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Mind/Body Approaches to Managing ADHD
Richard G. Petty, MD
Dr. Petty is Scientific Director, Promedica Research Center, Loganville, GA; Adjunct Professor, Georgia State University, Atlanta, GA. Dr. Petty is a consultant for AstraZeneca Pharmaceuticals and Janssen Pharmaceuticals, and serves on the speaker's bureau for AstraZeneca Pharmaceuticals, Janssen Pharmaceuticals, Abbott Pharmaceuticals, and Avanir Pharmaceuticals.
Apart from dietary interventions, mind/body approaches are one of the most popular groups of non-pharmacological approaches for the treatment of attention-deficit/hyperactivity disorder (ADHD). Many types have been tried, and practitioners need to be aware of the evidence concerning the many programs that are offered to parents of children with ADHD and to adults with the disorder. We are going to focus on four methods that have garnered the most research: biofeedback, meditation, yoga, and t'ai chi ch'uan.
The use of each of these has been given extra impetus by recent findings that meditation may produce sustained improvement in attention, together with structural and functional alterations in regions of the brain that are involved in attentional mechanisms.1-3
It may seem surprising that hyperkinetic children and adults with attentional problems should be able to slow down and focus enough to try yoga, meditation, or biofeedback. Yet there is good evidence that they can and they do, and that all three modalities can be helpful.
This is a patient-guided method that teaches an individual to control muscle tension, body temperature, electroencephalographic (EEG) activity, and other processes through relaxation, visualization, and other forms of cognitive control. Biofeedback that is aimed at developing skills to help people self-regulate the activity of their brains is usually referred to as neurofeedback. Clinicians may also see it referred to as "EEG biofeedback, "neurotherapy," and "neurobiofeedback." This technique involves recording a relatively simple form of continuous EEG in real time using scalp electrodes. Subjects are given immediate feedback and positive reinforcement, usually using a visual display.
In "frequency" training, people are asked to increase or decrease the activity of different EEG frequency bands. A second system of training is aimed to help people to regulate their level of cortical excitability. They are trained to generate and regulate slow cortical potentials (SCPs), which are slow event-related direct-current shifts of the EEG.
Most children and adults can learn the basic techniques within one or two sessions, although effective treatment usually requires twenty or more sessions. Many young people with ADHD look at it like a game and, therefore, quickly become engaged with it.
Studies of neurofeedback have shown some specific effects on attention and memory processes,4 and the effect size compares favorably to that seen with stimulant medications.5 The key point is that the improvements in performance are maintained once the person is engaged in real-life activities. The techniques can be used to help healthy people perform better, as well as helping people with problems.
Several studies have shown that children with ADHD had improvements in behavioral and cognitive variables after both frequency (e.g., theta/beta), training,6 and SCP training.7,8 Some of these improvements were sustained for as long as six months. It has also been possible to show improvements in some neurophysiological measurements. One confounding factor in the studies has been that most children were either kept on medications or were given other types of exercises, to reinforce what they were learning.
Results from well designed research utilizing brain imaging9,10 shows that neurofeedback in children with ADHD normalizes the functioning of the anterior cingulate cortex, a key neural circuit involved in selective attention.
Some experts remain unconvinced11 about the data concerning neurofeedback, but support the call for further research in the field.
There is also another type of feedback training. There is evidence that the level of activity in a classroom containing hyperactive boys can be reduced using feedback about the level of activity together with positive reinforcement. Some recent research12 has produced preliminary data in which investigators used a device that combines a beeper and actigraphy technology for measuring, monitoring, and modifying motor excess in children. The feedback reduced the activity level of seven out of nine hyperactive boys.
