Sahaja Yoga Meditation als Familienbehandlungsprogrammfür Kinder mit dem Hyperkinetischen Syndrom (AD/HS)
Eine Studie von Linda Harrison, Ramesh Manocha, und Katya Rubia, die im renommierten Journal for Clinical Child Psychology erschien, zeigt, dass Sahaja Yoga Meditation eine effektive Methode zur Verbesserung der klinischen Symptome von ADHD ist.
Das Hyperkinetische Syndrom oder Attention Deficit Hyperactivity (ADHD) ist die statistisch häufigste psychische Erkrankung bei Kindern. ADHD betrifft zwischen 3-10% aller Schulkinder und die Zahlen sind steigend. Kinder mit dem Hyperkinetischen Syndrom und deren Eltern nahmen sechs Wochen lang zweimal wöchentlich an Sahaja Yoga Meditationen teil und meditierten auch zu Hause.
Die Ergebnisse waren signifikante Verbesserungen der typischen Symptome wie Hyperaktivität, Impulsivität und Aufmerksamkeitsstörungen, bei gleichzeitiger Verbesserung des Selbstwertgefühls der Kinder und der Qualität der Beziehungen zu Gleichaltrigen, Eltern und Lehrern. Die Kinder und Eltern beschrieben Verbesserungen zu Hause (besseres Familienklima, weniger Ängste, bessere Schlafmuster) und in der Schule (weniger Konflikte mit Gleichaltrigen oder Lehrern, besseres Konzentrationsvermögen).
Diese Forschungsergebnisse zeigen, dass Sahaja Yoga Meditation im Rahmen einer integrativen Behandlung von Familien eine Methode zur Verbesserung der Situation für die ganze Familie bietet.
Sahaja Yoga Meditation as a Family Treatment Program for
Children with Attention Deficit Hyperactivity Disorder
Linda J. Harrison
Senior Lecturer, School of Teacher Education, Charles Sturt University, Bathurst, Australia
Katya Rubia
Senior Lecturer, Dept of Child Psychiatry, Institute of Psychiatry, Kings College, London, UK
Ramesh Manocha
Medical Practitioner & Research Fellow, Natural Therapies Unit, Royal Hospital for Women,
University of New South Wales, Sydney, Australia
Word Count: 7,663
Address all correspondence concerning this manuscript to:
Dr Linda Harrison
School of Teacher Education
Charles Sturt University
Bathurst, NSW 2795
Australia
Tel. (612) 6338 4872
Fax: (612) 6338 4417
Email: lharrison@csu.edu.au
Abstract
Although the use of complementary and alternative medicine (CAM) as
a treatment for children diagnosed with Attention Deficit
Hyperactivity Disorder (ADHD) is widespread, little is known on the
effectiveness of many such therapies. In this study, meditation was
investigated as a family treatment method for children with ADHD,
using the techniques of Sahaja Yoga Meditation. Parents and
children participated in bi-weekly clinic sessions and also
meditated at home. Pre- and post-treatment assessments included
parent ratings of ADHD symptoms, self-esteem, and child-parent
relationship quality. Child ratings of self-esteem were also
included. Additional data was collected via parent questionnaires
and child interviews. Results showed significant improvements in
children’s ADHD behavior, self-esteem, and relationship
quality over the six-week meditation program. Children described
benefits at home (better sleep patterns, less anxiety) and at
school (more able to concentrate, less conflict). Parents also
reported feeling happier, less stressed, and more able to manage
their child’s behavior.
KEY WORDS: attention deficit hyperactivity disorder ADHD;
child-parent relationships; complementary and alternative medicine
CAM; meditation; self-esteem
Introduction
The most
commonly used treatment for Attention Deficit Hyperactivity
Disorder (ADHD) in North America and Australia continues to be
psychostimulant medication (Goldman, Genel, Bezman, & Slanetz,
1998; Rubia & Smith, 2001; Vance & Luk, 2000), which has
been found to improve the core behavioral and cognitive features of
ADHD, such as behavioral inhibition and concentration, as well as
comorbid symptoms such as poor academic achievement, in about 80%
of the children (Barkley, 1997; Cara, 2002; Gage & Wilson,
2000). In the last 10 years, a five-fold increase in
methylphenidate prescription and consumption has been seen, with as
much as 30-40% of children in some American schools receiving
stimulant medication (Ghodse, 1999). Similar trends have been seen
in Australia. From 1990 to 2000, the rate of children receiving
stimulant medication for ADHD increased in the order of nine times
(Committee on Children and Young People, 2002). This, among other
factors, has made community concerns about possible
over-prescription and side effects of methylphenidate grow
(Vimpani, 1997). Common physiological short term side effects of
stimulant medication are insomnia, appetite loss, stomach-aches,
dizziness, and daytime drowsiness, in addition to emotional and
motor symptoms, such as mood lability and tics (Vance & Luk,
2000). Other factors include that psychostimulants can produce
abuse and dependency (Goldman et al., 1998) and that the potential
long-term side effects of lengthy treatments are not known
(National Institute of Health, 1998; Schachar & Tannock, 1993).
As such information becomes more widely available to the public, it
is not surprising that large numbers of parents seek out
complementary and alternative medicine (CAM) therapies (Chan,
Rappaport, & Kemper, 2003; Stubberfield & Parry, 1999) as a
response to their “concern about the physiological and
psychological effects that the drugs may have on their
children” (Rice & Richmond, 1997, p. 93). Support for CAM
has also come from clinicians who argue that an emphasis on medical
therapy alone draws attention to the control of symptoms, rather
than attending to the need for children to acquire important
behavioral and social skills (Zametkin & Ernst, 1999).
