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Attention
Deficit Hyperactivity Disorder: A look
at Non-Pharmacological Approaches, especially
EXERCISE
Written
by: Amy
Driebe, University
of Florida
Introduction:
Attention Deficit Hyperactivity Disorder
(ADHD) is estimated to occur in 3-5%
of school age children and is characterized
by cognitive and behavioral deficits
such as inattentiveness, hyperactivity,
and impulsivity
(5). Children with ADHD have
significantly impaired social, academic,
and/or occupational functioning, and
they have a high rate of disciplinary
problems, comprising 30-40% of referrals
to child guidance clinics (8).
Although ADHD features can widely vary,
some include a low frustration tolerance,
temper outbursts, mood fluctuations,
and poor self-esteem (2).
Unfortunately, many stigmas exist concerning
this disorder, and children with ADHD
are commonly viewed as lazy trouble-makers,
a misconception that can easily exacerbate
the mood and anxiety symptoms of the
disorder. Clearly, ADHD is a serious
disorder, one with symptoms that persist
into adulthood for 30-70% of diagnosed
children (2).
Given the significant implications
of ADHD and the many levels of functioning
that it affects, there is a considerable
need for an effective treatment. Although
the neuroanatomical structures and neurophysiological
mechanisms that explain ADHD are not
fully known, current research suggests
that the brain dopaminergic
systems are involved. The dopaminergic
dysfunction hypothesis is derived from
the fact that dopamine
agonists, such as methylphenidate
and amphetamine,
are often effective in treating the
symptoms of ADHD (2).
The assumed role of central nervous
system neurotransmitter depletion in
ADHD hyperactivity is supported by research
conducted in the 1970s by Shaywitz,
Yager, and Klopper, who found that hyperactivity
can be induced in rats by injecting
a dopamine depleting drug into their
brains (2).
Other support for the biological basis
of ADHD includes positron emission tomography
studies that indicate abnormal dopamine
levels in adolescents and adults diagnosed
with ADHD (2).
Given the considerable evidence for
a neurobiological dysfunction as the
cause of ADHD, pharmacologic treatments
aimed at dopaminergic systems are the
primary treatment for the disorder.
Non-Pharmacological Approach
The most commonly prescribed drug
for ADHD, methylphenidate,
is only moderately effective, with 20%
of children displaying serious side
effects, such as high blood pressure,
sleep problems, motor tics, headaches,
social withdrawal, and/or mood disturbances
(8). Therefore,
there is a crucial need for investigating
the efficacy of non-pharmacological
treatments. The current estimates of
the use of complementary and alternative
medicine (CAM) in all pediatric populations
are 2% for younger children and 68%
for older adolescents, but there is
an interest in alternative therapies
and 53% of parents wish to discuss CAM
with their pediatricians
(3). Children with attention
disorders, such as ADHD and autism,
frequently use CAM, often to supplement
more conventional medicine.
For example, electroencephalogram
(EEG) biofeedback is a non-pharmacological
technique that can be used as a treatment
for ADHD. EEG biofeedback is a painless,
non-invasive treatment that records
the brain’s natural electrical
activity during task performance
(10). Certain illnesses, such
as ADHD, are associated with distinctive
brain-wave patterns; with the help of
EEG biofeedback, patients can eventually
learn to maintain desirable brainwave
states when completing school or work
tasks. In one study on children receiving
Ritalin for ADHD, only those who also
received EEG biofeedback were able to
maintain the positive improvements of
the drug even after they stopped receiving
medication (3).
Despite the proven positive effects
of this treatment some families simply
will not have access to a therapist
trained in EEG biofeedback, and more
readily accessible and easily learned
forms of treatment exist.
Massage therapy is another popular
treatment for a wide variety of chronic
medical conditions, including ADHD.
Past studies have shown that massage
therapy decreases fidgeting and increases
serotonin levels (which may help modulate
elevated dopamine levels) in adolescents
with ADHD (6).
Children who receive massage therapy
find the experience enjoyable, and show
improved symptomatology including better
anger control, mood, sleep patterns,
social functioning, and academic performance
(6). However,
not only the children benefit. Parents
can be taught to administer the massage
therapy to their children, which can
promote parent-child bonding and allow
the parent a more pro-active role in
alleviating the symptoms of their child’s
disorder. One study reported that parents
given this rare chance to bond with
their child in a non-authoritative,
care giving manner felt both a renewed
closeness to their child and an alleviation
of frustration and guilt.
Importance of Exercise
Another alternative therapy for ADHD,
one that has received a great deal of
attention and has proven highly effective,
is exercise therapy. Exercise is associated
with a wide range of health and functional
benefits, but statistics show that 39%
of boys and 58% of girls ages seven
to eighteen years do not engage in the
recommended levels of exercise (3).
