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Yoga for Young People with ADHD and other Challenging Behaviours REVIEW OF TWO STUDIES : PAULINE JENSEN AND A/PROF. DIANNA KENNY SCHOOL OF BEHAVIOURAL AND COMMUNITY HEALTH SCIENCES FACULTY OF HEALTH SCIENCE Dr Pauline Jensen 1-3 October 2016 [email protected] THE UNIVERSITY OF SYDNEY 1 AIM OF THE FIRST STUDY • To evaluate yogic practices as an adjuvant treatment to pharmacological and behavioural management in reducing the primary and secondary symptoms of Attention Deficit Hyperactivity Disorder in boys aged 8-12 years. 1-3 October 2016 Dr Pauline Jensen [email protected] 2 Behaviours: Inattention/Hyperactivity/Impulsivity/Disorganisation/ Risk Taking-Sexual, Physical, Criminal, Drugs/Stealing / Fighting/Arson/Lying. Disorders: Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, (ODD) Conduct Disorder (CD) often comorbid, and often comorbid with Depression, Anxiety, Emotional Disorder. Disruptive behaviour and disorders have serious personal, social and educational implications (WicksNelson & Israel, 2003; DET, 1998), affecting peers, teachers, family and community. 1-3 October 2016 Dr Pauline Jensen [email protected] 3 RESEARCH PLAN Wait- List Control Randomised Study Participants- Referred by paediatricians Control group =7 boys (mean age= 9 years 2 months). All except one stabilised on medication. Yoga group n=11 boys (mean age=10 years 5 months). All except one stabilised on medication. Measures Pre and post test measures of symptoms of ADHD using : Conners Parent and Teacher Behaviour Rating Scales R-L. Test of Variables of Attention – TOVA 1-3 October 2016 Dr Pauline Jensen [email protected] 4 1-3 October 2016 Dr Pauline Jensen [email protected] 5 RESEARCH PLAN Procedure • Yoga groups attended 1 hour class per week for between 14 to 20 weeks at Educational Unit at Westmead Hospital. • Boys expected to practise yoga daily and record practice in diary provided. • Control group attended cooperative games session for 1 hour once a month for 20 weeks. 1-3 October 2016 Dr Pauline Jensen [email protected] 6 YOGIC PRACTICES IN PROGRAM • A Manual of Practices was created by the researcher. • The weekly program was based on this. • Each family was given a manual which included recommended home practice and record sheet. • The Program included: • Asanas (Postures) (active component) for body awareness, control and physiological benefits • Pranayama (Breathing Practices) – Deep Breathing, Nadi Shodan, Bhramari, Kapalbhati, • Concentration Exercises- Trataka • Relaxation Exercises- Yoga Nidra 1-3 October 2016 Dr Pauline Jensen [email protected] 7 Record sheet of Weekly Yoga Class DATE BREATHING EXERCISES 1 STANDING A JOINT EXERCISES (ankles, knees, hips, fingers, wrists, elbows,shoulders, neck). B HANDS IN 7 OUT BREATHING X5 C FOREWARD / BACKWARDS / SIDEWAYS STRETCHING BREATH X3 D WARRIORS POSE HOLD FOR X3 LONG BREATHS 2 A B C D SITTING DOG BREATHING X15 TIGER BREATHING X5 THE DOG X3 LONG BREATHS THE COBRA X3 LONG BREATHS E BACKSTRETCH X3 THEN HOLD X3 LONG BREATHS F THE WHEEL HOLD X3 LONG BREATHS 3 INVERTED POSES A B C THE CLOWN HOLD X3 BREATHS SHOULDER STAND HOLD X3 BREATHS THE HEADSTAND HOLD X3 BREATHS 4 BALANCE - TREE POSE HOLD X3 BREATHS 5 SALUTE HOLD X3 BREATHS SECTIONAL BREATHING A DIAPHRAMATIC BREATHING X5 B THORACIC (chest) BREATHING X5 C UPPER LOBAR OR CLAVICULAR BREATHING X5 D FULL YOGIC BREATHING X5 PRANAYAMA 1 KAPALBHATI (20 times R, 20 L, 20 B). 