The issue of community concern relating to the escalating use of
stimulants in the management of ADHD symptoms, treatment
acceptability, side effects, potential long-term effects, danger of
drug abuse and dependency, and consumer and parent preference of
non-pharmacological treatment, compels researchers to explore other
treatment options. According to Rice and Richmond (1997), the most
promising interventions are those which work with the whole family
system and which use medication in association with nonmedical
interventions. Nonmedical interventions for ADHD include a variety
of behavioral treatments, such as cognitive behavior therapy, as
well as complementary and alternative treatments, such as dietary
modification, biofeedback, relaxation training, and meditation (for
reviews of CAM and ADHD see Arnold, 2001; Chan, 2002; Pelham,
Wheeler, & Chronis, 1998). Arnold’s review of alternative
approaches to the management of ADHD noted that meditation was one
of a number of promising strategies and warranted further
systematic assessment. However, so far there have been only two
unpublished dissertations suggesting that meditation may improve
impulsiveness at home and in the classroom in children with ADHD
(Arnold, 2001).
Meditation is classified by Chan (2002) as one of a number of
“lifestyle/mind-body therapies,” which elicit the
relaxation response and reduce hyperarousal to stress (p. 41).
Reviews tend to present meditation and relaxation training methods
conjointly (Canter, 2003; Chan, 2002); however, some authors see
meditation as different to relaxation. For example, Manocha, Marks,
Kenchington, Peters, and Salome (2000) describe meditation as a
self-management strategy for acquiring personal awareness and
self-control. Although meditation may not be well understood or
defined by western therapeutic models, the eastern definition is
very clear: Meditation is a state of “mental silence”
characterised by elimination of unnecessary thought, effortless
attention on the present moment, and alert awareness (Srivastava,
1997). There are many different meditation techniques currently
taught in the West, including “listening to the
breath, repeating a
mantra, or detaching from the thought process, to focus the
attention and bring about a state of self awareness
and
inner calm” (Canter, 2003, p. 1049). Of these, Sahaja Yoga
Meditation (SYM), which is based on scientific principles
introduced by the founder, Shri Mataji Nirmala Devi Srivastava, has
shown promise in a number of clinical trials. SYM claims to relax
sympathetic nervous system by activating parasympathetic-limbic
pathways that relax body and mind (Srivastava, 1997). Direct
physiological effects of SYM include indicators of increased
parasympathetic activity such as decrease of blood pressure, of
heart, respiratory and pulse rates, and increase of galvanic skin
resistance (indicator of decreased sympathetic activity) (Rai et
al, 1988). Studies have included electrophysiological
investigations in which SYM has been associated with reduced
complexity of EEG patterns and increases in medium frequency and
low beta ranges suggestive of increased attentional control
(Aftanas & Golocheikine, 2001, 2002). Alteration of beta/theta
waves by means of biofeedback, on the other hand, has shown to
correlate with improvement of ADHD symptoms (for an overview see
Ramirez, Desantis, & Opler, 2001). It is thus possible that the
mechanisms of action of Yoga meditation resemble theta/beta
biofeedback techniques by enhancing overall altertness, attentional
focus and relaxation. Clinical treatment studies of SYM have
reported physiological and psychological benefits for patients with
asthma (Manocha et al, 2000), stress disorders (Rai, Setji, &
Singh, 1988), depression (Morgan, 2001), and epilepsy (Panjwani,
Gupta, Singh, Slevamurthy, & Rau 1995; Panjwani, Slevamurthy,
et al, 1996; Yardi, 2001). Teachers and yoga practitioners have
also noted that SYM helps to focus attention, enhance concentration
and memory, and improve children’s performance at school
(Srivastava, 1997). This background of neurological, physiological,
and psychological research, as well as practical experience,
suggests SYM as a useful alternative treatment for children with
ADHD.
Core symptoms of childhood ADHD, according to the DSM-IV (American
Psychiatric Association, 1994), are inattention, impulsivity, and
hyperactivity. Associated symptoms are academic underachievement
and impaired self-esteem (Cara, 2002; Treuting & Hinshaw,
2001). The typical pattern is thus one of a highly-energetic,
impulsive, delay aversed, unfocused and behaviorally poorly
controlled child who demands constant attention and redirection.
The central problem of the disorder is difficulty in
self-regulating own behavior (Anderson, 1997; Barkley, 1997, Rubia
et al., 2001). Structural studies have related abnormalities in the
frontal cortex and the basal ganglia with ADHD (Castellanos, Lee,
Sharp, Jeffries, & Goldstein, 2002). Electrophysiological
studies have pointed to functional deficits in the brain as
correlates of poor regulatory control in hyperactive children (eg.,
Barry, Clarke, & Johnstone, 2003; Barry, Johnstone &
Clarke, 2003) and modern functional imaging studies have associated
abnormal activation of frontal brain areas with deficits of
inhibitory and attentional control (Vaidya et al., 1998; Rubia,
Overmeyer, et al., 1999; Rubia, Taylor, et al, 2001).
Neurotransmitter abnormalities, such as dopamine dysregulation,
have also been linked to ADHD (reviewed in Rubia & Smith,
2001); notably, that dopamine transporter (DAT) levels are elevated
in the striatum of children (Cheon et al., 2003) and adults with
ADHD (Krause, Dresek, Krause, Kung, & Tatsch, 2000).
In considering a psychological etiology of this disorder, authors
have looked to transactional models that explain poor
self-regulatory behavior within the wider context of family
dynamics and parent-child relationships. Certainly, research shows
that an ADHD child may unduly strain these relationships. Cara
(2002) notes that parents often feel frustrated, anxious, and angry
that parenting techniques effective for other children appear
useless in the child with ADHD, who seems not to understand the
consequences of inappropriate behavior or to learn from punishment.