However, studies show that school-aged
children who exercise have improved
academic performance, cognitive abilities,
self-esteem, and classroom behavior,
as well as gains on alertness, memory,
problem solving, and rate and accuracy
of decision making (7).
Although the level of benefit can vary
somewhat for each individual, the consensus
reached by the U.S. Department of Health
and Human Services is that regular moderate
to vigorous physical activity (MVPA)
can help an individual maintain a variety
of cognitive abilities, including alertness
and concentration (7).
When considering the cognitive and functional
benefits of exercise for the general
population, it is no wonder that exercise
is such a popular and effective treatment
for attention disorders, like ADHD.
One form of exercise that has documented
health benefits for children and adolescents
with ADHD is the Chinese martial art
Tai
Chi. Hernandex-Reif et al. conducted
a study in which thirteen adolescent
males with a DSM-IV diagnosis of ADHD
learned Tai Chi postures for five weeks.
The beginning of the thirty minute session
began with slow raising and lowering
of the arms while engaging in breathing
exercises. The children then practiced
slow turning and twisting movements
of the arms and legs, shifting weight
from one leg to the other, rotating
from side to side, and changing directions
during a sequence of Tai Chi forms.
The researchers found that this exposure
to Tai Chi improved anxiety, mood, hyperactivity,
and conduct, and the benefits persisted
in the two-week follow-up period with
no Tai Chi (4).
Yoga
is similar to Tai Chi in that it focuses
on physical postures and deep breathing,
and both forms of exercise are recommended
for children and adolescents with ADHD.
While certain forms of exercise are
proven to be especially effective in
alleviating the physical symptoms of
ADHD, research shows that sport participation
in general reduces anxiety in children
with ADHD. For example, Kiluk, Weden,
and Culotta found that children who
play three or more sports display fewer
symptoms of anxiety and depression than
those who play fewer than three sports
(2). These
findings are especially promising because
children and adolescents with ADHD are
at high risk for emotional difficulties,
and they often experience anxiety and
depression. Physical exercise can increase
the self-esteem of these children as
they learn to constructively interact
with peers and gain a mastery of the
sport. A child or adolescent who engages
in sports has a positive distraction
from life’s stressful events,
which will elevate his sense of well-being.
When the social and emotional facets
of the child are addressed, the child
has a far greater chance of maximizing
his or her cognitive and functional
potential.
Additionally, some studies show, including
one by a group of researchers at Nova
Southeastern University, that physical
exercise can promote calmness in children
with ADHD. The study was based on the
fact that age-appropriate reinforcers
have been found to be effective promoters
of attentiveness and calmness in children
with ADHD; according to the Premack
Principle however, the reinforcer
must be a high-frequency behavior to
have any effect on the emergence of
low-frequency behavior (1).
The researchers wanted to know if scheduled
vigorous exercise in conjunction with
descriptive praise could serve as a
reinforcer for calmness, and they made
sure to provide control measures for
the effects of descriptive praise and
non-contingent exercise alone on calmness.
The study was conducted with a four-year-old
boy diagnosed with ADHD comorbid with
autism, who was often described as “disruptive”
and “fidgety” by his teachers
(1).
The researchers found that the child
was the most attentive, characterized
by sitting still without gross movement
of the arms, legs, and body, for the
longest period of time when the child
received play time and descriptive praise
as a reward for paying attention (1).
Alone, neither descriptive praise nor
non-contingent exercise was as effective
as the baseline treatment with no intervention
(1). These findings have considerable
implications for teachers and parents,
who often expect praise alone or exercise
alone to motivate students with ADHD
to focus and control their excess energy.
However, allowing the child to work
toward a tangible goal, such as play
time, with the encouragement of teachers
and parents seems to be the most effective
strategy in lessening the symptoms of
ADHD.
Location of Exercise
One of the most puzzling facets of
ADHD is the fact that although the functional
and cognitive deficits associated with
the disorder are chronic and typically
severe, they are not always consistent.
Generally, children with ADHD perform
worse than same-age peers on tasks involving
attention, but they can also perform
at the same level or substantially better
(9). Therefore,
the problem lies not in the child’s
initial ability, but in his ability
to maintain a certain level of performance
over time. In fact, these symptomatic
fluctuations are so unusual that many
physicians believe ADHD is better described
as an “attention inconsistency”
rather than an attention deficit (9).
Unfortunately, little evidence exists
explaining the cause of short-term fluctuations
in ADHD symptoms, but research does
exist that explains when and why the
deficits abate.
