studies that neurofeedback would result inpositive changes in attention and emotional selfregulation. Given that the normative mean quotientscore of the IVA-2 test is 100 and its standarddeviation is 15, any increase of eight or morequotient score points (i.e., greater than one half of astandard deviation) is considered clinicallysignificant. This section will first address the mainhypotheses. Next, more specific IVA-2 componentmeasures of auditory and visual attention will beexamined in an exploratory analysis with the alphalevel set to .10 in order to explore more in-depth anychanges in attention and their relationship toimprovements in well-being.In order to evaluate whether or not neurofeedbacktraining improves auditory and visual attention,paired sample t-tests were computed comparingpretreatment IVA-2 AAQ and VAQ quotient testscores with each individual’s IVA-2 test scores aftercompleting 20 and then 40 sessions. As indicated inTable 1, veterans (N 20) significantly increasedtheir AAQ score after 20 sessions of treatment froma mean of 83 (Mildly Impaired) to 96 (Average), a13-point increase, t(19) 2.68, p .007, Cohen’s d 0.5.AAQ scores were also found to besignificantly higher after 40 treatment sessions (seeTable 2, N 19) and increased from 82 to 100, an18-point improvement, t(18) 4.53, p .0001,Cohen’s d 0.8.Vol. 4(3–4):114–124 2017doi:10.15540/nr.4.3-4.114

McReynolds et al.NeuroRegulationTable 1Paired Sample t-tests comparing mean IVA-2 Quotient scale scores at Baseline and after veterans (N 20)completed 20 neurofeedback training sessions.Cohen'sBaseline(N 20)20SessionsQ ScoreChangePooledSDSig.Auditory Attention Quotient839613240.0070.5Auditory Vigilance88979280.15n.a.Auditory Speed8410016220.0020.7Auditory Focus91943170.21n.a.Visual Attention Quotient849612270.0040.5Visual Vigilance86948280.080.3Visual Speed9210313220.030.5Visual Focus849612260.0070.5IVA-2 Attention ScalesdTable 2Paired Sample t-tests comparing mean IVA-2 Quotient scale scores at Baseline and after veterans (N 19)completed 40 neurofeedback training sessions.Baseline(N 19)40SessionsQ ScoreChangePooledSDSig.Cohen'sdAuditory Attention Quotient8210018240.00010.8Auditory Vigilance8710013270.030.5Auditory Speed8210220230.00090.9Auditory Focus91976140.010.5Visual Attention Quotient849511310.060.4Visual Vigilance87903350.37n.a.Visual Speed9010212220.040.5Visual Focus839714250.020.6IVA-2 Attention ScalesIn Figure 1, the continued improvement in auditoryattention from 20 to 40 sessions that was significantcan be viewed, t(18) 1.83, p .04, Cohen’s d 0.2.The IVA-2 VAQ test scores significantlyincreased 12 points after 20 sessions, t(19) 2.99,p .004, Cohen’s d 0.5; and 11 points after 40sessions, t(18) 1.64, p .06, Cohen’s d 0.4.Unlike AAQ scores, VAQ measures were not foundto significantly change after an additional 20 trainingsessions as seen in Figure 1. Thus, these testresults support the hypothesis that neurofeedbacktraining led to a significant improvement in globalmeasures of both auditory and visual attention.Figure 1. Changes in the IVA-2 Auditory Attention (AAQ)and Visual Attention (VAQ) standard Q scale scores after20 and 40 sessions of neurofeedback.118 www.neuroregulation.orgVol. 4(3–4):114–124 2017doi:10.15540/nr.4.3-4.114

