Patient/Client Assessment

Intake assessment has several purposes and methods. The use of these methods produces various quantitative and qualitative types of information. After collecting intake information, the practitioner integrates it with EEG findings, and their clinical experience and knowledge of the science on which neurofeedback is based. The practitioner then shares a holistic summary with the client to arrive at a mutually agreed upon common understanding of the presenting problem, a goal, and treatment options, so that the client can make a decision about whether to embark on a particular course of NFB training. Graphic © Motortion Films/Shutterstock.com.

BCIA Blueprint Coverage

This unit covers Patient/Client Assessment (VI A-D). Professionals completing this unit will be able to discuss:

Patient/Client Assessment
A. Intake Assessment
B. EEG Assessment
C. Ongoing Assessment
D. Assessment Demonstration

Intake Assessment

Purposes of Intake Assessment

The general purposes of intake assessment include gathering information, sharing information, and decision-making. In parallel to these, an important purpose is to build a trusting working relationship that inspires confidence that neurofeedback will be of help. The results of the intake assessment describe the problem qualitatively and quantitatively, and provide the baseline against which progress is measured. The information from intake contributes to constructing a formulation of problem, that is, an understanding of why the problem occurs and what will alleviate it. This formulation sets the stage for planning neurofeedback training, and helps the client give informed consent. In some clinical practice situations, another purpose may be to make a diagnosis.

Optimum Performance Assessment

Some practitioners focus their practice of neurofeedback and biofeedback on what is variously known as peak performance, optimum performance or simply performance training. Individuals who present for such training do not generally perceive themselves to have a "presenting problem" but primarily want to improve their performance in a sport, a musical career, in academic achievement or other endeavour. For such clients, the goals of the assessment are quite similar to that of the clinical client. The identification of levels of function, differences from typical and other measures can be very helpful in guiding optimum performance training. The ultimate goal is performance enhancement and the desired outcomes are often measured by indicators specific to the client’s interests, such as improved scores, better ratings, or improved musical opportunities, improved academic results, and the like.

A concern when working with optimum performance clients is that assessment will reveal a clinical issue and sharing this information with the client can be a delicate task. Also, practitioners who are not licensed or registered health professionals may not even recognize such issues and may train the client in ways that may exacerbate such findings. Thus, it is important for practitioners working with optimum performance clients to use comprehensive assessment techniques as described in this section to ensure a thorough understanding of the client is obtained to avoid negative outcomes.

Intake Assessment Methods

The methods that a neurofeedback practitioner uses during their intake assessment are guided by the nature of the presenting problem, goal, practitioner skill set, and wishes of the client. Some of the methods outlined below (e.g., questionnaires and rating scales) may be carried out in advance of first meeting the client, whereas others (e.g., tests) may occur during or after an initial appointment.

Preliminary Steps

After the client or referral source contacts the practitioner to request neurofeedback, the practitioner may use that initial contact to collect basic background information, either by phone or by sending a questionnaire. If a background questionnaire is sent to the client, it may be accompanied by standardized or non-standardized rating scales or other questionnaires that the client is instructed to complete and bring with them to their first face-to-face meeting. Alternatively, background forms, questionnaires, and rating scales may administered at the practitioner’s office just before the intake interview. If the client is a child, then questionnaires and rating scales may be sent to the parent or to some other significant person in the client’s life such as a teacher. Consent forms can also be sent in advance.

Introduction and Consent

For the first face-to-face meeting, the provider needs to introduce herself or himself, and give an outline of the methods involved in the intake assessment. This enables the client to participate to the best of their ability. An essential part of intake assessment occurs at the outset with review of confidentiality and the limits of confidentiality, before verifying that the client then wants to proceed. Consent should be documented.

Throughout the intake assessment, the provider should use active listening skills and other supportive communication skills to build a working relationship with the client (Silverman, Kurtz, & Draper, 2013). The use of these skills not only fosters trust and credibility, but also puts the client at ease so that they can provide the best possible information to the practitioner.

If identifying information details are not fully collected prior to the intake interview, the practitioner can ask the client directly for particulars such as name, birthdate, address, and phone number, as well as information related to billing and whom to contact in the case of an emergency.

Problem Description

Following this opening introduction, information needs to be gathered about the client’s presenting problem and their goal (Schwartz, 2016). This may begin with a simple open-ended question, followed by allowing the client sufficient time to respond. A great deal can be learned in these first few minutes of an interview by listening to the client present their concerns and goals unimpeded and in their own words. The practitioner is then better able to follow up with a series of specific questions to understand the problem more completely.

