The Appropriateness of a qEEG Referral
What You Will Learn in This Chapter
Most disappointing qEEG assessments were doomed before the cap came out of the drawer. Someone accepted a referral without pinning down what was actually being asked. The provider then answered a question adjacent to the one the referral source cared about, and everyone walked away feeling the method underdelivered.
This unit is about the conversation that should happen first. You will learn the range of legitimate purposes a qEEG referral can serve, from characterizing a client and contributing to a diagnosis, through identifying biomarkers and building neurofeedback protocols, to monitoring progress and comparing groups in research.
You will also learn to test a referral against two independent standards. The first is whether the science supports using qEEG for this question at all. The second, which practitioners skip more often, is whether the question falls inside your own scope of practice, training, and licensure. A referral can pass the first test and still be one you must decline.
IQCB Blueprint Coverage: This unit addresses IX. Clinical Practice/Forensic, specifically E. The appropriateness of a qEEG referral.
Learning Objectives
After completing this section, you will be able to:
Explain why clarifying the referral question is the first and most consequential step in a qEEG assessment.
List the purposes for which a qEEG referral may be appropriate.
Describe the conditions for which qEEG contributes to diagnosis, and identify which of these require a medical practitioner.
Explain how serial qEEG assessment supports ongoing management and protocol revision.
Convert an overly broad forensic referral question into one with probative value.
Evaluate a referral against both the scientific support for the method and your own scope of practice.
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Start With the Referral Question
qEEG referrals, with their diverse purposes, underscore the crucial need to clarify the initial referral question. This step is paramount in ensuring the effectiveness and relevance of the subsequent qEEG assessment.
qEEG assessment may be appropriate for characterization of a client, diagnosis, identifying biomarkers, development of neurofeedback protocols, evaluation of outcome, and, in a scientific arena, for characterizing groups and group differences. qEEG is also relevant for forensic applications. Usually, for each of these purposes, qEEG is part of a multimethod assessment.
Although one might receive a referral for the purpose of characterizing or describing a client, for example asking whether this client has a qEEG signature consistent with CNS overarousal, the referral source typically intends to go beyond simple description. In these cases it is important to clarify the referral question so as to best serve the referral source and the client.
Referrals That Bear on Diagnosis
Characterization of a client's EEG may be requested to provide findings that bear upon a diagnosis. If the qEEG provider is a medical doctor, it is possible to entertain referrals for identifying epileptogenic activity relevant to the diagnosis of seizure disorder. qEEG is also a valuable tool in the differential diagnosis of dementia, monitoring neurological disorders, and assessing CNS function related to cognitive impairment in Parkinson's disease.
The effectiveness of the qEEG largely depends on the expertise of the clinicians and the quality of the laboratory performing the analysis. qEEG findings are also relevant for the diagnosis of many neuropsychiatric conditions such as anxiety, PTSD, depression, ADHD, and autism spectrum disorder, so the referral source may ask whether qEEG findings are consistent with any such conditions.
A qEEG referral is appropriate in cases where detailed brainwave analysis can provide additional diagnostic or monitoring insights, particularly in complex neurological and psychiatric conditions.
Other Legitimate Purposes
qEEG data can also be used to identify biomarkers, not only of diagnosable conditions but of a likely response to treatment.
Very often, referral is made to conduct qEEG assessment in order to propose helpful neurofeedback training protocols.
qEEG methods are appropriate for monitoring neurological conditions and for providing ongoing management. Serial qEEG assessment, where a series of assessments is conducted to assess neurofeedback progress, is a common practice. This not only provides a record of progress but can also reveal a lack of progress and the need to change protocols.
In the realm of science, investigators regularly refer in the sense of engaging collaborators who conduct qEEG assessments to compare groups of subjects and changes that may result from an experimental intervention.
A qEEG referral can legitimately serve characterization, diagnosis, biomarker identification, protocol development, outcome evaluation, ongoing monitoring, forensic testimony, and research. What these have in common is that each implies a different assessment, a different database, and a different report. That is why the referral question has to be settled before anything else, and why a referral phrased only as a request for a brain map is not yet a referral you can act on.