McReynolds et al.NeuroRegulationAn examination of the changes in AAQ and VAQ ona clinical basis was completed to further explore andpredict the potential benefit of neurofeedback on anindividual basis. In order to do so, a positive ornegative change in IVA-2 quotient scale scores ofeight or more was considered clinically significant.After 20 sessions, 80% of the veterans improved ineither AAQ or VAQ scores by eight points or moreand for 40 sessions the treatment success rate was74%. IVA-2 testing after 20 sessions found that15% did not improve or declined (greater than eightpoints) in either AAQ or VAQ scores, and at 40sessions, 10% still did not show any change in theirattentional functioning. Only one person, or 5% ofthe veterans at 20 sessions, decreased significantlyin his VAQ score and had no meaningful change inAAQ indicating that he was more impaired in visualattention when evaluated for the second time. At 40sessions, three individuals performed significantlymore poorly in respect to visual attention and had noimprovement or decrement in their auditoryattention. In general terms, these results indicatethat it is reasonable to expect that about four out offive veterans will significantly benefit fromneurofeedback training, but that about 1 out of 10will actually decline (eight or more points) in ent in their auditory attention.Changes in self-reports of well-being were assessedby comparing the initial scores on the GWBS withrating scores obtained after 40 sessions of treatmentwere completed using a paired sample t-test.Table 3Paired Sample t-Test comparing the GWBS Well-Being rating scale scores at Baseline and after veterans(N 19) completing 40 neurofeedback training sessions.GWBS Well-BeingRating ScaleGWBS Rating Scale ScoreBaseline(N 19)40SessionsQ ScoreChangePooledSDSig.Cohen'sd587214240.0010.8As can be seen in Table 3, the GWBS rating scalescores significantly improved 14 points from 58 to72, t(18) 3.55, p .001, Cohen’s d 0.8. Apositive change of five points or more in the GWBStotal score was found for 84% of the participants.The changes are graphed in Figure 2.Figure 2. Changes in the General Well-Being Scale(GWBS) after veterans completed 40 neurofeedbacksessions.119 www.neuroregulation.orgThe GWBS has three primary interpretive categoriesfor labeling a person’s score: Severe Distress (0–60), Moderate Distress (61–72) and Positive Wellbeing (73–110). Initially, 79% of the individuals inthis study, who completed it, rated themselves aseither experiencing severe or moderate distress and21% reported having scores reflective of positivewell-being which they maintained during this study.Distress was defined as an “inner personal state”with elevated feelings of anxiety and depressioncombined with limited reports of good generalhealth, vitality, positive well-being, and the ability forself-control (Dupuy, 1977). To evaluate the vements in well-being were defined as achange from a more impaired level of distress to lessimpaired using the category labels provided abovefrom the test manual. Of the 15 individuals whowere identified as having either severe or moderatelevels of distress prior to treatment, nine (60%)significantly improved in their well-being and sevenof these nine veterans (78%) rated themselves ashaving a positive state of well-being after completingtreatment. One veteran became clinically worse(7%) and the five individuals (33%) did not change intheir ratings of well-being. These results show thatneurofeedback is likely to help 6 out of 10 veteransVol. 4(3–4):114–124 2017doi:10.15540/nr.4.3-4.114