Inquiry about the details of the presenting problem helps to construct a description or definition of the client’s main concern. The problem may be an excess or a deficit, and may relate mainly to the client’s emotional functioning, thinking, behavior, or somatic functioning. The problem definition may include information related to frequency, intensity, and duration of occasions when the problem occurs.

Context matters, so that motivational conditions, antecedents, and consequences of the behavior may be useful to describe. When the problem first had its onset, and surrounding circumstances may be relevant to the assessment. How the problem has waxed and waned over time, as well as factors that worsen or relieve the problem can be valuable pieces of information. What the client and others have attempted insofar as changing the problem is also of importance, and whether the client is receiving any ongoing treatment. How the problem affects or limits the client helps to illustrate the severity of the concern.

This information is used by the provider and client to define a goal for training, for example, to decrease a problem that represents an excess of some sort, or to increase function that is deficient in some respect. Of course, results of EEG assessment are part of goal-setting.

Personal and Family History

Information about the larger context of the problem is important as well (Stucky & Bush, 2017). Categories of such information are referred to as personal and family history. The client’s personal history includes topics of medication, drug and alcohol use, diet and exercise, sleep, medical issues, psychiatric problems, family and social relationships, education, work experiences, legal matters, and military service. In several of these categories, it is helpful to inquire about treatment, training, and special accommodations that the client may have had. The client’s typical level of function is useful to elicit. This may be done for areas of personal care, completion of domestic chores, socialization, community access, education or work, and leisure and recreation.

Family history contains relevant information about parents, siblings, and possibly other family members. Although topics noted for personal history can serve as areas of inquiry about family members, it is usually the case that collection of family history information is more focused and limited to items that are particularly relevant to the client’s presenting problem and goals (e.g., medical and psychiatric concerns).

Diagnostic Interviewing

For some providers who are registered/licensed health professionals, the intake information may contribute to making a diagnosis. Several semi-structured interview formats have been developed to elicit information for making a psychiatric differential diagnosis. Medical practitioners may also make a diagnosis based on interview, physical examination, and test findings.

Barriers, Strengths, and Client Perspective

In addition to describing the problem and its course, and to outlining likely contributing factors, the intake interview also examines possible personal, social, and material resources that are available to aid in problem resolution. These may include, for example, motivation, encouraging family members, and access to transportation or the internet. Barriers may similarly be personal, social, or material. Additionally, the client’s own view about the causes of the problem and what it will take to remedy it are also valuable points of inquiry.

Behavioral Observation and Mental Status Examination

The client’s way of moving and speaking during the intake interview can be very informative in arriving at a description of the problem and goal, and understanding the client.

In some clinical situations, the practitioners may administer somewhat more formal questions to understand aspects of client’s emotional and cognitive condition. A mental status exam (Sadock, Sadock, & Ruiz, 2017) provides a format for such observation, and for briefly assessing areas of mental functioning. Topics include speech, emotion and affect, thought content and form, perceptual disturbances, cognition, reasoning, insight, and judgment.

Collateral Interview

Especially with clients who may be less than completely able to provide reliable information, an interview with a close relative or someone with significant direct experience with the client is very helpful. This information may fill in gaps left from the client interview and add new information. Inconsistencies between the client and collateral information may also suggest potential client deficits.

EEG Assessment for Neurofeedback

Depending on the presenting problem and goal, and practitioner training, initial EEG assessment may be more or less elaborate. The complexity of initial assessment also relates to the number of electrode sites that are used, which, in typical neurofeedback practices ranges from one to 19.

In addition to examining the analog waveform of the EEG signal, a number of variables can be evaluated quantitatively. Data from single sites may be represent by absolute or standardized (i.e., z scores) values of amplitude or power, in single-Hertz bins or in bands. Power values may also be given in ratios that compare bands.

If the practitioner uses more than one electrode for assessment, then additional ratios can be calculated, for example, comparing left and right prefrontal sites, or anterior and posterior sites. Sites can also be compared with variables such as coherence and phase. In cases when 19-channel records are obtained, various LORETA analyses can be performed which reveals EEG activity at Brodmann areas that are not limited to the cortical convexity. LORETA analyses enable the practitioner to examine the details of functioning in networks such as the default mode, salience, and attention networks. Normative databased are used with such analyses to compare the client’s EEG function to a healthy age-matched reference group.

Both qualitative and quantitative EEG findings are interpreted to generate hypotheses that are integrated with the information from the other components of the intake assessment.

Examples of quantitative approaches to EEG assessment include those described by Collura (2014), Demos (2019), Kaiser (2008), Soutar and Longo (2011), Swingle (2015), Thatcher (2020), Thompson and Thompson (2015), and Van Deusen (Ribas, Ribas, & Martins, 2016).