2 CANDRA ANULOMA VILOMA (LEFT NOSTRIL BREATHING) X5 SLOW DEEP BREATHS 3 SURYA ANULOMA VILOMA (RIGHT NOSTRIL BREATHING) X5 SLOW DEEP BREATHS 4 NADI SHODANA (ALTERNATE NOSTRIL BREATHING). X5 5 BHRAMARI (HUMMING BREATH) TRATAKA 1 1-3 October 2016 CONCENTRATION & FOCUSING ON COLOURED SHAPE OR WORD YOGA NIDRA 3 TO 10 MINS Dr Pauline Jensen [email protected] 8 Typical Classes 1-3 October 2016 Dr Pauline Jensen [email protected] 9 BACKGROUND RESEARCH Neurological effects of yogic breathing techniques and implications for neurological dysfunction in ADHD The manipulation of the nasal cycle effects:- ADHD Dysfunction • Increase in oxygen consumption/ glucose metabolism (Telles et al, 1994) • Lower oxygen consumption/ glucose metabolism (Zametkin et al, 1990) 1-3 October 2016 Compared to controls Dr Pauline Jensen [email protected] 10 Neurological effects of yogic breathing techniques and implications for neurological dysfunction in ADHD The manipulation of the nasal cycle effects:- ADHD Dysfunction Compared to controls • Changes in cognition functioning (Naveen et al, 1997) 1-3 October 2016 • Cerebral laterisation deficits (Heilman et al, 1991) Dr Pauline Jensen [email protected] 11 Neurological effects of yogic breathing techniques and implications for neurological dysfunction in ADHD • The manipulation of the nasal cycle and relaxation techniques effects : • Changes in brain wave activity. (Hoffman 1998) • ADHD Dysfunction Compared to controls • Differences in brain wave bands (Mann et al,1991) 1-3 October 2016 Dr Pauline Jensen [email protected] 12 Neurological effects of yogic breathing techniques and implications for neurological dysfunction in ADHD The manipulation of the nasal cycle effects:- ADHD Dysfunction Compared to controls • Changes in neurotransmitter activity and in autonomic activity.(Kennedy et al, 1986) • Neurotransmitter dysfunction (Pliszka et al, 1994) 1-3 October 2016 Dr Pauline Jensen [email protected] 13 Neurological effects of relaxation training techniques and implications for neurological dysfunction in ADHD Relaxation Training • Decreases anxiety (Rauhlal et al, 1990) ADHD Dysfunction Compared to controls • Comorbid anxiety disorder • Medication can increase anxiety levels ( Tannock et al, 1995) 1-3 October 2016 Dr Pauline Jensen [email protected] 14 CPRS-Oppositional Pre and post test scores 76 74 72 70 68 66 GROUP 64 Yoga 62 Control 1 2 REPEAT 1-3 October 2016 Dr Pauline Jensen [email protected] 16 CPRS - Global Index (Restless/Impulsive) Pre and Post Test Scores 82 80 78 Mean Scores 76 GROUP 74 Yoga 72 Control 1 2 Time 1-3 October 2016 Dr Pauline Jensen [email protected] 18 CPRS-Emotional Lability Pre and post test scores 76 74 72 70 68 66 GROUP 64 Yoga 62 Control 1 2 REPEAT 1-3 October 2016 Dr Pauline Jensen [email protected] 19 CPRS - Global Index Total Pre and Post Test Scores 80 78 Means Scores 76 74 GROUP 72 Yoga 70 Control 1 2 Time 1-3 October 2016 Dr Pauline Jensen [email protected] 20 CPRS - DSMIV Symptoms- Inattentive Pre and Post Test Scores 6.0 5.5 5.0 Mean Scores 4.5 4.0 GROUP 3.5 Yoga 3.0 Control 1 2 REPEAT 1-3 October 2016 Dr Pauline Jensen [email protected] 21 Connors Parent Ratings for DSM IV Inattentive Symptoms Conners' Parent Rating Scale DSM IV Symptoms Subscale Inattentive 10 "Pre Yoga" "Post Yoga" 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 "Pre Control" Symptom Score Above 5 suggestive of possible DSM IV diagnosis. Symptoms Score Above 5 suggests possible DSM IV Diagnosis 10 Conners' Parent Rating Scale DSM IV Symptoms Subscales Inattentive "Post Control" 9 8 7 6 5 4 3 2 1 0 1 2 Subjects 1-3 October 2016 3 4 5 6 7 Subjects Dr Pauline Jensen [email protected] 22 CONCLUSIONS • Given the limitations of this study- ie. small numbers and relatively short intervention and high needs