Research concerning treatment for the
fluctuations in ADHD symptoms began
with an analysis of an environmental
psychology theory called Attention
Restoration Theory (ART). This theory
was developed by William James to explain
why individuals in the general population
report a sense of rejuvenation after
exposure to natural environments, and
there are three tenets of ART that are
especially applicable to the study of
ADHD (9).
The first facet of the theory is that
attention draws on both “deliberately
directed, effortful forms of attention”
and “involuntary, effortless forms
of attention” (9).
The idea of two mechanisms controlling
attention explains why children with
ADHD have no problems using involuntary
attention and focusing on tasks that
they find interesting, but cannot as
easily use effortful attention to focus
on tasks they find less interesting.
Second, James proposed that deliberately
directed attention is subject to fatigue,
and with overuse, this form of attention
becomes increasingly difficult to use
(9). Fortunately,
this form of attention can be recovered
with rest and gently absorbing activities
that focus on involuntary attention
(9). This
explanation supports the fact that children’s
ADHD symptoms worsen throughout the
day. Finally, ART posits that certain
environments have different implications
for attention: fatiguing environments
draw on deliberate attention, whereas
gently absorbing environments draw on
involuntary attention (9).
Therefore, children with ADHD should
be exposed to gently absorbing environments,
like natural settings, to draw on their
involuntary attention and restore their
voluntary attention. In fact, a recent
study found that children’s ability
to concentrate vastly improved when
they exercised (in this case by walking)
in an urban park versus a downtown or
residential area (9).
The two less natural settings showed
no significant difference in concentration,
but concentration in the park setting
was significantly better than in the
other two (9).
In fact the positive effects of a walk
in the natural setting were so considerable
that they were roughly as large as both
the deficit due to ADHD and the peak
effect of extended-release methylphenidate
(9). These
results suggest that children with ADHD
will benefit from doing a wide range
of activities outside, such as reading,
playing games, and participating in
sports. Unlike other treatments, spending
time outdoors has no negative side effects,
unusual risks, or social stigmas, and
spending time outdoors is generally
free and quite enjoyable. This research
is also particularly applicable to schools
that might include more natural elements
in schoolyards and classrooms and include
more windows with views of natural settings.
These changes are not only beneficial
for children with ADHD, and a study
of forty schools and more than four
hundred students found that environmentally
based curricula were linked to multiple
benefits, including increased engagement
and enthusiasm for learning and higher
scores on standardized tests (9).
Conclusion
Those with ADHD, especially children
and adolescents, must make sure to get
the recommended amount of sleep and
to eat a well-balanced diet. Children
need at least ten hours of sleep per
night, adolescents need at least nine
hours, and adults need at least seven
(7). The
effects of sleep deprivation go beyond
fatigue, loss of vigor, and mental confusion
(7). Sleep
deprivation also affects important aspects
of cognition, such as attention, concentration,
and memory functions (7).
These side-effects are especially costly
for those with ADHD, who have some level
of impaired cognitive function even
when they get the recommended amounts
of sleep.
Furthermore, those with ADHD need to
get the required amounts of protein
at breakfast and lunch: children ages
four to ten need at least ten grams,
children ages eleven to fourteen need
20 grams, males ages fifteen to eighteen
need 25 grams, females fifteen and older
need 20 grams, and males nineteen and
older need 25 grams (7).
Those who do not consume the required
amount of protein show a range of adverse
effects, including diminished immediate
recall, recognition memory, spatial
memory, and visual and auditory short-term
memory (7).
ADHD is certainly not caused by sleep,
dietary, or exercise habits, but these
factors do constitute the foundation
for attention and behavioral control.
Although ADHD is a serious disorder
associated with intense cognitive and
functional impairments, children, adolescents,
and adults with ADHD do not have to
be limited by the disorder. A correct
combination of traditional and alternative
therapies, as well as the proper school
and/or work environment, can allow those
with ADHD to function at their maximum
potential. A wide variety of alternative
therapies, including electroencephalogram
(EEG) biofeedback and massage therapy,
have been proven to be effective in
improving the symptoms of ADHD, but
exercise therapy is both a highly successful
and readily available form of treatment.
Exercise that focuses on physical postures
and deep breathing, like Tai Chi or
Yoga, improves the physical symptoms
of ADHD, and sport participation in
general enhances psychological wellness.
Natural settings are the most suitable
locations for exercise because gently
absorbing environments improve effortful
attention, a form of attention that
those with ADHD cannot use as easily.
Given the fact that pharmacological
approaches for ADHD are only moderately
effective, alternative therapies merit
further research.
Works
Cited
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