Although pharmaceutical intervention for ADHD is helpful to many children, some do not benefit, others continue to be impaired despite deriving important treatment benefits, and others experience side effects that preclude long-term medication treatment.  Behavioral therapy has also been shown to be an effective ADHD treatment; as with pharmaceutical intervention, however, many children continue to experience impairment from ADHD symptoms despite receiving this intervention.  Although the combination of medication and behavior therapy may be more potent than either intervention used alone (see http://www.helpforadd.com/2003/    ) even multimodal treatment does not result in normalization of ADHD symptoms for a substantial proportion of children.

For these reasons, it remains important to develop and document the effectiveness on interventions for ADHD that can complement medication and behavioral approaches.  For example, in prior issues of Attention Research Update I have reviewed studies of neurofeedback and the Interactive Metronome, both of which have yielded some promising results.  In this issue, I will review a study in which Yoga was examined as a potential complementary ADHD treatment.  This study was published in the May 2004 issue of the Journal of Attention Disorders (Jensen, P., & Kenny, D.T. “The effects of yoga on the attention and behavior of boys with ADHD, 7, 205-216).

As described by the authors, “yoga is a systematic body of knowledge concerned with the physiological and mental processes that change the physiology of the body through respiratory manipulation (breathing techniques), postures, and cognitive control (relaxation and meditation).  The effects of yoga on brain functioning have been demonstrated with both PET scans EEG techniques; there is also evidence that yoga may influence aspects of neurotransmitter activity.  These changes, argue the authors, suggest that yoga would be potentially useful in the management of ADHD symptoms.

To examine this possibility, 14 8-13 year old boys who had been diagnosed with ADHD were recruited to participate in a 20-session yoga program.  In addition to the supervised sessions, boys were instructed to complete daily practice sessions at home.  Nearly all boys were receiving medication treatment when the study began, and continued to do so throughout the yoga program.  As discussed above, the authors conceptualized yoga as a complementary ADHD intervention rather than an alternative to traditional approaches; for this reason, they did not seek to recruit non-medicated participants or to have children discontinue their medication during the study. 

The participants represent a relatively small percentage of the 80 children who were originally recruited for the study; for the remaining boys, parents either failed to respond or declined to let their child take part.  As a result, the sample size is quite small and is not representative of the population of children with ADHD.  For these reasons, it is appropriate to regard this as a preliminary investigation of yoga as a complementary ADHD intervention.

Half the boys were randomly assigned to receive the yoga program; the other 7 participated in a supervised group that involved playing cooperative games and practicing turn-taking and listening skills.  The cooperative group lasted for the same 20 weeks as the yoga program. This was done to control for the possibility that any supervised group activity - and not specifically yoga - might lead to a reduction in ADHD symptoms.  Boys assigned to the control condition were given the opportunity to take the yoga program after the first 20-session program ended.

Prior to beginning the yoga sessions, baseline data was collected by having parents and teachers complete the Conners Rating Scale, a standardized behavior rating scale in which children’s are rated in a variety of areas.  The areas include: oppositional behavior, cognitive problems, anxiety, social problems, and ADHD symptoms.  These scales were completed again after the yoga program ended so that changes that may have resulted from the yoga program could be assessed.


RESULTS

Attendance at the yoga classes ranged from 5 to 19 sessions; the average number of classes attended was 13 out of the scheduled 20.  The number of practice sessions completed ranged from 14 to 116, with an average of 54.

Comparison of parent ratings before and after the yoga program indicated that boys made significant improvements on a number of the Conners scales.  The scales where improvements were found included oppositional behavior, emotional lability (i.e., emotional reactivity), perfectionism, hyperactivity/impulsivity, and total DSM-IV ADHD symptoms.  Thus, the yoga program was associated with a number of positive changes based on parents' reports.  The situation was very different with teachers, however, where no significant improvements were evident.

Although results from the parent ratings appear quite promising, it was the case that parents of boys in the control condition - those who engaged in cooperative activities alone - also reported that significant improvements had occurred.  Based on pre vs. post ratings from these parents, improvements were evident for anxiety, social problems, perfectionism, hyperactivity-impulsivity, and total DSM-IV ADHD symptoms.  As with boys who participated in the yoga training, no improvements were evident on the teacher ratings.


SUMMARY AND IMPLICATIONS

Although the authors of this study are to be commended for making a serious effort to study yoga as a complementary intervention for ADHD, results from this initial study are  inconclusive.  There are several reasons that this is the case.

First, the number of participants was very small, and represented only a small percentage of the boys originally recruited for the study.  Even when significant results are obtained, findings that are based on a small and non-representative sample should be considered preliminary and require replication with a larger group of participants.

Second, although boys in the yoga intervention improved in a range of areas according to parents' report, so did boys in the cooperative activity group.  Although the 2 groups were not compared directly, there was little indication that yoga was any more helpful than a supervised, cooperative group activity that was not expected to provide the same type of therapeutic benefits.  The possibility that children’s symptoms diminished naturally over time, or that the findings represent a placebo effect, cannot be ruled out.

Third, although parents' reports were indicative of improvement, there was no evidence of significant change according to teachers' reports.  The authors suggest this may have been the case because boys were receiving medication during the school day, so their ADHD symptoms would have been less noticeable at school to begin with.  As a result, teachers would be less likely to notice any improvement.  This is certainly possible, but the study provides no indication that yoga training can enhance the functioning of children with ADHD at school.  Whether change at school would have been evident if children were not being treated with medication remains unknown.

The authors conclude by noting that this study would need to be replicated with a considerably larger sample that yielded more definitive results before yoga could be recommended as a reliable complementary intervention for ADHD.  Because inexpensive and non-intrusive ADHD treatments are sorely needed, the authors should be commended for their effort to investigate a potential complementary ADHD intervention.  It is unfortunate that more research on alternative and complementary treatments for ADHD is not appearing in the literature, and I will do my best to provide you with summaries of such studies as I am able to locate them.

In this same issue of the Journal of Attention Disorders, there was a brief report on trends in the use of multiple medications for treating children with ADHD that I wanted to share with you (Bhatra, et al., 2004. National trends in concomitant psychotropic medication with stimulants in pediatric visits: Practice vs. knowledge, 7, 217-226).

Although it is well known that the use of stimulant medications for treating ADHD has increased substantially during the past decade, the increasing number of children who are treated with other medications in addition to stimulants has been less widely reported.

Data available for this study came from the National Ambulatory Medical Care Survey (NAMCS), a large national survey designed to select a nationally representative group of physicians in office-based practices.  The data on which the report is based covers the period 1993-1998.

During this period, the authors report that during visits in which stimulant medication was prescribed, the percentage of visits in which an additional psychiatric medication was also prescribed increased from 7.5% to 20.3%, a nearly 300% increase.  The medications most commonly prescribed along with stimulants were antidepressants and alpha-andrenergic agonists such as clonodine. 

The authors conclude by noting that this sharp rise in "concomitant" pharmacotherapy has not been matched by an increase in safety/efficacy data to support the use of this practice.  Thus, although the value of stimulant medications for treating ADHD is supported by numerous clinical trials, there is surprisingly little data on the use of stimulants in conjunction with other agents.   The authors argue that additional research data are particularly needed to support the commonly used combination of stimulants and antidepressants in youth.

Until such data becomes available, caution should be exercised in the use of combined pharmacotherapy in children with ADHD.  Data from the MTA Study suggests that when stimulant medications are used properly, the use of additional agents will rarely be necessary (see http://www.helpforadd.com/mtastudy.htm ).