population sample, the results do indicate some significant changes in the behaviour of boys with ADHD. 1-3 October 2016 Dr Pauline Jensen [email protected] 23 The Second Study: The Impact of Yoga on Children and Adolescents with Disruptive Behaviour Disorders Addressed limitations of previous study • larger number of participants (n=87), • more supervised yoga practice -Up to 40 sessions over a 14 week period) • and a broader range of measures – 11 measures 1-3 October 2016 Dr Pauline Jensen [email protected] 24 Disruptive Behaviour Disorders (DBD) On the increase in the school age population in Australia. The effects of these disorders impact on the total wellbeing of the sufferer and those in contact with them (Beiderman et al, 1995). Current treatments fall short of adequately treating these disorders.(Greenhill et al, 1996). Research indicates a neurological basis for ADHD with genetic and environmental factors contributing to all DBD’s and AD’s(Cantwell 1996). 1-3 October 2016 Dr Pauline Jensen [email protected] 25 Design • Participants aged 8-16 years • Diagnosed or displaying DBDs and comorbid EDs and ADs • Students (n=87) enrolled at NSW Department of Education and Training (DET) schools for students with disruptive behaviour and emotional disturbance (Behaviour Schools with enrolments of approximately 20 students) • 30- 40-minute sessions three days a week, over a fourteen-week period, to groups of 2 to 6 students, in 9 schools, over a 19 month period. 1-3 October 2016 Dr Pauline Jensen [email protected] 26 Measuring Breathing patterns during relaxation session (Summit 2000). Self-reported Physical, Emotional and Mental States (Jensen 2005) Self-reported Feelings of Happiness, Calmness, Enjoyment and Competency. (Checklist post yoga classes -Jensen 2004) Behavioural Observations in Classroom and in Yoga classes using computerized Behavioral System (BASC- AGS Publishing 2003) plus observation notes by Classroom Teacher or Aide. Parent and Teacher’s Perception of Behaviour (CTRS –R-L & CPRS-R-L Conners, 1997) Anxiety (STAI/C – (Spielberger, 1983, 1973) Yoga survey –(Jensen 2004) Attention -Sustained and Selective. (TEACH -Manly, Nimmo-Smith, Anderson, 1999) Self Esteem (Self-Description Questionnaire-SDQ- 1& 2 -Marsh 1990) 1-3 October 2016 Dr Pauline Jensen [email protected] 27 Students’ Background • Students’ backgrounds include domestic violence; sexual, emotional, physical abuse and neglect; multiple parents or guardians; economic hardship; and family pathology including parental substance abuse, criminal activity and mental health disorders. 1-3 October 2016 Dr Pauline Jensen [email protected] 28 Effects of Background • Such circumstances have adverse effects on • Physical body (muscle tightness; digestive problems; excretory problems etc), • Emotional state (anxiety, depression, anger, etc) • Social functioning (anti –social behaviour) • Mental functioning (confusion;arrogance, stubbornness, dullness; controlling; inflexibility) • causing disturbances in anatomical, physiological, psychological, neurological functioning. 1-3 October 2016 Dr Pauline Jensen [email protected] 29 Benefits of Yoga • Yoga postures stretch, flex, tone, strengthen and relax the muscular system, lubricate joints and massage the body; stimulate and relax the digestive and excretory systems ; release tension in an overstimulated nervous system, and regulate the respiratory and circulatory system. • Yoga relaxation calms the nervous system, relaxes muscles and quietens the mind. • Yoga breathing practices can influence oxygen consumption and the functioning of the brain. • Yoga mind sound resonance deepens the breath, focuses and quietens the mind. 1-3 October 2016 Dr Pauline Jensen [email protected] 30 How Yoga was introduced to the students. • Yoga works on your mental, physical and emotional self. • Ancient to modern Yoga. • Animal to Human Yoga • Sportspeople and teams who practise yoga Tom Carroll, surfing champion. 