Slow cortical potential training (Birbaumer)

1. Introduction

Version followed: the Tübingen SCP-neurofeedback protocol of Strehl, Birbaumer and colleagues for children with ADHD (Strehl et al. 2006; manualised multicentre version, Strehl et al. 2017). The Zurich variant (Drechsler et al. 2007) is noted where it differs. For epilepsy, the Tübingen protocol for adults with drug-resistant focal epilepsy (Strehl et al. 2011; 10-year follow-up, Strehl et al. 2014) is followed. Device settings, thresholds and trial timings are left out on purpose. Ask the manufacturer and your trainer for those.

What it is. Slow cortical potentials (SCPs) are slow shifts in the EEG baseline. They can go negative or positive. In the Tübingen work, negative shifts are linked to more cortical excitability (getting the brain "ready"), and positive shifts to inhibition or less excitability [source: Strehl et al. 2017; Drechsler et al. 2007]. In SCP training the client learns, through operant feedback, to produce both polarities when asked. Then they practise doing it without feedback, so the skill can be used in daily life. The Zurich authors describe the aim as "the control of cortical regulation and at the efficient allocation of resources" [source: Drechsler et al. 2007].

How change is thought to happen.

ADHD: the child learns to raise cortical activation (negativity) when a task demands attention. They then carry this skill into homework and school using a transfer card as a cue [source: Strehl et al. 2006; Strehl et al. 2017].
Epilepsy: the authors write that negative shifts "reflect low excitation thresholds that precede epileptic seizures" [source: Strehl et al. 2014]. Patients therefore learn to produce positive shifts (inhibition) and use the skill in situations where seizures are likely [source: Strehl et al. 2011; Strehl, Trevorrow, Veit et al. 2006].

One summary of the 2014 paper reads as if negative shifting were the goal in epilepsy. The authors' own wording and the 2006 and 2011 papers point to training positivity and suppressing negativity [uncertain on that one summary sentence only].

Brain-computer-interface (BCI) history. The same Tübingen group used SCP self-regulation to build the "Thought Translation Device". This was a spelling device for completely paralysed (locked-in) patients, for example people with ALS [source: Birbaumer et al. 1999]. Patients first learned to move a cursor to a target. Next they copy-spelled with a reduced alphabet. Finally they spelled freely, choosing letters by repeatedly halving the alphabet [source: Iversen et al. 2000]. BCI work is specialist research and rehabilitation-engineering practice, not psychotherapy. It appears here because it shows the core idea: with feedback, people can learn reliable voluntary control of SCPs.

Who delivers it.

In the ADHD trials, sessions were run by a licensed clinical psychologist or by supervised graduate students [source: Strehl et al. 2006].
In the multicentre trial, trainers at each site took a 2-day course, attended regular meetings and followed a detailed manual, and supervision visits checked adherence [source: Strehl et al. 2017].
A trained psychotherapist can deliver SCP training within their competence and licence.
For epilepsy, deliver it only together with the treating neurologist, as an add-on. It never replaces antiseizure medicines [source: Strehl et al. 2014; synthesis for the collaboration rule].

Certification route (BCIA, clinical track). As summarised from BCIA's published requirements [source: Wikipedia, BCIA; verify current figures with BCIA [uncertain: secondary]]:

a bachelor's degree in a clinical health-care field;
36 hours of didactic education covering the Neurofeedback Blueprint of Knowledge;
an anatomy and physiology course or exam;
25 contact hours with a BCIA-approved mentor;
100 client sessions and case-conference presentations;
a written exam;
agreement to BCIA's ethical principles;
recertification every 4 years.

BCIA certification does not by itself give a licence to treat. Practise within your own licensed scope.

Evidence status (attributed).