There remain some unanswered questions about biofeedback in the treatment of ADHD. John Gruzelier and Tobias Egner from London have recently pointed out that use of neurofeedback has grown and been widely adopted with little supportive research.13 However, their own work has shown that the technique can help improve cognition, and they provided the first evidence of conscious control over the ratio of alpha and theta waves in the brain.14
The evidence supporting use of biofeedback is growing, and since it is non-invasive and may be associated with other improvements in mood and cognition, it will likely be an important option for some people with ADHD. Unfortunately, there are many commercially available bio- and neuro-feedback machines for which there is little evidence of efficacy.
There are hundreds of different types of yoga, but the one that has been examined the most is hatha yoga. Many experts and yoga teachers consistently report that they have students with ADHD who have improved markedly when they follow a regular yoga regimen; however, the research base remains thin. Some studies have been published in India, and there have also been small studies that included children with ADHD. The first specific ADHD study was a small (N=19) six-week open trial of twice weekly hatha yoga lessons for both parents of, and children with, ADHD. The participants were also encouraged to practice at home. At the end of the six weeks, there were subjective improvements in behavior, and in those who practiced at home, there was an improvement in emotional lability.15
Another pilot study, this one from Heidelberg in Germany, suggested that yoga can be an effective complementary or concomitant treatment for ADHD.16 That was also the conclusion from a recent review article:17 yoga, like most of the other complementary methods of treatment, may be a good adjunct, but we do not have enough evidence to use it in place of existing treatments.
Eugene Arnold's review18 of unorthodox treatments for ADHD cites two studies from the 1980s that showed significant improvements in the behavior of children who were taught to practice meditation. (Kratter J. The use of meditation in the treatment of attention deficit disorder with hyperactivity. Dissertation Abstracts International. 1983;44:1965 and Moretti-Altuna G. The effects of meditation versus medication in the treatment of attention deficit disorder with hyperactivity. Dissertation Abstracts International. 1987;47:4658.) Neither of the reports is easily available, and the studies were not published in peer-reviewed journals. A small six-week pilot study using Sahaja Yoga meditation for children with ADHD and their families reported a small but useful benefit.19
As mentioned in the introduction, there are some good theoretical reasons for thinking that meditation should help attention, and this continues to be a fertile area for further research.
T'ai Chi Ch'uan
There are a large number of anecdotal reports of people with ADHD improving if they practice t'ai chi or qigong. However, the research base is quite small.
First, there is an interesting and well-designed study involving 13 adolescents with an average age of 14.5 years.20 They were taught basic t'ai chi moves for 30 minutes twice a week for five weeks. The sessions consisted of breathing exercises, accompanied by slow raising and lowering of the arms, twisting and turning of the arms and legs, shifting body weight, and rotating and changing direction.
The researchers used the 28-item Connors' Teacher Rating Scale to evaluate the students' behavior prior to the t'ai chi classes, during the classes, and two weeks after the classes ended. The adolescents' teachers perceived them as less anxious, emotional, and hyperactive. These improved scores remained consistent throughout the two-week follow-up period.
The anecdotal reports and empirical research into the benefits of t'ai chi ch'uan and qigong with respect to attention, concentration, depression, and anxiety21 imply that they would be good candidates for further research in ADHD.
Recent research has indicated that attention can be trained, but the evidence for attentional training in ADHD is, so far, only suggestive.
There is growing evidence that neurofeedback may be helpful for children with ADHD.
There are many commercially available neurofeedback machines, but most have little data to support them, relying instead on statement about neurofeedback in general. Thus, practitioners should insist on seeing data obtained with a specific model.
Yoga, meditation, and t'ai chi ch'uan may all help children, and also perhaps adults with ADHD, though the research base is small, and at the moment, each should be considered an adjunctive treatment.
There are no recognized adverse effects associated with any of the mind/body therapies that we have discussed, apart from the potential problems of eschewing established treatments in favor of ones with less scientific validity.
[Editor's Note: Dr. Petty is the author of Healing, Meaning and Purpose, and has lectured to more than a quarter of a million people in 45 countries. His newsletter, reports, blogs, and podcasts on health, personal growth, and integration are available at www.richardgpettymd.com or call (770) 554-8812.]
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