When oppositional, noncompliant behavior is characteristic, parents
may be less appreciative of their children’s efforts, less
willing to reward them, and more negative, directive and
controlling (Rice & Richards, 1997). An alternate
interpretation suggests that deficits in self-regulation may be
related to insecure parent-child attachment relationships (Olson,
1996; Steifel, 1997), which are characterised by a pattern of
conflicted, angry parent-child interchanges (Bowlby, 1969/1982). To
date, few studies have examined attachment status in children with
ADHD. Researchers in New Zealand have reported that maternal
responsiveness and synchronous interaction (which are known
predictors of attachment security, eg. de Wolff & van
IJzendoorn, 1997) were significantly lower in ADHD mother-child
dyads than in a matched control group (Keown & Woodward, 2002).
In Australia, Clark, Ungerer, Chahoud, Johnson, and Stiefel (2002)
noted consistent associations with insecurity in children with
ADHD. across three different representational assessments of
attachment, in a comparative study of five-to-ten-year-old boys
diagnosed with ADHD and control children. The ADHD group showed
heightened emotional expression and out-of-control affects,
suggesting an insecure-ambivalent or disorganised attachment
relationship with the parent.
The present study sought to assess the contribution of Sahaja Yoga
Meditation (SYM) to a more effective management of the main
problems experienced by children with ADHD, such as stability of
attention and concentration, motor activity, problems of inhibition
and easily frustrated mood, as well as associated problems such as
poor self-esteem and difficulties at school. By presenting SYM as a
family practice and encouraging parents to meditate regularly with
their child, we sought to assess the extent of individual benefits
for parents as well as any improvement in the security of the
parent-child relationship. It was expected that SYM would be an
adjunct to children’s on-going medical therapy and would
provide a means of working with the whole family. The aims of the
program reflected the goals for appropriate treatment identified by
the American Academy of Pediatrics (Cara, 2002); that is, to
improve core symptoms of ADHD, reduce associated symptoms, and
improve functional outcomes. These aims were tested in a voluntary
clinic provided at the Royal Hospital for Women, Sydney, Australia
with the help of a team of experienced instructors of Sahaja Yoga
Meditation.
Method
Recruitment
The Sahaja Yoga
Meditation (SYM) trial treatment program was publicised by a
newspaper article and an introductory lecture, which was open to
parents of school-age children with ADHD. Interested parents were
invited to participate with their child in a six-week program of
bi-weekly sessions teaching SYM. Inclusion criteria were that the
child had a formal diagnosis of ADHD, that is, met the DSM-IV
criteria made by a paediatrician or child psychiatrist (National
Health & Medical Research Council, 1996), and scored above
threshold for ADHD (score of 15 and over) on the Conners
Parent-Teacher Questionnaire (National Institute of Mental Health,
n.d.) (see Assessment Procedures - Child Assessment Measures:
Parent Report).
Participants
General
information on the children’s age, diagnosis of ADHD,
medication status was collected prior to the commencement of the
meditation training. Forty-eight children (41 boys, 7 girls),
including four sets of siblings, met the criteria for inclusion in
the program. The majority of children (n
=
31) were receiving medication, 14 were not medicated, and
medication information was not provided for the other three
children. Demographic information showed that families represented
a diverse population. About three-quarters of the 44 families were
in couple relationships and one-quarter comprised single parents or
guardians. Adult participants who provided personal data included
38 mothers, 22 fathers, and one grandmother. Mothers ranged in age
from 27 to 50 years (M
=
38.8; SD
=
5.9); fathers were slightly older than mothers (range = 35 to 55
years; M
=
43.1; SD
=
5.2). Education levels for both mothers and fathers ranged from
less than secondary school to doctoral studies, with the majority
having completed tertiary level studies (mothers, 62%; fathers,
73%). Parent ethnicity was less diverse: 95% of participants
identified themselves as White/Caucasian.
Because of the large number of interested families and the
requirement for individualised training in the SYM program, it was
necessary to separate the children into two groups and run a
two-stage treatment program. For the first session, Study 1, older
children (19 boys, 1 girl) and their parents were invited to
participate. Ages ranged from 8 to 12 years of age
(M
=
10.09, SD
=
1.13). There was also a 6-year-old female sibling who was included
in this group. The program began at the end of the January summer
holidays and continued into the first term of school. The second
session, Study 2, began in the April school holidays. Children
invited to participate in Study 2 were more diverse in age: range =
4 - 12 years; M
=
7.4 years; SD
=
2.0. Participants for Study 2 included 16 “wait-list”
children whose parents who attended the initial recruitment session
in January, and a further 11 children whose parents expressed an
interest in joining the second program.
Sahaja Yoga Meditation Program
The intervention
was conducted over a six-week period, using Sahaja Yoga Meditation
(SYM) techniques developed and described by Shri Mataji Nirmala
Devi Srivastava (n.d.). SYM uses a simple meditation method that
can be easily taught to children and adults. The treatment program
consisted of twice-weekly 90-minute clinics, held in large meetings
rooms at the hospital. For the first three weeks, the clinic
consisted of guided meditation sessions, with parents attending one
group and the children another. The meditation process involved
practising techniques whereby participants were helped to achieve a
state of thoughtless awareness. Instructors directed participants
to become aware of this state within themselves by becoming silent
and focussing their attention inside. Parents were also asked to
conduct shorter meditation sessions at home twice a day.
In the clinic, there were usually two periods of meditation of five
to fifteen minutes each, supplemented by information about how to
meditate and sharing of experiences. The parent sessions had one to
two instructors, but the child sessions had a higher
instructor-to-child ratio (normally, one instructor for every three
children). From week 4 to week 6, one of the weekly sessions was
conducted as a joint parent-child meditation. This enabled
instructors to train parents in guiding their child’s
meditation. Children and parents were asked to meditate regularly
at home and to record their progress in a diary, which was checked
each week to encourage compliance.