Reports

Several types of reports may be relevant to intake assessment. These include medical and psychiatric reports, academic and vocational reports. If the client has been referred by another professional, a report from that professional can be illuminating. Although such a report may be written, a phone conversation with referral source can be very informative as well. Such a conversation can help to clarify the reason for referral, possible goals, and likely predisposing, precipitating, and perpetuating causes for the problem. The client should be asked for their consent to request reports that are likely to be helpful.

Questionnaires and Rating Scales

Questionnaires often consist of checklists and places for the client to provide responses in their own words. This allows the client to provide basic background information, problem description, and personal history information. Items may be open-ended and qualitative (e.g., describe you concern), closed-ended (e.g., have you ever had a seizure), or multiple-choice (e.g., check each type of caffeinated beverage you drink).

Rating scales help to quantify a problem (Baer & Blais, 2010). They may be standardized and have norms that compare the client’s results with those of groups matched to the client, for example, based on age or education. Alternatively, they may be constructed with items that the provider has developed for use in her or his specific setting, and may or may not have norms developed in the practitioner’s office.

Both questionnaires and rating scales can collect information about cognitive, emotional, behavioral, and physical symptoms or problems (Psychology Tools, n.d.). They can also gather information about the functional consequences of symptoms, that is, the effect that problems have on practical real-world ability and social adjustment (Űstűn, Kostanjsek, Chatterji, & Rehm, 2010).

Information from questionnaires helps to describe the presenting problem in qualitative terms and gives the provider insight into how the client sees the problem. Rating scales, together with EEG results, provide quantification of the problem, and can serve as a baseline for recognizing progress, or the lack of progress, once training has begun.

As noted above, questionnaires and rating scales can be sent to the client in advance of the intake interview or completed immediately before or after the interview. Collecting information by questionnaire can make the intake interview much more efficient and help to focus the interview on the most salient aspects of the client’s concerns.

Whereas some questionnaires and rating scales are proprietary, others are available in the public domain. Informant versions of some questionnaires are also available.

Cognitive Tests

Not only in research settings, but frequently in clinics, practitioners will often administer tests of thinking and cognition (Lezak, Howieson, Bigler, & Tranel, 2012). Depending on the goals of neurofeedback for a particular client, domains assessed may include one or more of the following: attention, memory, language, visual-spatial perception and construction, and executive functioning. Intellectual functioning, academic performance, sensorimotor ability, and effort/performance validity may also be assessed. For example, deficient attention may be the reason that the client requested neurofeedback, in which case a continuous performance test such as the Conners Continuous Performance Test (2014) may be used to assess sustained attention and distractibility. Or, improved academic performance may be the client’s goal, with the practitioner using an academic screening instrument such as the Wide Range Achievement Test (Wilkinson & Robertson, 2017).

Alternatively, a measure of intelligence (e.g., Wechsler Adult Intelligence Scale – IV; Wechsler, 2008), or collection of executive function or cognitive self-regulation measures may be of interest (e.g., Delis-Kaplan Executive Function System; Delis, Kaplan, & Kramer, 2001). Cognitive test batteries have a number of tests that assess representative domains of cognition, and may include, for example, measures of aspects of attention, memory, and executive function (e.g., CNS Vital Signs; Gaultieri & Johnson, 2006).

Tests should be selected critically, with consideration given to standardization methods, normative groups, reliability, and validity. Many tests are available only to professionally qualified health practitioners, while many other tests can be purchased with fewer requirements. While many tests use paper and pencil, or objects to manipulate, other tests are administered by computer.

Those tests that use paper and pencil, or manipulable objects, usually require administration by a well-trained individual. However, those tests that are administered by computer reducing the cost of clinician time, both for administration and scoring. Nevertheless, results should be interpreted by a practitioner with appropriate professional background in order for the results to have validity and value for the client.

Psychophysiological Assessment

Some practitioners integrate neurofeedback with other treatment modalities they are trained to offer. These may include counseling or psychotherapy, medication management, audiovisual entrainment, brain stimulation, or peripheral biofeedback. For the latter, psychophysiological assessment can help to identify which physical system to treat, and provides a baseline for judging progress (Khazan, 2013; Peper, Tylova, Gibney, Harvey, & Combatalade, 2008).

Conclusion of the Intake Assessment

The intake assessment concludes with several important steps. The practitioner summarizes the important information that has been gathered from the various assessment methods and validates this by asking the client if there is anything to correct or add. The practitioner then integrates the information with EEG findings, and also with their scientific and clinical knowledge. This provides a formulation or an understanding of the problem for the client to consider. The client then is invited to share their thoughts and to ask questions.