1-3 October 2016 Dr Pauline Jensen [email protected] 31 Access,Recruitment and Assessment • Ethics Approvals • Locating Special Schools(n=11 in Sydney Region) • Gaining approval from Principals and cooperation from staff • Permission from parents • Organise assessments pre and post program with teachers, parents and blind assessors. 1-3 October 2016 Dr Pauline Jensen [email protected] 32 Various reasons why students didn’t practise yoga in classes taught. • • • • • • • Suspended or ion –school suspension TAFE course Home school intervention Work experience Sick or truanting Asked to leave because too disruptive Too lazy or couldn’t be bothered 1-3 October 2016 Dr Pauline Jensen [email protected] 33 When attending Yoga class: • Can eat breakfast or lunch before session • Can be talkative • Can react to others • Can be chaotic and restless • Can be uncooperative • Can refuse to participate • Can be lethargic • Can be sore and stiff HOWEVER • Often do follow the program • Often enjoy the postures • Often do relax 1-3 October 2016 Dr Pauline Jensen [email protected] 34 How the class was conducted • Short relaxation • Pawanmuktasana -Joint Warm Ups • Spinal warm ups • Variety of postures- forward bends, backward bends, sideways, upwards, twists, balances (no inversions) and sequences. • Breathing practices • Chanting sounds • Relaxation 1-3 October 2016 Dr Pauline Jensen [email protected] 35 Results Nil Effect • Standardised psychometric tests with pre and post testing over 12 week period attributed to small dose, no control over other aspects of life. 1-3 October 2016 Effect • Self report before and after yoga classes on physical, mental and emotional states. • Feelings checklist after class 1x week. • Observations of behaviour during yoga classes. • Breathing patterns Pre, during and Post Yoga Nidra. Dr Pauline Jensen [email protected] 36 Feelings Checklist 1-3 October 2016 Dr Pauline Jensen [email protected] 37 Feelings Of Happiness, Calmness, Enjoyment and Competency after weekly Yoga Class ( n= 61) Happiness 5 Rating Average:5 highest 4 Calmess 3 Enjoyment 2 1 Competency 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Week in Yoga program 1-3 October 2016 Dr Pauline Jensen [email protected] 38 SELF REPORT PHYSICAL STATE - UP TO 12 PARTICIPANTS PRE AND POST YOGA CLASSES 12 AVERAGE RATING :0-10 10 8 PRE PHYSICAL STATE POST PHYSICAL STATE 6 4 2 0 1 1-3 October 2016 2 3 4 5 6 7 8 9 10 YOGA CLASS NUMBER Dr Pauline Jensen [email protected] 11 12 39 SELF REPORT EMOTIONAL STATE-UP TO 12 PARTICIPANTS PRE AND POST YOGA CLASSES 12 AVERAGE RATINGS;1-10 10 8 PRE EMOTIONAL STATE POST EMOTIONAL STATE 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 YOGA CLASS NUMBER 1-3 October 2016 Dr Pauline Jensen [email protected] 40 SELF REPORT MENTAL STATE-UP TO 12 PARTICIPANTS PRE AND POST YOGA CLASSES 12 AVERAGE RATING :1-10 10 8 PRE MENTAL STATE POST MENTAL STATE 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 YOGA CLASS NUMBER 1-3 October 2016 Dr Pauline Jensen [email protected] 41 One minute screen shots of breathing effort pre, during and post Yoga Nidra for individual student with Conduct Disorder, Learning Disorder and Emotional Disorder Pre Yoga Nidra 1-3 October 2016 Pauline Jensen PostDrYoga Nidra [email protected] During Yoga Nidra 42 Teachers Observations of Students Doing Yoga • 3249 positive comments eg. joined in, participated, did posture, relaxed , settled did well. • 775 negative comments eg. Silly, unsettled restless, not participating. 