Assessment Procedures
Children and
parents contributed to a range of data collection procedures, which
drew on three sources – child self-report questionnaires,
parent-rated questionnaires, and examiner testing and interviews.
Child data included information on ADHD symptoms, medication
status, self-esteem, cognitive testing, and perceptions of the
meditation program. Child-parent relationship quality was also
assessed. Parents were asked to give their views on the
effectiveness of the program, for their children and themselves.
Assessments were conducted at three points: recruitment or
commencement of the meditation program (week 1), midway point of
the program (week 3), and the end of the program (week 6). The full
schedule of assessments was completed for the Study 1 sample. Study
2 used fewer measures and assessments were only completed at the
commencement and end of the program.
Child Assessment Measures: Parent-Report
Conners
Parent-Teacher Questionnaire. ADHD symptoms
were assessed via parent-report, using shorter version of the
Conners Parent-Teacher Questionnaire (National Institute of Mental
Health, n.d.) which are commonly-used tools in research and
clinical practice (reviewed in Connors, Sitarenios, Parker, &
Epstein, 1998). The measure chosen for the present study presents
11 items achieving a high level of internal reliability.
Coefficient alphas ranged from .74 to .86. Ratings on the 11 items
were summed to give a total score for ADHD symptoms at each
assessment point (minimum = 0; maximum =
33).
Perceived
Outcomes of SYM for the Child. At the mid- and
endpoints of the program, parents were asked to complete a short
questionnaire asking whether they felt the meditation had benefited
the child, and whether it had made a change to the relationship
they had with the child. Simple 5-point rating scales were used to
obtain information on the level of benefit for the child in the
areas of emotions (anxiety, anger, able to manage negative
feelings), self-esteem (confidence), attention (memory, able to
settle down), and sleep. Additional questions were included at the
final point about benefits for the child’s schoolwork, eg.
positive attitudes about going to school, social relations with the
teacher and other children, and attention to schoolwork and
homework.
Psychostimulant
Medication. The SYM
treatment program did not ask or advise parents to reduce their
child’s pharmacological treatment for ADHD, but it was clear
from comments made by a number of parents at recruitment that they
were looking for alternatives to medication. For example, some
parents said that they did not use medication during the school
holiday period, but felt pressured by teachers to medicate their
child at school. Therefore, at the mid- and endpoints of the
program, parents were asked about any changes they may have made to
their child’s level of medication. The question asked was
“have you been able to reduce your child’s level of
medication and still maintain an acceptable level of
behavior?” If medication had been reduced, parents were asked
to report the proportion; that is, less than half, half, or more
than half.
Biobehavioral
Indicators of Self-Esteem. Study 1 included
Burnett’s (1998) 13-item Biobehavioral Indicators of
Self-Esteem (BIOS) questionnaire,
which asks parents to rate their child’s behavior over the
previous two weeks on a 5-point scale. Statements assess social
interaction, confidence, and involvement. Parents completed the
scale at the commencement of the program (week 1), at the mid-point
(week 3), and the final point (week 6). Internal consistency was
high, coefficient alphas ranged from .81 to .94. Ratings on the 13
items were combined and averaged, to give a mean score for
indicators of self-esteem at each of the three points of the
program.
Child Assessment Measures: Child
Self-Report
Burnett
Self-Scale. Study 1 included
an adapted abbreviated version of the Burnett Self-Scale (Burnett,
1994), which covers self-evaluation and self-description on peer
and parent relationships and self-evaluative items. Internal
consistency of the modified scale was high; coefficient alpha =
.95.
Child Assessment Measures: Examiner Testing and
Interviews
Peabody
Picture Vocabulary Test-Third Edition. Cognitive
testing was undertaken at the commencement of Study 1, using the
Peabody Picture Vocabulary Test-Third Edition (PPVT-III) (Dunn
& Dunn, 1997). The PPVT measures receptive language ability and
has been shown to provide a good overall measure of verbal
comprehension and to correlate highly with measures of academic
performance.
Child
Interviews. Audiotaped
interviews were conducted individually with Study 1 children at the
end of the 6-week meditation program. Questions focused on the
children’s experience of the meditation program, whether they
liked meditation, what they liked about it, whether they felt it
had helped them, and how it had helped.
Parent Measures
Perceived
Outcomes of SYM for the Parent. Parents were
asked to report on their own experiences of the meditation program
and whether they felt it had been beneficial to them, in a short
questionnaire presented at the mid- and final points of the
program. A 5-point rating scale was used asking parents to rate the
extent to which they felt happier, less stressed, more able to
manage stress, less angry, and more able to manage anger. At the
end of the program, parents were also asked to provide written
examples of recent positive and negative interactions with their
child.
Child-Parent
Relationship Scale. Parents in Study
1 completed the 30-item Child-Parent Relationship Scale (CPRS),
which assesses the quality of the parent-child relationship. The
CPRS is an adaptation of Pianta’s (1990) Student-Teacher
Relationship Scale, which has been used extensively in studies of
relationship quality in Australia (Harrison et al., 2003) and the
United States (NICHD Early Child Care Research Network, n.d.;
Pianta & Steinberg, 1992). Questions in the CPRS tap four
dimensions of child-parent attachment: warmth, conflict,
dependence, and open communication. Higher scores reflect a more
positive parent-child relationship. Internal consistency was high,
coefficient alpha = .84 and .86, at weeks 1 and
6.