Strehl et al. 2017 (multicentre RCT, 150 children aged 7–9): SCP neurofeedback beat a semi-active EMG-biofeedback control on parent-rated ADHD symptoms (d = 0.57 completers; 0.40 with baseline observation carried forward). There was no between-group difference on teacher ratings. Self-regulation performance did not correlate with clinical outcome.
Drechsler et al. 2007: the overall advantage over a CBT group programme was probably due largely to nonspecific factors such as parental support. A specific effect appeared in children who learned to regulate.
Arns et al. 2020: in a review applying stricter APA criteria, the authors rated "standard" neurofeedback protocols as a well-established ADHD treatment [source: Arns et al. 2020, abstract only]. Whether SCP is among the protocols they count as standard could not be checked from the abstract [uncertain].
Epilepsy (Strehl et al. 2014): in a small 10-year follow-up (11 patients analysed), seizure reduction was sustained. The authors conclude SCP feedback "may be considered" for intractable epilepsy as an adjunct and call for replication. A separate study reported an IQ gain after SCP training in drug-resistant partial epilepsy [source: Strehl et al. 2011].
German S3 ADHD guideline (version 2.0, 2026 update): contains neurofeedback recommendations 1.4.2.1–1.4.2.2. Their wording and strength are not verified here [uncertain: not verified].
NICE: its position on neurofeedback for ADHD (NG87) and for epilepsy was not verified [uncertain]. Check the current NICE guidance before quoting it to families.
Device status: not verified here. Confirm with the manufacturer that the amplifier and software are legally marketed medical devices for your jurisdiction and use [uncertain].

Related guides: 045 Alpha training (Kamiya), 046 Alpha-theta training and the Peniston protocol, 047 Sensorimotor-rhythm training (Sterman), 048 Theta-beta training (Lubar), and 050 QEEG-guided, z-score and LORETA neurofeedback. SCP differs from these frequency-band methods because it trains slow potential shifts in two directions rather than the power of a band [source: Drechsler et al. 2007].

2. Framework

The course moves through six phases. Session counts are those published. Device parameters are omitted.

Phase 0 – Referral, intake and medical clearance (1–3 appointments).

Goal: confirm the diagnosis, eligibility, safety and consent.
ADHD trials required [source: Strehl et al. 2006; Drechsler et al. 2007; Strehl et al. 2017]:
- a formal ADHD diagnosis confirmed by structured or semi-structured interview;
- IQ of about 80 or above;
- no known neurological illness.
The multicentre trial also excluded bipolar disorder, psychosis, serious OCD, chronic tics or Tourette syndrome. Oppositional defiant disorder and conduct disorder were allowed [source: Strehl et al. 2017].
Epilepsy trial required [source: Strehl et al. 2014]:
- focal epilepsy diagnosed at least 2 years earlier;
- no seizure reduction after 2 years on medication;
- IQ above 80;
- no psychogenic (non-epileptic) seizures and no DSM-IV psychiatric disorder;
- referral by a neurologist or GP.
Medication: prescribed medicines stay under the prescriber's control. Parents in the ADHD studies were asked to keep stimulant medication constant during training [source: Strehl et al. 2006; Drechsler et al. 2007]. In the epilepsy studies, medication was unchanged from baseline until 1 year after treatment ended [source: Strehl et al. 2014].
Move on when: diagnosis and clearance are documented, written consent (and the child's assent) is obtained, and baselines are collected.

Phase 1 – Baseline assessment.

ADHD: parent and teacher symptom ratings, quality of life, and attention or IQ testing before training, after training and at about 6 months [source: Strehl et al. 2006; Strehl et al. 2017].
Epilepsy: a seizure-diary baseline (12 weeks in Strehl et al. 2011), then follow-up at 6 and 12 months [source: Strehl et al. 2011].
Move on when: a stable baseline exists.

Phase 2 – First training block.

Goal: learn to tell the two polarities apart with feedback, and begin transfer trials.
Format [source: Strehl et al. 2006; Strehl et al. 2017; Drechsler et al. 2007; Strehl et al. 2011]:
- Tübingen 2006: 10 daily sessions on school-day afternoons over 2 weeks.
- Multicentre 2017: 12 sessions at 2–3 per week.
- Zurich: an intensive 2-week holiday course of double sessions.
- Epilepsy: 20 sessions.
- Each session lasts about an hour including preparation.
- Both polarities are requested in random order.

Phase 3 – Training break with home practice (about 4–6 weeks; 5 weeks in Zurich).

Goal: practise the skill without the machine, using transfer or memo cards (and, in 2017, a practice video), with a daily practice log.
The trainer stays in contact by phone or email (Zurich) [source: Strehl et al. 2006; Drechsler et al. 2007; Strehl et al. 2017].

Phase 4 – Further training block(s).

Format:
- Tübingen 2006: two more 10-session phases (30 sessions in all).
- Multicentre 2017: 13 more sessions (25 in all).
- Zurich: 5 double sessions during term.
- Epilepsy: 15 more sessions (35 in all).
Change in emphasis: later sessions put more weight on the clinically relevant polarity. For ADHD this is negativity (activation). For epilepsy, the second phase changed the balance of tasks, which the authors link to suppressing negativity (the published ratio's direction is not fully explicit) [source: Strehl et al. 2017; Strehl et al. 2011; uncertain on the epilepsy direction].
ADHD in-session homework: in the last block, the child does homework in the lab with the card while the trainer guides only the cueing [source: Strehl et al. 2006; Strehl et al. 2017].
Move on when: the planned sessions are complete and the polarities are reliably told apart in transfer trials. If they are not, see Section 5.

