By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.
Attention Deficit Hyperactivity Disorder (ADHD), as outlined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), is a relatively newly defined mental health condition that has achieved wide notoriety in modern society. However, excessive hyperactive, inattentive and impulsive children have been described in the medical literature for the last 200 years. While the clinical nomenclature has changed over time, many of the historical descriptions are consistent with the modern diagnostic criteria for ADHD. The three clusters of ADHD symptoms are inattention (easily distracted, wandering off task, difficulty sustaining focus, disorganized), hyperactivity (restlessness, moving constantly when it is not appropriate, excessive fidgeting, tapping or talking), and impulsivity (hasty actions without forethought that may have high potential for harm or negative consequences, desire for immediate rewards or gratification, socially intrusive behavior). Given the similarity between these symptoms, and those resulting from the chronic sleep deprivation that is universally common in children, adolescents, and adults, it is important that a careful diagnosis be made by qualified clinicians. ADHD affects children and teens and can continue into adulthood. In fact, ADHD is one of the most prevalent psychiatric disorders of childhood with an estimated prevalence of 5%.
This condition may have a negative impact on a child’s lifestyle by negatively affecting academic achievement, social relationships, and quality of life. Other common associated clinical features include disturbed sleep, which may impact cognitive functioning, and obesity, which seems especially prevalent in children with ADHD. In addition, individuals are at a high risk for comorbid disorders from the presence of depression in approximately 30% of patients and anxiety in more than 25% of patients. The presence of these exacerbating and comorbid risk factors warrants special treatment considerations. While conventional psychotherapy may address the comorbid risk factors, it usually does not provide training in self-regulation which may help children with ADHD to choose and adopt socially appropriate behaviors. In addition, current pharmacotherapy treatments including stimulants, while relatively effective in the short term, may carry serious side effects such as low appetite, cardiovascular irregularities, suicidal thoughts, and sleep disturbance. For these reasons, the safety and effectiveness of behavioral, complementary, and integrative therapies need to be further evaluated.
Yoga may prove to be one of those therapeutic approaches since the ability to calm the incessant fluctuations of the mind is a fundamental component of yogic philosophy and practice. In fact, advanced practitioners report less mind wandering and distractibility. This suggests that more traditional forms of yoga, which include meditation, could be useful to promote the control of attention. Indeed, mindfulness meditation can improve neuropsychological deficits present in ADHD patients such as attention control, emotion regulation, and executive functioning by strengthening the brain regions believed relevant to these deficits. A further benefit of mindfulness meditation in ADHD is that patients learn to observe and become aware of emotional states as temporary passing events, thereby enhancing emotional regulation, which helps to prevent impulsive reactions to emotions. Recent studies indicate that mindfulness meditation training has ameliorating effects on ADHD symptoms, which makes traditional forms of yoga, which include meditation, a viable alternative to conventional psychopharmacological treatments. In addition, yoga incorporates the benefits of physical exercise, which has shown moderate to large positive effects on inattention, hyperactivity, impulsivity, anxiety, executive function, and social disorders in children with ADHD.
There are fewer than a dozen research studies of yoga on ADHD patients, although this number is likely to increase with the growing prevalence of yoga and meditation in the treatment of neuropsychiatric disorders. Most of the studies do not have a control group and contain a high risk of bias due to design limitations. The general findings, without being conclusive, do suggest that yoga could improve several of the risk factors associated with ADHD. For example, a 2004 randomized controlled trial (RCT) assessed 19 boys who were stabilized on medication and then randomly assigned to a yoga or a control group where they carried out cooperative activities. The yoga group received postural training which included stretching and load bearing in combination with rhythmical respiratory exercises. The yoga group also received relaxation training where participants progressively relaxed different body parts. Finally, a concentration technique called Trataka was imparted where participants focused on a word or shape followed by seeing the image with eyes closed while staying concentrated. The results showed several significant improvements in the yoga group but not in the control group on five subscales of the Conners’ Parents Rating Scales (CPRS), a standardized ADHD questionnaire, which measures opposition, emotional liability, restlessness, and the ADHD index. Although the small sample size and limited data set did not provide strong support for the use of yoga for ADHD, the findings did suggest that yoga may have merit as a complementary treatment for boys already stabilized on medication.
Another much more recent study was conducted by the prestigious National Institute of Mental Health and Neurosciences in Bengaluru, India in 2013 and evaluated 9 children diagnosed with ADHD. After 8 yoga sessions, researchers noted a significant improvement in the ADHD symptoms as assessed via several tools including the ADHD rating scale and disease severity. However, non-adherence among children to the yoga practice post-discharge from the child psychiatry unit in this study highlights one of the limitations of long-term yoga therapy for children. Despite the small sample size and lack of a control group, this study showed that children can learn yoga and that in-patients with ADHD do receive benefits from a yoga practice. A separate Indian study of a peer-mediated multimodal behavioral program, conducted in a poor urban setting in India showed similar improvements in students with ADHD. Local high school student volunteers facilitated the implementation of the Climb-Up program consisting of yoga, meditation and play therapy for 69 younger students aged 6 to 11, which resulted in remarkable improvements in the students’ school performances that were sustained throughout the year. By using local volunteers who also acted as mentors for the younger children, the study demonstrated that yoga could be a cost-effective solution that can be easily implemented in schools.
In summary, the published single-arm studies and pilot RCTs are statistically underpowered but provide preliminary support for the use of yoga with meditation in the treatment of individuals with ADHD. However, given the fact that this is a new field of clinical investigation, findings need to be replicated on larger groups and contain follow-up data to evaluate the long-term outcomes of yoga for ADHD. Ongoing research at the University of California, Davis is in fact using a RCT design for a 6-week yoga intervention in pre-school age children with, or ‘at risk’ for, ADHD. Investigators will examine behavioral symptoms, attention control and heart rate variability (HRV), which is an indicator of self-regulatory capacity. Another new study, at New York University, is focusing on children with increased levels of emotion dysregulation and inattention at the Girls Preparatory Charter School of the Bronx. Researchers are looking at the capacity of Little Flower Yoga for Kids, a yoga and mindfulness program for children to improve a child’s ability to sustain attention and regulate emotion. It is likely that new publications will appear regularly from recently completed clinical trials in this growing field of research.
By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.