Results
Results are
presented in four sections. First, baseline ADHD data for child
participants, demographic characteristics, and SYM program
retention and completion rates are reported for Study 1 and Study
2. Second, the impact of SYM on changes in ADHD symptoms, along
with medication status and perceived child outcomes are examined,
by drawing on data from the combined Study 1 and 2 samples. In the
third section, SYM effects are examined in relation to a wider
range of psychological assessments, including cognitive
achievement, self-esteem, and parent-child relationship quality,
using data from Study 1. Finally, results of the SYM program for
parent participants are presented.
Baseline
ADHD symptoms: Demographic factors and SYM program
retention
Baseline
information on ADHD symptoms was provided for 48 children (41 boys,
7 girls) at the initial recruitment or commencement stage of the
SYM program. Comparisons of
mean scores, using t-test
analyses, were conducted to assess the effects of child and family
demographic factors. There were no differences between groups of
children allocated to Study 1 versus Study 2 (Ms
= 23.00 and 22.37, respectively, t
=
.24, ns)
or between boys and girls (Ms
= 22.59 and 23.00, respectively, t
=
.05, ns).
Children from couple families had significantly lower ADHD symptom
scores (M
=
21.25, SD
=
3.88) than children from single parent families
(M
=
25.58, SD
=
3.68), t
=
11.19, p
=
.002, and children whose parents had completed tertiary education
had lower scores (M
=
21.23, SD
=
4.34) than non-tertiary educated parents (M
=
24.13, SD
=
4.09), t
=
5.17, p
=
.029.
Retention rates for the two six-week SYM programs were reasonably
good, especially considering that many families travelled long
distances to attend the hospital clinic and that children attended
outside-school activities, which competed with the clinic times and
home meditation expectations. For Study 1, 16 of 21 children
completed the full six-week program -- a retention rate of 76%. For
Study 2, 19 of 27 children completed – 70% retention.
Unfortunately, due to organisational problems in the final week,
endpoint data was only available on 10 of the Study 2 children.
Therefore, 26 children from the combined studies provided pre- and
post-treatment data. Comparisons of mean AHDH scores, using
t-test,
showed there were no
differences between the participants who provided complete data
(N
=
26) and the participants who did not provide final data
(N
=
22), on any of the demographic measures (child’s age and sex,
mother’s and father’s age and education, family marital
status) or in the proportion of children receiving
medication.
The two-stage administration of the SYM program provided an
opportunity to assess ratings of ADHD symptoms for wait-listed
children on two occasions prior to the treatment program. Twelve
children provided data at the initial recruitment stage in January
and several months later at the commencement of Study 2 in April.
Analyses showed that children’s ADHD scores were consistent
across these two occasions, r(12)
= .68, p
=
.015, and had remained at a similar level (M1
=
22.08, SD
=
4.72; M2
=
21.17, SD
=
4.69), t
=
.84, ns.
Change to ADHD-related symptoms: Pre- and post-SYM treatment
program
Results for the
26 children who provided pre- and post-treatment data showed a
marked improvement in ADHD symptoms as measured on the Conners
Parent-Teacher Questionnaire over the course of the meditation
program. Mean scores dropped from Mpre
=
22.54, SD
=
4.61, to Mpost
=
14.62, SD
=
5.15. The average mean drop in reported ADHD symptoms was 7.91
points, SD
=
4.91 (range = 0 to 19), which represented an improvement rate of 35
percent. Statistical analysis using paired samples
t-test
showed that the difference in pre- and post-treatment scores was
highly significant, t
=
8.23, p
<
.001.
Because of the possibility that the improvement in behavior may
have been due to the medication children were receiving rather than
the SYM program, further comparisons were made to assess whether
medication status may have contributed to this change. Results
presented in Table 1 (lines 1 and 2) show a similar reduction in
ADHD symptoms for the 20 children who were receiving medication
compared to the 6 children who were not receiving medication, Mean
reduction scores = 7.83, SD
=
5.15, and 7.95, SD
=
4.97, respectively. ANOVA comparison of means showed there was no
significant difference in the scores for these two groups,
F(1,25)
= 0.00, ns.
This data suggests that the reduction in ADHD symptoms was not
related to children’s pharmacological treatment.
It was also noteworthy that, in a number of cases, parents stated
that they had been able to reduce their child’s medication
during the course of the SYM program. Of the 20 children who were
receiving medication when they started the program, 11 had reduced
the dose during SYM treatment -- two by less than half, six by
half, and three by more than half -- and 9 did not change the dose.
Table 1 (lines 3 and 4) presents the change in ADHD symptoms data
for these two subgroups. Comparison of means using ANOVA
indicated that
the improvement in the level of ADHD symptoms was significantly
greater for the 11 children who had reduced their medication
(Mreduction
=
10.18, SD
=
4.79) than for the 9 who had maintained the same level of
medication (Mreduction
=
5.22, SD
=
3.83), F(1,19)
= 6.31, p
=
.022. These findings suggest that SYM treatment not only
contributed to the reduction in children’s ADHD behavior
scores, but also had the added benefit of helping children manage
their own behavior with a reduced level of medication.
Post-treatment interviews with the children showed that being able
to stop or reduce daily medication was seen as a positive outcome
of the SYM program. A child who had stopped his medication
completely said he “felt great”, adding “I used
to hate having to be on my medication.” The children
identified a number of other benefits of SYM, not only during
meditation itself, which was described as “easy,”
“relaxing,” and like being “in your own bubble,
where no-one else can stop you from doing what you’re doing
at the time,” but also in other situations at home or at
school. One child said meditation “helps me with my
headaches;” another said he was “getting into less of a
panic;” another that meditation “gave him more energy,
but not energy to get ‘hyped-up’.” Many children
said they were able to get to sleep more easily. Benefits for
attention at school were also given; for example, children
commented that “it keeps me focused on my work;”
“it’s made me smarter; I seem to be able to concentrate
more;” “if my friends are talking around me, now I can
bring my mind straight back to my work.” Children also
mentioned having fewer social problems, such as “not getting
into trouble” or being able to ask the teacher for help
instead of retaliating when children were teasing them.