Phase 5 – Generalisation, outcome review and ending.

Outcome review: repeat the post-training measures and the seizure diary.
Daily-life plan: carry the card and use the strategy in named situations.
Booster sessions: the Tübingen ADHD and epilepsy studies gave none, and effects were still reported at follow-up [source: Strehl et al. 2006; Strehl et al. 2014]. Offering boosters is your own clinical option [synthesis].
Follow-up: at about 6 months (ADHD) and at 6 and 12 months (epilepsy).

3. Guiding principles

Training a skill, not applying a treatment to a passive client. Practical meaning: frame every session as learning self-regulation (the children's version was a game to "speed up" the brain) [source: Strehl et al. 2006].
Both polarities, then the clinically relevant one. Practical meaning: always train both directions so the client learns the contrast. Weight the target polarity later. Do not train only one direction from the start [source: Strehl et al. 2017; Strehl et al. 2011].
Transfer is built in from the start. Practical meaning: mix trials without continuous feedback into every session, and treat transfer performance as the real test [source: Strehl et al. 2006; Strehl et al. 2017].
The client finds their own strategy. Practical meaning: offer examples that have worked for others, never prescribe one, and ask the client to put their strategy into words between runs [source: Strehl et al. 2006].
Generalisation into daily life is part of the treatment. Practical meaning: use cards, home practice, supervised homework and a list of target situations (homework, exams, seizure-prone situations) [source: Drechsler et al. 2007; Strehl et al. 2014].
Use behavioural principles and the relationship. Practical meaning: give token reinforcement, praise effort, and attend to the alliance. The Zurich team called the therapeutic relationship fundamental [source: Drechsler et al. 2007].
Parents are co-therapists in the child's version. Practical meaning: invite them to sessions and ask them to prompt card use and award points. Parental support predicted improvement [source: Drechsler et al. 2007].
Medication belongs to the prescriber and neurologist. Practical meaning: SCP training is an add-on. Never suggest stopping or reducing stimulants or antiseizure medicines. Route every question to the prescriber [source: Strehl et al. 2014; synthesis].
Measure, don't assume. Practical meaning: track regulation in feedback and transfer trials, plus clinical outcomes. Learning to regulate and clinical change can come apart, so watch both [source: Strehl et al. 2017; Drechsler et al. 2007].
Manual and supervision. Practical meaning: work from the published manualised structure, get training, and use case supervision [source: Strehl et al. 2017].
Honest expectations. Practical meaning: tell families the evidence and its limits, including the role of nonspecific factors [source: Drechsler et al. 2007; Strehl et al. 2017].

4. Intervention inventory

4.1 Referral, intake and medical clearance

Purpose: confirm that SCP training fits the client and is safe, and set up collaborative care before any training.
Steps:
1. Get a documented diagnosis.
  - ADHD: made by a qualified clinician with a structured or semi-structured interview [source: Strehl et al. 2017; Drechsler et al. 2007].
  - Epilepsy: a neurologist-confirmed diagnosis and seizure type. The published protocol is for focal drug-resistant epilepsy and excluded psychogenic non-epileptic seizures [source: Strehl et al. 2014].
2. Screen for the published exclusions: neurological illness (for ADHD), psychosis, bipolar disorder, serious OCD, chronic tics or Tourette syndrome, and IQ below about 80 [source: Strehl et al. 2017].
3. Take a developmental and health history [source: Strehl et al. 2006].
4. Record current medicines and the prescriber's name. With consent, write to the prescriber or neurologist. Explain that training is an add-on, that you will not advise on medication, and how you will report seizures, side effects or deterioration [synthesis].
5. Epilepsy: get the neurologist's written agreement. Agree a seizure first-aid and emergency plan for the training room, and check whether screen stimulation is a concern for this patient [synthesis].
6. Check the skin of the scalp and ears where electrodes will sit, and ask about skin conditions [synthesis].
Example language (illustrative): "This training is an extra alongside your neurologist's treatment. It does not replace your tablets. Any question about medicines goes to Dr X, and I will keep them updated with your permission."
Watch for: pressure to stop medication; seizures that may be non-epileptic (refer back for assessment); undiagnosed attention problems that need a medical work-up first [synthesis].