McReynolds et al.NeuroRegulationimprove their general well-being and that about 5 outof these 6 individuals who have severe to moderatelevels of distress prior to treatment are likely toreturn to a healthy state of positive well-being afterneurofeedback.In Table 4, the correlations between the GWBSrating scores and the IVA-2 global and primarymeasures of auditory and visual attention completedafter treatment are reported.The question ofinterest was whether or not improvements in eitherauditory or visual attention contributed to increasesin an individual’s feelings of well-being. Prior to anytreatment, the correlations between the first GWBSrating scale scores and the IVA-2 CPT test scoreswere examined and no significant correlations werefound. After neurofeedback treatment, a significantcorrelation of .44 (p .03) was found for the globalAAQ, which consists of the Vigilance, Speed andFocus primary scale scores. The auditory Speedscale, which is a measure of the discriminatoryresponse time to the IVA-2 targets (i.e., click if youhear the number one), was found to have asignificant correlation of .57 (p .005) with theGWBS. No significant correlations were identifiedfor any IVA-2 visual scale.Table 4Correlations of the IVA-2 Attention Scales and theGWBS After Veterans Completed 40 Sessions ofNeurofeedback Training.GWBS RatingScoresSig.Auditory Attention Quotient (AAQ)0.440.03Auditory Vigilance0.28n.s.Auditory Speed0.570.005Auditory Focus0.28n.s.Visual Attention Quotient (VAQ)0.17n.s.Visual Vigilance0.14n.s.Visual Speed0.16n.s.Visual Focus0.00n.s.IVA Attention ScalesTables 1 and 2 are useful in that they show that priorto treatment (i.e., baseline) the mean attention scalescores for both auditory and visual were in what islabeled as a mild impairment. After neurofeedbacktreatment was completed, all global and primaryIVA-2 scale scores fell for the most part in the middleof the Average range. After 20 sessions, the fourmeasures of visual attention appeared to reach a120 www.neuroregulation.orgmaximum level of improvement and continuedtraining did not seem to lead to any further changesin visual attention with mean scale scores remainingwell within the average range and effect sizesessentially being equivalent. In contrast, continuedneurofeedback training did seem to strengthen theattention skills of participants. To support thisconclusion, it can be seen that the total Q scorechange after 20 more training sessions for the fourauditory scales increased by 16 points (39%). Inaddition, the effect size after 20 sessions wasmedium for two scales and nil for the other twoscales, because those two scales did notsignificantly improve. But after 40 sessions, all fourauditory scales were found to significantly improveand the effect sizes were identified to be large forboth AAQ and Speed scales and medium forVigilance and Focus. It is interesting to note that theonly two significant correlations between the IVA-2scales and the GWBS discussed above were theAAQ and Speed scales, which after 40 sessionsshowed large effect sizes.Given this study was archival, EEG protocols te by the clinicians working with theveterans. Consequently, any statistical analysis ona group basis in order to examine possible EEGlearning effects was not possible due to the fact thatthe clinically selected training protocols varied andwere modified by clinicians during the course of thetreatment in order to maximize the learning processfor each individual. The agency providing supportfor these neurofeedback services did so with theunderstanding that services were provided on anindividualized basis and not as a research study toevaluate a specific fixed neurofeedback trainingprotocol.DiscussionThe positive benefits of neurofeedback as atherapeutic intervention for helping reduce PTSDsymptomatology have been reported in a number ofstudies discussed above (Othmer & Othmer, 2009;Peniston & Kulkosky, 1991; van der Kolk et al.2016). This study specifically identified that artifactcorrected neurofeedback, which works by filteringout the contamination that continually results fromnaturally occurring EMG artifacts such as eye blinks,eye movements and facial activity, significantlyimproved both auditory and visual attention asmeasured by the IVA-2.As a group, theseindividuals initially presented with mild attentionalimpairments. After 20 half-hour treatment sessions,both their auditory and visual attention abilities wereVol. 4(3–4):114–124 2017doi:10.15540/nr.4.3-4.114

McReynolds et al.NeuroRegulationnormalized with standardized scale scores falling inthe middle of the average range and effect sizes inthe medium range.While this study utilized archival data and there wasno control group to control for possible test practiceeffects, the IVA-2 is an objective measure ofattention which controls for practice effects in bothits simplistic design (i.e., the test rule is to click if yousee or hear the number one) and in its tunities for individuals to practice the testbefore taking it. The reliability study in the testmanual found that on retesting subjects did notsignificantly change by more than three to fourpoints in either direction (Sandford & Sandford,2015). Thus, any group increases in IVA-2 quotientscores greater than three to four points can bevalidly interpreted as a result of an active treatmentand not due to practice effects. In this study, it wasfound that 20 additional neurofeedback sessions ledspecifically to the significant enhancement ofauditory attention as evidenced by the greater effectsizes observed and the significant increase in theAAQ from 20 to 40 sessions (see Tables 1 and 2

Visual and Auditory Continuous Performance Test - Version 2 (IVA-2 CPT) global measures of visual and auditory attention (VAQ and AAQ scale scores, respectively) would show a significant improvement after both 20 and 40 sessions of treatment. A second hypothesis was that the ratings of well-being