Parent perceptions of the outcomes of SYM for their child confirmed
these findings. When asked if they felt their child had benefited
from the SYM program, 92% agreed that they had. Particular benefits
for the child that were rated highly (over 3 on a 5-point scale) by
parents were “more confident in him/herself”
(M
=
3.35, SD
=
.93), “improved sleep patterns” (M
=
3.27, SD
=
1.42), and “more cooperative” (M
=
3.18, SD
=
1.01). High ratings for benefits related to school included
“less difficulty with the teacher” (M
=
3.64, SD
=
.92), “more able to manage schoolwork”
(M
=
3.56, SD
=
1.03), “more able to manage homework”
(M
=
3.47, SD
=
1.33), and “positive about going to school”
(M
=
3.43, SD
=
1.09).
As a further test of the effectiveness of the SYM treatment in
reducing ADHD symptoms, child (sex, age, medication status) and
family (mother’s age, secondary versus tertiary education,
single parent versus couple families) factors were tested as
covariates in six repeated measures analyses. Results showed that
none of the child or family factors contributed significantly to
the model. The conclusion from these analyses was that the
reduction in children’s ADHD behavior scores was attributable
to the SYM treatment, not to medication status, child, or family
characteristics.
Changes in ADHD-associated symptoms: Pre- and post-SYM treatment
program
Results
presented in this section are based on Study 1. Baseline data
indicated considerable variability in children’s scores.
Standardised scores on the Peabody Picture Vocabulary Test (PPVT)
ranged from a 48 to 139 (M
=
94.79, SD
=
23.43). Eight children had moderately low to extremely low scores
(less than 85), seven were average (85 to 115), and four had
moderately high to extremely high scores (over 115). Parent ratings
of behavioral indicators of child self-esteem ranged from low
(2.31) to high (4.54), with the mean score for the sample
(M
=
3.23, SD
=
.75) being mid-range, according to Burnett’s (1998)
descriptions. Children’s self-descriptive and self-evaluative
ratings of themselves were within normal range (M
=
4.18, SD
=
.46, range = 3.47 to 4.94) in comparison with the range of scores
reported by Burnett (1996) for children of a similar age. Quality
of child-parent attachment, as measured by Pianta’s
Child-Parent Relationship Scale (CPRS), ranged from low (2.33),
which indicated insecurity in the relationship, to moderately high
(4.03), which shows secure aspects. The overall mean score for the
30-item scale was midway on a 5-point scale (M
=
3.05, SD
=
.44) suggesting that, as a group, there were both insecure and
secure qualities in children’s relationships with their
parents. Examination of the subscale scores showed that scores on
the 13-item conflict subscale were elevated, M
=
3.47, SD
=
.80, indicating that the nature of the insecurity centred on angry,
difficult, and unpredictable interactions. This is consistent with
the insecure-ambivalent or -disorganised model of attachment
reported by Clarke et al (2002) for Children with ADHD. Scores for
open communication (3-item subscale, M
=
3.60, SD
=
.73) and warmth (8-item subscale, M
=
4.03, SD
=
.48), were moderate-to-high, indicating that dimensions of security
were also evident in the child-parent relationship.
Correlation analysis showed that children who were rated by their
parents as having higher self-esteem, and who rated themselves more
highly in their self-descriptions and self-evaluations, had more
positive relationships with their parents, rs(19)
= .47 and .47, respectively, ps
< .05. ADHD symptoms were not significantly related to
parent-child relationship quality or child self-esteem. There was
no relationship between PPVT scores and ratings of ADHD symptoms,
child self-esteem, or parent-child relationship
quality.
Post-treatment
scores showed that SYM was associated with significant improvements
in all of the parent-rated measures. Results are presented in Table
2. For each measure, mean pre- and post-treatment scores were
compared using paired sample t-test
analysis. ADHD symptom scores at the mid-point and final point were
significantly lower than the baseline score, Mpre
=
22.62, Mspost
=
15.94 and 16.25, ts
= 5.81 and 5.65, respectively, p
<
.001. A similar improvement was seen in parents’ reports of
their children’s confidence and social behavior, with average
scores increasing by a half-point at the mid- and endpoints of the
meditation program, Mpre
=
3.24, Mspost
=
3.69 and 3.73, ts
= -3.06 and -3.62, respectively, p
<
.01. Child-parent relationships also improved during the course of
the SYM treatment, rising by one-third of a point,
Mpre
=
3.06 Mpost
=
3.35, t
=
-3.34, p
<
.01. Examination of the subscale components of the CPRS showed that
this change was accounted for by lower scores for relationship
conflict, Mpre
=
3.37 Mpost
=
2.94, t
=
3.08, p
<
.01.
As a further check of the effectiveness of the SYM intervention, we
tested whether the observed changes in ADHD symptoms, self-esteem,
and relationship quality from weeks 1 to 6 were related to
individual child differences in cognitive ability, using repeated
measures analyses with baseline PPVT scores entered as a covariate.
Results for ADHD and self-esteem showed no significant contribution
of children’s PPVT scores, suggesting that the observed
improvements were not explained by differences in children’s
cognitive ability.
Scores for children’s self-description and self-evaluation
ratings of self-esteem did not change significantly from the
commencement to the end of the meditation program (see Table 2). It
should be noted, however, that the average scores were fairly high
at both points (4.2 and 4.3 on a 5-point scale), which may partly
explain the lack of significant change. Children with ADHD have
been known to inflate self-reported self-esteem (Hoza, Pelham,
Milich, Pillow, & McBride, 1993).