4.2 Consent, assent and safeguarding (children and young people)

Purpose: valid consent from those with parental responsibility, the child's own agreement, and child protection.
Steps:
1. Parents and children signed informed consent in the Tübingen study [source: Strehl et al. 2006].
2. Explain in plain words: what will happen; the time commitment (about 25–35 sessions plus home practice); the electrodes and gel; the evidence and its limits; the alternatives (including medication and behavioural parent training, via the referrer); and that the child may stop at any time [synthesis].
3. Get the child's assent in age-appropriate language, and check it again at the start of each block [synthesis].
4. Safeguarding [synthesis]:
  - follow local child-protection procedures and policies on chaperones and lone working;
  - if the trainer watches from an adjoining room by video and intercom, as in the Tübingen set-up [source: Strehl et al. 2006], tell parents and get their consent for the video link;
  - do not record unless consent covers it;
  - keep a parent or carer on the premises for young children.
5. Age: the published ADHD trials enrolled children aged 7–9 (multicentre) and 8–13 or 9–13 (single sites). The epilepsy trial enrolled people aged 14–50 [source: Strehl et al. 2017; Strehl et al. 2006; Drechsler et al. 2007; Strehl et al. 2014]. No regulator's age limit for SCP training was found [uncertain]. Work within the device's labelled age range and your service's policy.
Example language (illustrative, to a child): "We're going to play a computer game where you move a ball with your brain, not your hands. You can tell me if you want a break or don't want to play."
Watch for: reluctant assent; family conflict about the training; disclosures during sessions. Follow your safeguarding procedure for any disclosure [synthesis].

4.3 Baseline and outcome measurement

Purpose: set a baseline and track the clinical effect, not just the EEG.
Steps:
1. ADHD:
  - parent and teacher ratings of ADHD symptoms;
  - a behaviour inventory;
  - quality of life;
  - attention or IQ testing. These are given before and after training and at about 6 months, at the same time of day each time. The Strehl et al. 2006 battery included the Eyberg Child Behavior Inventory, the German Conners scales, DSM-IV checklists and the KINDL [source: Strehl et al. 2006; Strehl et al. 2017]. Use licensed instruments; do not copy items.
2. Epilepsy: a daily seizure diary through baseline, training and follow-up. The baseline was 12 weeks, with follow-up at 6 and 12 months [source: Strehl et al. 2011; Strehl et al. 2014].
3. Record regulation performance in feedback trials and transfer trials separately. Software usually produces this [source: Strehl et al. 2017].
Watch for: medication changes between assessment points, which make change hard to interpret. The trials asked for medicines to be kept constant, but that decision rests with the prescriber [source: Strehl et al. 2006].
Example language (illustrative): "Before we start, I'll ask you and the teacher to fill in some ratings, and we'll repeat them at the end so we can see what changed." [synthesis]

4.4 Psychoeducation and framing

Purpose: give the rationale and a motivating frame.
Steps:
1. Explain in plain words that the brain's slow electrical activity can be shifted towards "switched-on and ready" or "calm and switched-down", and that people can learn to do this with feedback [source: Strehl et al. 2017; Drechsler et al. 2007].
2. For children: present it as a computer game for speeding up the brain so that they can concentrate in hard situations [source: Strehl et al. 2006]. The Zurich system used cartoon characters, with red for activation and blue for deactivation [source: Drechsler et al. 2007].
3. For epilepsy: link the positive or inhibitory direction to raising the brain's threshold for seizures. Say clearly that this is a skill added to medical treatment [source: Strehl et al. 2014; Strehl et al. 2011].
4. Explain that there will be easy and hard days, and that the card practice at home matters as much as the sessions [synthesis].
Example language (illustrative): "Your job is to find a way of thinking or feeling that pushes the ball up, and another that pushes it down. Nobody can tell you exactly how. You'll discover it."
Watch for: a child who feels the game is a test they can fail, or parents expecting quick results; reframe and set expectations. [synthesis]