Together with this understanding of the problem, the provider shares her or his perspective on how neurofeedback training protocols may be of use, together with the degree of scientific evidence that supports them. Details about recommended neurofeedback training are also helpful to provide. These can include a description of neurofeedback equipment, what the provider will do, what the client will do, and what the client should expect during the course of training. Possible side-effects and how they will be addressed can be reviewed. The likely duration and costs of training should be reviewed, along with how and when progress will be monitored. Possible outcome and durability of success can also be described.

Alternatives to neurofeedback can be reviewed, including no intervention or behavioral and lifestyle interventions. In some cases, the information collected during intake may suggest that neurofeedback is unlikely to be helpful at the present time. The provider considers her or his own expertise and shares it with the client. In light of the characterization of the presenting problem, the scientific evidence, and the provider expertise, the provider and client then consider what resources are available for treatment and review the client’s own preferences. Taken together, this discussion supports the client in giving a well-informed consent for neurofeedback.

The provider then may conclude the assessment by determining if it is advisable to send a report, and, if so, to obtain consent to do so. A time for a subsequent appointment is made, and, if relevant, the practitioner summarizes what the client and provider will do in the interim (e.g., self-monitoring of symptoms by the client).

Summary

The practitioner uses a variety of methods during the intake assessment, and organizes the resulting information into a summary that has utility for describing and understanding the client’s problems and goals, and for planning subsequent steps, including neurofeedback training. Information collected with a variety of methods helps the client to make a confident and well-informed decision about whether to proceed with neurofeedback training.

Glossary

classical conditioning: unconscious associative learning process that builds connections between paired stimuli that follow each other in time.

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Assignment

Now that you have completed this unit, which sounds do you prefer when you have succeeded during neurofeedback training? Which visual displays are more motivating for you?

References

Bear, L., & Blais, M. A. (Eds.) (2010). Handbook of clinical rating scales and assessment in psychiatry and mental health. Springer Nature.

Collura, T. F. (2014). Technical foundations of neurofeedback. Routledge.

Conners, C. K. (2014). Conners Continuous Performance Test (3rd ed.). Multi-Health Systems.

Delis, D. C., Kaplan, E. F., & Kramer, J. H. (2001). Delis-Kaplan Executive Function System. The Psychological Corporation.

Demos, J. N. (2019). Getting started with EEG neurofeedback (2nd ed.). W. W. Norton & Company.

Gaultieri, T., & Johnson, L. G. (2006). Reliability and validity of a computerized neurocognitive test battery, CNS Vital Signs. Archives of Clinical Neuropsychology, 21, 623-643.

Kaiser, D. A. (2008). Functional connectivity and aging: Comodulation and coherence differences. Journal of Neurotherapy, 12, 123-139.

Khazan, I. Z. (2013). Clinical handbook of biofeedback: A step-by-step guide for training and practice with mindfulness. Wiley-Blackwell.

Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological assessment (5th ed.). Oxford University Press.

Peper, E., Tylova, H., Gibney, K., H., Harvey, R., & Combatalade, D. (2008). Biofeedback mastery: An experiential teaching and self-training manual. Association for Applied Psychophysiology and Biofeedback.

Psychology Tools. (n.d.). Psychological assessment tools for mental health. Retrieved March 9, 2021, from https://www.psychologytools.com/download-scales-and-measures/

Ribas, V. R., Ribas, R. de M.. G., & Martins, H. A. de L. (2016). The Learning curve in neurofeedback of Peter Van Deusen: A review article. Dementia and Neuropsychologia, 10, 98-103.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2017). Kaplan and Sadock's concise textbook of clinical psychiatry (4th ed.). Wolters Kluwer.

Schwartz, M. S. (2016). Intake and preparation for intervention. In M. S. Schwartz & F. Andrasik (Eds.), Biofeedback: A practitioner’s guide (4th ed.) (pp. 217-232). Guilford Press.

Silverman, J., Kurtz, S., & Draper, J. (2013). Skills for communicating with patients (3rd ed.). CRC Press.

Soutar, R., & Longo, R. (2011). Doing neurofeedback: An introduction. ISNR Research Foundation.

Stucky, J., & Bush, S. S. (2017). Neuropsychology fact-finding casebook: A training resource. Oxford University Press.

Swingle, P. G. (2015). Adding neurofeedback to your practice: Clinician’s guide to ClinicalQ, neurofeedback, and braindriving. Springer.

Thatcher, R. W. (2020). Handbook of quantitative EEG and EEG biofeedback (2nd ed.). ANI Publishing.

Thompson, M., & Thompson, L. (2015). Neurofeedback book: An introduction to basic concepts in applied psychophysiology (2nd ed.). Association for Applied Psychophysiology and Biofeedback.