Final analyses examined the inter-relationships among the three
parent-rated measures by computing “improvement” scores
from the difference between pre- and post-treatment scores, and
comparing these using correlation analysis. Results showed no
relationship between improvement in child self-esteem and changes
in ADHD symptoms or CPRS. However, a decrease in ADHD symptoms was
strongly correlated with an increase in CPRS scores, that is, less
conflicted (more secure) parent-child interaction,
r(14)
= -.67, p
<
.01. Interestingly enough, the relationship between baseline ADHD
symptoms and relationship quality was not significant
(r(19)
= -.36, ns),
but at the end of the treatment the outcome scores on these
measures were highly correlated (r(14)
= -.66, p
=
.01), suggesting a change in family functioning processes during
the treatment program.
Parent responses to SYM
The SYM
intervention was designed as a family treatment program, which was
expected to impact on parents as well as children. At the end of
the program, 92% of parents agreed that the program had been
personally beneficial. The overall benefit was rated at 4
(M
=
3.91, SD
=
.92) on a 1 (low) to 5 (high) scale. Specific benefits rated highly
(over 3 on a 5-point scale) were “more able to manage
stress” (M
=
3.79, SD
=
.93), “less stressed” (M
=
3.67, SD
=
.96), “happier” (M
=
3.45, SD
=
1.01), “more able to manage anger” (M
=
3.37, SD
=
1.25), and “less angry” (M
=
3.29, SD
=
1.23). Parents were also asked to rate the extent to which they
felt that SYM had benefited the relationship they had with their
child. Mean scores on a 5-point scale showed a consistent pattern
of benefit, specifically for “more open communication”
(M
=
3.83, SD
=
.72), “less exhausting” (M
=
3.50, SD
=
.91), “more able to manage conflict”
(M
=
3.42, SD
=
.67), and “less conflict” (M
=
3.33, SD
=
.78). A number of parents commented that participating in the
program had made a positive change to their relationship with their
child. A father mentioned his pleasure at being able to laugh with
his son for the first time in years. One mother wrote “I
truly understand how me meditating and becoming more relaxed has
helped my son 150% because he feeds off a calmer mum.”
Parents also said they had used meditation at home to help deal
with difficult situations. One mother commented “I’m
now able to get N... to calm down (using meditation). He is then
able to focus and carry on with his day.” Another wrote about
how she dealt with a difficult time: “We had a good
meditation and he went off to bed quite calm and relaxed and went
straight to sleep.”
Discussion
The results of
this trial program indicate that Sahaja Yoga Meditation has a
potential for being a promising adjunct therapy for children with
ADHD, when offered via a family treatment approach and in
combination with existing medical treatment. Although results are
limited by the small number of children for whom complete data was
available, the consistency of the findings, which drew on different
measures of child outcomes, two treatment groups, and both parent
and child respondents, along with the significance of the results,
make a case for the benefits of the treatment. The results were
consistent with the three aims of the study. Firstly, core symptoms
of ADHD were improved: Parent ratings on the Conners Parent-Teacher
Questionnaire, which assesses attention, hyperactivity and
impulsivity, were significantly reduced over the course of the
program. Children also reported that they felt calmer, less
panicky, and more relaxed. Secondly, associated symptoms of ADHD,
such as anxiety and poor confidence, were reduced: Parent ratings
of child self-esteem showed significant improvements in
children’s confidence, social abilities, and involvement.
Thirdly, functional benefits were noted: Child-parent relationship
quality improved through a significant reduction in the level of
conflicted interactions. Parents reported that the children’s
approach to school and homework had improved during the SYM
program, and the children themselves said that they were more able
to concentrate at school. Improved sleep was another positive
outcome reported by parents and children.
Evidence for the effectiveness of the SYM intervention, over other
possible contributors, was provided by the group of
“wait-list” children whose baseline ADHD scores
remained the same over two pre-treatment assessment points, and
then dropped significantly over the six-week SYM program.
Statistical evidence for the benefits of SYM in improving child
outcomes was demonstrated in a series of repeated measures
analyses, which entered child and family factors as covariates.
These tests showed that the reduction in ADHD symptoms and the
improvements in self-esteem and child-parent relationship quality
were not explained by child age, sex, medication status, or
cognitive ability, or by family structure, mothers’ age, or
education.
This initial investigation of SYM for managing ADHD was not able to
include the design features of a clinical trial, which would allow
allocation and comparison of treatment groups such as SYM in
combination with pharmacological treatment and SYM alone. The
children who entered the program also varied in the severity of
their ADHD symptoms and use of medication. Three-quarters of the
children were receiving psychostimulant drugs at the commencement
of the program and combined this with the SYM treatment, while the
non-medicated children only used SYM. Although the numbers in the
latter group were very small, it was noteworthy that the observed
reduction in ADHD symptoms did not differ by children’s
initial medication status. Further evidence that the improvements
were attributable to the SYM intervention (and not to medication)
comes from the fact that over half of the children who were taking
prescribed medication had been able to reduce their medication
during the course of the treatment. Furthermore, these children
also showed significantly greater improvements in ADHD-related
behaviors than the children who maintained their initial level of
medication. The fact that the SYM effects occurred regardless of
concurrent medication suggests an interesting corollary to reports
from the Multimodal Treatment (MTA) Study of children with ADHD
that “intensive behavioral treatments are a viable
alternative to medication in treatment of ADHD” (Pelham et
al, 2000, p. 523). In the current study, the treatment was not
behavioral, but it was intensive in design, involving parents and
children in twice daily meditation sessions at home and regular
clinic sessions with trainers. Like the MTA findings, the SYM
results are encouraging for parents and communities seeking ways to
minimise child medication.