4.5 Session set-up and equipment safety (general terms)

Purpose: a clean, safe signal and a comfortable client.
Steps:
1. Apply the electrodes as the manufacturer and your training specify. SCP recording uses a single central scalp site with reference electrodes, and also records eye movements, because eye artefacts contaminate slow potentials [source: Drechsler et al. 2007; Strehl et al. 2006]. Settings are not given here.
2. Ask the client to sit still and keep eyes on the screen. Explain that blinking or eye-rolling "moves" the signal and does not count. The software excludes trials with artefacts [source: Drechsler et al. 2007].
3. Electrical and hygiene safety [synthesis]:
  - use only medical-grade, isolated amplifiers as supplied;
  - follow the manufacturer's cleaning and single-use rules;
  - do not apply electrodes over broken skin;
  - keep liquids away from the equipment.
4. The Tübingen trainer watched the EEG and the child's screen from an adjoining room and could intervene by intercom or by going in [source: Strehl et al. 2006]. Sitting beside the client is also a choice [synthesis].
Watch for: skin irritation from gel or abrasion, fatigue, and headaches. Record them and pass relevant events to the medical team. The multicentre trial reported treatment-related adverse events in 6% of the neurofeedback group and 7% of the EMG group [source: Strehl et al. 2017].
Example language (illustrative): "This gel feels cool and a bit sticky. Tell me if anything itches or feels uncomfortable, and we'll stop and sort it out." [synthesis]

4.6 Feedback trials (both polarities)

Purpose: the core operant learning.
Steps:
1. On each trial a cue (a goal at the top or bottom of the screen, a colour, or a letter) tells the client which direction is wanted. An object such as a ball moves in proportion to the SCP shift. Success is marked by a reward signal: a smiley, a sun, a jingle, points or an animation [source: Strehl et al. 2006; Strehl et al. 2017; Drechsler et al. 2007; Strehl et al. 2011].
2. Present negative-shift and positive-shift requests in random order. Early sessions balance them [source: Strehl et al. 2006; Strehl et al. 2017].
3. Run a few blocks per session with short breaks between them [source: Strehl et al. 2006; Strehl et al. 2017].
Example language (illustrative): "Ball up at the top: try your 'switch-on' idea. Ball at the bottom: try your 'switch-off' idea. Let's see what happens."
Watch for:
- The client succeeds on only one polarity. This is common: in Zurich, positivity was present from the start while negativity changed with training [source: Drechsler et al. 2007].
- Success comes through muscle tension or eye movement instead of genuine regulation [synthesis].
Working when: the client can tell the polarities apart reliably. See 4.12.

4.7 Strategy discovery and verbalisation

Purpose: help the client find and keep strategies that work.
Steps:
1. Do not prescribe one strategy. Give examples that have helped other children, and encourage the client to find their own [source: Strehl et al. 2006].
2. Between runs, ask the client to describe what they did. Keep the strategies that worked and try new ones for those that did not [source: Strehl et al. 2006].
3. Help the client build an activation strategy and a deactivation strategy, plan where to use them, and keep a training diary [source: Drechsler et al. 2007].
Example language (illustrative): "That run the ball went up nearly every time. What was going on in your head? Let's write it down so you can use it at school."
Watch for: strategies that rely on movement or breath-holding. Steer towards mental strategies [synthesis].

4.8 Transfer trials (no continuous feedback)

Purpose: to practise self-regulation the way it will happen in daily life, without a ball to watch.
Steps:
1. Mix transfer trials in with feedback trials. The cue appears and the EEG is recorded, but the moving object is not shown [source: Strehl et al. 2006; Drechsler et al. 2007].
2. In the Tübingen ADHD version, success is shown only at the end of a transfer trial, for example as a smiley or a sun. In the multicentre trial, one whole block in every session ran this way [source: Strehl et al. 2006; Strehl et al. 2017]. In the epilepsy protocol, transfer trials showed only the cue letters. Fewer than half of all trials gave feedback [source: Strehl et al. 2011; Strehl et al. 2014].
3. Ask the client to use the same strategy they used in the feedback trials.
Example language (illustrative): "This time the ball hides. Do exactly what you did before, and at the end we'll find out if it worked."
Watch for: good regulation with feedback that falls apart in transfer. This happens often. In the multicentre trial, 53.7% of the neurofeedback group were learners in transfer, against 67.9% with feedback [source: Strehl et al. 2017]. Practise more transfer trials and review the strategy with the client [synthesis].