1-3 October 2016 Dr Pauline Jensen [email protected] 43 Survey completed by primary students after yoga program n=27 • • • • • • • • Question Yes % Do you have more energy? 74.1 Are you a calmer person? 66.7 Are you more flexible? 77.8 Do you feel stronger? 80 Are you able to relax easier? 63 Do you have less mood swings? 46.2 Do you experience less anger? 63 1-3 October 2016 Dr Pauline Jensen [email protected] No % 25.9 33.3 22.2 20 37 53.8 37 44 Trust, Co-operation and Fun 1-3 October 2016 Dr Pauline Jensen [email protected] 45 Group Endeavour and Support 1-3 October 2016 Dr Pauline Jensen [email protected] 46 Determination and Togetherness 1-3 October 2016 Dr Pauline Jensen [email protected] 47 Peace 1-3 October 2016 Dr Pauline Jensen [email protected] 48 References Biederman, J., Milberger, S., Faraone, S.V., Kiely, K., Guite, J., Mick, E. et al. (1995). Impact of adversity on functioning and comorbidty in children with attention deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (11), 1495-1503. Cantwell, D.P. (1996). Attention deficit hyperactivity disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 35(8), 978-987. Greenhill, L., Halperin, J.M. & Abikoff, H. (1999) Stimulant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 38(5), 503-512. Heilman, K.M., Voeller, K.K. & Nadeau, S.E. (1991). A possible pathophysiologic Hoffman, E.(1998) Mapping the brains activity after Kriya Yoga. Bindu, 12, 10-12. Scandinavian Yoga School. Sweden Kennedy, B, Ziegler, G.C., Shannahoff-Khalsa, D.S. (1986). Alternating lateralisation of plasma catecholamines and nasal patency in humans. Life Sciences, 38, 1203-1214. Mann, C.A., Lubar, J.L., Zimmerman, A, W., Miller, C.A., Muenchen, MS. (1991). Quantitative analysis of EGG in boys with attention deficit hyperactivity disorder controlled study with clinical implications. Paediatric Neurology, 1, 30-36. Nagendra, H.R., Mohan, T., Shriram, A. (1998). Yoga in education. Vivekananda Kendra Yoga Prakashan. Bangalore India Naveen, K.V., Nagarathna, R., Nagendra, H.R. & Telles S.(1997). Yoga breathing through a particular nostril increases spatial memory scores without lateralised effects. Psychological Report, 81, 555–561. Plizska, S.R., Maas, J.W., Javors, M.A., Rogeness, G.A. & Baker, J. (1994). Urinary catecholamines in attention deficit hyperactivity disorder with and without comorbid anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 33(8), 1165-1173. Rauhala, E, Alho, H., Hanninen, O. & Helin, P. (1990.) Relaxation training combined with increased physical activity lowers the psychophysiological activity in community home boys. International Journal of Psychophysiology, 10, 63-68. Saraswati, S.S. (1983). Asana, Pranayama, Mudra, Bandha. Bihar School of Yoga, Munger, Bihar. Tannock, R., Ickowicz, A. & Schachar, R. (1995). Differential effects of methylphenidate on working memory in ADHD children with and without comorbid anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 34 (7), 886-896. Telles, S., Nagararthna, R.& Nagendra, H. (1994). Breathing through a particular nostril can alter metabolism and autonomic activities. Indian Journal of Physiology, Pharmacology, 38(2), 133-137. Zametkin, A., Nordahl, T.& Gross, M. (1990) Cerebral glucose metabolism in adults with hyperactivity with childhood onset. New England Journal of Medicine, 323, 1361-1366. 1-3 October 2016 Dr Pauline Jensen [email protected] 49