Forensic Referrals
In forensic settings, there are numerous potential litigant conditions for which qEEG evaluation may be useful in court. Generally, any cognitive, behavioral, or emotional condition that is probative or relevant to the legal action may be reasonable for making a referral for qEEG assessment.
A circumscribed condition such as planning ability in the cognitive domain, impulsivity in the behavioral domain, or fear in the emotional domain may be suitable for qEEG assessment that could then provide relevant information to the trier of fact about brain anomalies related to planning, impulsivity, or fear. It is not necessary for a forensic qEEG evaluation to address the full range of symptoms that comprise a clinical diagnosis.
Put another way, it is most useful for the expert witness to carefully discuss with the litigator what the exact referral question is and what information will have the most probative value. For example, an overly broad referral question such as "Is the defendant psychotic?" is not as useful as a referral question focused on the crux of a defense, such as "At the time of the alleged crime, did the defendant have any compromise to their brain function that would be likely to impair planning and decision-making?"
Defense counsel calls and asks you to determine whether her client is psychotic. That is not a question the qEEG can answer, and accepting it as stated sets you up to either overreach or disappoint. The productive move is to ask what the defense actually turns on. If it turns on whether the defendant could plan and deliberate, then the answerable question becomes whether there is evidence of compromise in brain function associated with planning and decision-making around the time of the offense. Narrower, answerable, and considerably more probative than the question you were handed.
Scope of Practice
An appropriate referral may be made that requests qEEG for multiple purposes. It is important in all referrals to evaluate the referral not only in terms of whether there is scientific support for using qEEG, but also in terms of one's scope of practice. One should only accept referrals for those questions and conditions for which one has the necessary training, supervision, and professional licensure.
Two tests govern whether you take a referral, and both must pass. The first is whether the science supports using qEEG to answer this question. The second is whether the question sits inside your training, supervision, and licensure. Identifying epileptogenic activity for a seizure diagnosis is scientifically supported and still outside the scope of a litigant-facing practitioner who is not a physician. Declining on scope grounds protects the client, the referral source, and you.
Check Your Understanding
- Name five distinct purposes for which a qEEG referral may be appropriate, and explain how each would change the assessment you conduct.
- Why does a referral asking only for a brain map need to be clarified before you accept it?
- What does serial qEEG assessment contribute that a single baseline assessment cannot?
- Rewrite the referral question "Is this client anxious?" so that it has probative value for a qEEG assessment.
- Describe a referral that is scientifically supportable but that you should still decline, and explain why.
Cutting-Edge Topics in qEEG Research
From Diagnosis to Treatment Prediction
The referral question the field has historically been asked is whether findings are consistent with a diagnosis. The question increasingly being asked instead is whether findings predict who will respond to which treatment. Biomarkers of likely treatment response are a different target than biomarkers of diagnosis, they are easier to validate against a concrete outcome, and they are more directly useful to the referring clinician.
Serial Assessment as Standard Practice
Repeat assessment during a training course is shifting from optional documentation to expected practice. Its real value is asymmetric: a series that shows progress is reassuring, but a series that shows no progress is more useful, because it triggers a protocol change months earlier than clinical impression alone would. Referral sources are beginning to ask for the schedule of reassessment up front.
Assignment
Now that you have completed this unit, write out a referral question you have received or could plausibly receive, then rewrite it so that it is specific enough for a qEEG assessment to answer. Explain what you would need to discuss with the referral source to make that revision, and state whether the revised question falls within your own scope of practice.
Glossary
litigant: a person involved in a civil legal case, either because they are making a formal complaint about someone or because a complaint is being made about them; a claimant, party, or plaintiff.
multimethod assessment: evaluation using multiple assessment tools.
probative: tending to prove a particular proposition or to persuade as to the truth of an allegation. The probative value is the relative weight of the particular evidence.
trier of fact: the judge or jury who decides the facts and law of the court case.
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