4.9 Reinforcement and token system

Purpose: to keep motivation up across a long course.
Steps:
1. Count the success signals in each session and exchange them for tokens. Children trade tokens for small toys, stickers, vouchers or gifts. Tübingen used items worth about 1.50 euros [source: Strehl et al. 2006; Strehl et al. 2017].
2. Parents can give reward points for card practice at home [source: Drechsler et al. 2007].
3. Praise effort and the use of strategies, not only success [synthesis].
Watch for: rewards that come to matter more than learning, or that are too delayed to work. Keep exchanges frequent and small [synthesis].
Example language (illustrative): "Every time the ball moves the right way, you earn a point, and points add up to tokens you can swap at the end." [synthesis]

4.10 Shifting the polarity emphasis across phases

Purpose: to concentrate practice on the polarity that matters clinically, once the client can tell the two apart.
Steps:
1. In the early sessions, ask for each polarity equally often.
2. Later, give more trials of the target polarity. For ADHD this is negativity, which the multicentre authors judged more important for the disorder. For epilepsy, the second phase changed the balance of tasks, linked to suppressing negativity [source: Strehl et al. 2017; Strehl et al. 2006; Strehl et al. 2011]. The published ratios are left out here, and the direction of the epilepsy ratio is not fully explicit in the source [uncertain].
3. Keep training both directions throughout [source: Strehl et al. 2017].
Watch for: losing the ability to tell the polarities apart once one dominates. If that happens, rebalance as your trainer advises [synthesis].
Example language (illustrative): "Now that you can move the ball both ways, we'll practise the 'switched-on' direction more often." [synthesis]

4.11 Training break with transfer cards and home practice

Purpose: to use the skill without the equipment, in real settings.
Steps:
1. Give the client a transfer or memo card: a picture of the training screen, with the ball and goal box. The Zurich version used red and blue cards for activating and deactivating [source: Strehl et al. 2006; Drechsler et al. 2007; Strehl et al. 2017].
2. Set daily home practice: look at the card, call up the strategy and hold it. Log the practice daily [source: Strehl et al. 2006]. The multicentre trial also gave a video of a sequence of positive and negative trials to practise with [source: Strehl et al. 2017].
3. Ask the client to carry the card into target situations such as homework or exams [source: Drechsler et al. 2007].
4. Keep in touch during the break by phone or email [source: Drechsler et al. 2007].
Example language (illustrative): "When you sit down to homework, put the card on the desk, picture the ball rising and switch on your strategy before you start."
Watch for: empty practice logs. See Section 5.

4.12 Supervised homework with cueing (final block)

Purpose: to link the skill directly to schoolwork.
Steps:
1. After the session, or as part of it in the final block, the child does real homework in the clinic and uses the card as a cue [source: Strehl et al. 2006; Strehl et al. 2017].
2. Guide only the use of the cue. Do not help with the homework itself [source: Strehl et al. 2006].
Example language (illustrative): "I'm not going to help with the sums. I'm only going to remind you to use your card when you get stuck."
Watch for: the session turning into tutoring. Keep the focus on cueing [source: Strehl et al. 2006].

4.13 Everyday generalisation planning

Purpose: to name the situations where the client will use the skill.
Steps:
1. ADHD: list the situations that demand attention, such as homework, tests, and listening in class. Plan when to use the card or the imagined screen in each [source: Drechsler et al. 2007; Strehl et al. 2006].
2. Epilepsy: identify situations in which seizures tend to occur, and use the self-regulation skill there to inhibit excessive excitation [source: Strehl et al. 2014; Strehl et al. 2011]. Use the seizure diary to find these situations [synthesis, based on Strehl et al. 2014].
3. Review in each session where the skill was tried, and with what result. Problem-solve any difficulties with transfer [source: Drechsler et al. 2007].
Example language (illustrative): "Looking at your diary, seizures cluster when you're exhausted in the evening. Let's plan to use your 'calm-down' strategy then."
Watch for: an epilepsy patient using the skill instead of taking medication or following the emergency plan. Correct this at once and tell the neurologist [synthesis].

4.14 Parent or carer involvement

Purpose: to support home practice and reinforcement.
Steps:
1. Invite parents to sessions and ask them to supervise card practice at home [source: Drechsler et al. 2007].
2. Ask them to remind the child, encourage use of the card, and give points [source: Drechsler et al. 2007].
3. Review home practice with the parent at each visit [synthesis].
4. Keep teachers informed, with consent, so the card can be used in class [synthesis].
Watch for: low parental support. In Zurich, effective parental support was related to improvement in parent-rated inattention, so address barriers early [source: Drechsler et al. 2007].
Example language (illustrative): "Could you remind them to use the card before homework and give a point each time? That helps the practice stick." [synthesis]

4.15 Monitoring learning and clinical progress

Purpose: to decide whether to continue, adjust or stop.
Steps:
1. After each session, review how well the client separated the polarities in feedback trials and in transfer trials [source: Strehl et al. 2017; Drechsler et al. 2007].
2. Classify the client as a learner or a non-learner using your system's criteria, as the trials did [source: Strehl et al. 2017].
3. Compare clinical ratings or seizure diaries against baseline at the end of each block [synthesis].
Watch for: regulation and outcome coming apart. In the multicentre trial, regulation performance did not correlate with clinical outcome. In Zurich, it did correlate among the good performers [source: Strehl et al. 2017; Drechsler et al. 2007].
Example language (illustrative): "Your scores at moving the ball are getting better. Let's also look at what the school ratings say." [synthesis]

4.16 Liaison with the prescriber or neurologist

Purpose: to make collaborative care safe.
Steps:
1. With consent, send a short letter at the start, after each block and at the end, covering attendance, regulation learning, outcome measures, seizure diary trends and adverse events [synthesis].
2. Report straight away any rise in seizures, a new seizure type, injury, possible non-epileptic attacks, side effects of medication the client mentions, low mood or suicidality, or safeguarding concerns [synthesis].
3. Medication questions: listen to ambivalence, explore it, and route it to the prescriber. Never advise a change [synthesis].
Example language (illustrative): "It sounds like you're wondering whether you still need the tablets if the training works. That's an important question for your neurologist. Shall we write it down for your next appointment?"
Watch for: letters that drift into medication advice, delays in passing on seizure changes, or consent that does not cover what you share. [synthesis]

4.17 Ending, booster option and relapse planning

Purpose: to consolidate the skill and plan how the client will keep using it.
Steps:
1. Do the post-training assessment. Plan the follow-up at about 6 months, or at 6 and 12 months for epilepsy [source: Strehl et al. 2006; Strehl et al. 2011].
2. The client keeps the card and a written plan of the target situations [source: Strehl et al. 2006; synthesis for the written plan].
3. The Tübingen studies gave no booster sessions [source: Strehl et al. 2006; Strehl et al. 2014]. Offering one or two refresher sessions if gains fade is your own option [synthesis].
4. Hand back to the referrer, with a summary [synthesis].
Watch for: fading home practice after the end. Agree a reminder routine with the family [synthesis].
Example language (illustrative): "Keep the card in your pencil case and use it before tests, just as we practised." [synthesis]

4.18 SCP brain-computer interfaces (history and pointer)

Purpose: for orientation only. This is not a psychotherapy intervention.
Description: in the Thought Translation Device, SCP shifts moved a cursor so that locked-in patients could spell [source: Birbaumer et al. 1999]. Training went in stages: first moving the ball to a target, then copy-spelling with a reduced alphabet, then free spelling. Each letter was chosen by repeatedly splitting the alphabet into two halves [source: Iversen et al. 2000].
Psychotherapist's role [synthesis]: support the patient's mood, coping and the family. Help with communication goals and consent, alongside the BCI and rehabilitation team.
Example language (illustrative): "The team will explain how the device works. I'm here to support you and your family through it." [synthesis]
Watch for: unrealistic hopes about communication devices; support the family alongside the BCI team. [synthesis]

4.19 Training and supervision of the trainer

Purpose: to deliver the training faithfully.
Steps:
1. Get formal neurofeedback training, such as the BCIA route in Section 1, plus specific instruction in the SCP protocol. The multicentre trainers did a 2-day course, followed a detailed manual, had regular meetings, and received supervision visits [source: Strehl et al. 2017].
2. Book regular case supervision with an experienced SCP practitioner. Present cases as BCIA's route requires [source: Wikipedia, BCIA] [uncertain: secondary].
Example language (illustrative): "I've trained in this specific protocol, and I have regular supervision on my cases." [synthesis]
Watch for: drifting from the manual or working beyond your training; take cases to supervision. [synthesis]

5. Handling problems

Most of the guidance below is [synthesis], drawn from general behavioural and neurofeedback practice. Items backed by a source are tagged as such.

The client cannot tell the two polarities apart (a "non-learner"). Expect this in a sizeable minority. In the multicentre trial, about a third of the neurofeedback group were not learners even with feedback [source: Strehl et al. 2017]. To respond:
- check for artefacts first;
- go back to strategy verbalisation (4.7) and offer new example strategies;
- make the rewards more immediate;
- shorten the runs.
If there is still no separation after the first block, review the plan with the family and the referrer, and consider other treatments. The Zurich data showed a specific effect only in the children who learned to regulate [source: Drechsler et al. 2007]. [synthesis for the responses]
The client is good with feedback but fails in transfer trials. Practise more transfer and imagery with the card, and ask the client to describe exactly what they do in the feedback trials so they can do the same without the display [synthesis; transfer gap documented in Strehl et al. 2017].
Boredom, low motivation, refusing a session (children). Courses run to 25–35 sessions, which is a lot for a child. To respond:
- use the token economy and small, frequent rewards [source: Strehl et al. 2006];
- vary the screen animation if your system allows;
- schedule sessions at a time that suits the child;
- take breaks between runs;
- check that the child still agrees each time and respect a "no".
If assent is persistently withdrawn, stop the training [synthesis].
No home practice during the break. Make the logging simpler, agree a fixed daily slot, get parents to supervise and award points, and phone in the middle of the break [source: Drechsler et al. 2007 for parent points and phone contact; synthesis for the rest].
Parents or family under strain. Parental support predicted gains [source: Drechsler et al. 2007]. To respond:
- assess what is getting in the way;
- offer short parent-support sessions;
- consider referring for behavioural parent training alongside or instead [synthesis].
Overwhelm, frustration or crying in a session. Pause and normalise the difficulty. Switch to a run the client is confident in, or one with balanced polarity, and end on a success. Review the length of the session [synthesis].
Rupture or mistrust of the trainer. Repair it openly, explain again why you watch from another room if you work that way, and invite the child's feedback. The Zurich team treated the therapeutic relationship as fundamental [source: Drechsler et al. 2007; synthesis for the repair steps].
Medication changes during training. If the prescriber changes a medicine, note it, because it makes outcome hard to interpret. Never suggest a change yourself. In the trials, the family was asked to keep medicines constant, and children were excluded from follow-up analysis if they started medication [source: Strehl et al. 2006; synthesis].
A client or parent wants to stop antiseizure or ADHD medicines because of the training. Explore their reasons and give the facts: the epilepsy studies kept medication unchanged and present SCP as an adjunct [source: Strehl et al. 2014]. Refer the question to the prescriber or neurologist straight away [synthesis].
A seizure in the session (epilepsy). Follow the first-aid and emergency plan agreed with the neurologist. Stop the session, record what happened, and inform the neurologist. Only restart training once you have their agreement [synthesis].
Seizures increase, or a new seizure type appears. Pause training, contact the neurologist, and review the diary [synthesis].
Possible psychogenic non-epileptic seizures. These were excluded from the published protocol [source: Strehl et al. 2014]. Refer back for diagnostic review. Psychological treatment of PNES is a separate pathway [synthesis].
Headache, skin irritation or tiredness. Check the electrode preparation and the session length, and record the event as an adverse event. Treatment-related adverse events were similar in the neurofeedback and EMG groups (6% and 7%) [source: Strehl et al. 2017; synthesis for the steps].
ADHD symptoms worsen. Contact the referrer and reassess. In the multicentre trial, one child in the EMG control group was withdrawn after symptoms got worse [source: Strehl et al. 2017; synthesis].
Unrealistic expectations, or marketing claims. Share the evidence as the authors themselves state it, including the gap between parent and teacher ratings and the role of nonspecific factors [source: Strehl et al. 2017; Drechsler et al. 2007]. Do not promise a cure [synthesis].
Request for at-home or consumer "SCP" devices. Say that the published protocol is clinic-based and supervised. Home use of medical EEG equipment without training risks poor signals and practice that is never checked [synthesis].
Gains fade after the course ends. Revisit the cards and the plan of target situations. Consider a few refresher sessions [synthesis]. The published studies gave no boosters, yet reported effects persisting at 6 months and, in epilepsy, at about 10 years [source: Strehl et al. 2006; Strehl et al. 2014].
Safeguarding concern or disclosure. Follow local child-protection procedures and inform the designated lead. Keep a record, and do not investigate yourself [synthesis].
Low mood, anxiety or suicidality. Assess risk using current standard practice. Make a safety plan and inform the GP or prescriber. Treat comorbid problems directly, or refer for treatment [synthesis].

Sources

Online sources:

Not verified, so verify before relying on them [uncertain]:

BCIA's own certification pages (bcia.org)
the full text of Arns et al. 2020
NICE NG87 and NICE epilepsy guidance on neurofeedback
device regulatory status
the published SCP treatment manuals

← Previous · IX-048Theta-beta training (Lubar)Next · IX-050 →QEEG-guided, z-score and LORETA neurofeedback