Despite these
promising results, the study is not without its limitations. The
small sample size has been mentioned. A replication using larger
numbers of participants will be essential to replicate the observed
findings. Another criticism is that significant findings relied
solely on parent-rated questionnaires. The reported improvements in
child outcomes and child-parent relationship might be ascribed to
parents wanting to present themselves and their child in the best
light. If this were the case, however, one would expect to see
similar levels of change across the three parent-rated
questionnaires, whereas results showed that improvement in ratings
of self-esteem were independent of improvements in ADHD symptoms
and relationship quality. This suggests that parents were not
reporting a non-discriminate or overly positive picture of their
child, but were giving an accurate report based on observed
behavior. In fact, other studies have shown that parents’
ratings of their children’s improvements are similar to
ratings by teachers and counsellors (Pelham et al., 2000).
Furthermore, endpoint interviews with the children provided many
examples of the benefits they had experienced from the SYM program,
which supports the accuracy of their parents’ reports. It is
also possible that the findings of this study are biased by the
relatively large drop-out rate. It is conceivable that some of
those parents who did not continue the treatment were also those
who did not notice an improvement.
This study was a within-group design and we did not include a
control group. Clearly, to prove the effectiveness of the method,
future study designs will have to include a control group, use
stricter methodologies including larger and more homogenous
populations, unified treatment protocols, valid and reliable
outcome measures, teacher as well as parent ratings, and follow-up
reports to investigate the longevity of benefits.
We noted that scores on self-report measure of child self-esteem
(which had been relatively high at both points) did not show any
change over the six-week intervention. Previous research suggests
that children with ADHD may inflate self-rated measures of
self-esteem (Hoza et al, 1993). This would make it difficult, in a
small mixed sample, to interpret child scores reliably. It may also
be that the measure used in the present study, which was not
designed for clinical samples (Burnett, 1994, 1998), does not
adequately tap the problems of self-esteem that children with ADHD
suffer.
Questions remain
about the underlying processes that may account for the success of
the SYM intervention. The strong association between decreased ADHD
symptoms and greater security in the child-parent relationship over
the course of the SYM program points to a transactional model of
effects. The observed interrelationship between ADHD symptoms and
more conflict in the child-parent relationship is consistent with
Keown and Woodward’s (2002) finding that “boys who
experienced less synchronous interactions (which are characteristic
of insecure relationships) with their mothers were 8 times more
likely to be hyperactive than comparison children” (p. 549).
Interactional synchrony, they argue, is more likely when parents
are more able to manage their child’s behavior. Because the
benefits of the SYM treatment reported by parents included being
more able to manage stress, angry feelings, and conflict in
relationships with their child, it is not implausible to suggest
that an important outcome of the meditation program was
parents’ sense of being more relaxed and competent in dealing
with their child’s ADHD-related problems. Relationship
benefits may also be linked to the nature of the intervention,
which provided instruction for parents in SYM techniques that they
could use with their child at home.
While the mechanism of action of SYM in managing ADHD has yet to be
identified, a neural regulatory mechanism also seems likely. Recent
modern functional imaging studies have shown that the reduction of
thoughts in the meditation process reduces activity in frontal and
other cortical brain regions (thought to originate thought
processes), while increasing activation in limbic brain areas (Lou
et al., 1999, Lazar et al., 2000). High resolution EEG studies have
shown that SYM leads to increased alpha and theta power over
anterio-frontal and fronto-central brain regions, and to reduced
complexity of EEG patterns (Aftanas & Golocheikine, 2001,
2002). Because decreased complexity of the EEG from fronto-cortical
regions is correlated with increased attentional control over
cognitive processing (Molle et al., 1995, Lutzenberger et al.,
1995), it has been suggested that reduced complexity of EEG
patterns during meditative experience in SYM may reflect switching
off irrelevant networks for the maintenance of focused internalised
attention and inhibition of inappropriate information (Aftanas
& Golocheikine, 2002). It is thus possible that the causal
mechanism underlying the positive effect of SYM on the improvement
of ADHD symptoms occurs via changes on frontal brain activation in
ADHD children during the meditation. Since frontal dysfunction is
the most consistent finding in ADHD (Rubia & Smith, 2001), a
change in frontal brain activation during the six weeks of SYM may
well have been the cause for the symptom improvements.
Other possible, yet unexplored mechanisms of action, could be a
balancing effect of meditation on neurotransmitter systems. In
fact, a recent study using positron emission tomography has shown
that meditation increases endogenous levels of dopamine in the
striatum by as much as 65%, which correlated with an increase in
EEG theta activity (Kjaer et al., 2002). As ADHD has been
associated with elevated dopamine transporter (DAT) levels (Cheon
et al., 2003; Dougherty et al., 1999; Krause et al., 2000),
a
meditation-induced
change in endogenous striatal dopamine levels could, in fact, be a
plausible hypothetical mechanism for the amelioration of ADHD
symptoms. Further research using modern imaging techniques will be
necessary to explore the mechanisms of action of
SYM.
In sum, this is
the first study investigating the effect of Sahaja Yoga Meditation
as treatment for ADHD behaviors. The study aimed to investigate SYM
as an additional family-oriented treatment, alongside any
conventional medical treatment that was received by the children,
and the design of the study was not meant to compete with
medication treatment. Preliminary findings provide initial evidence
of the benefits of SYM in alleviating the behavioral symptoms of
children diagnosed with ADHD, confirmed through parent report and
children’s own evidence. According to the children, these
benefits extended beyond the immediate environments of the home
into the classroom. Furthermore, the fact that confirmatory
analyses provided evidence that medication did not add
significantly to the changes observed with SYM, it may be of
interest for the future to compare the meditation effects in
medication-free and medicated children, or even to compare SYM with
other behavioural treatments for ADHD. Rigorously controlled
clinical trials on larger samples would be needed to assess the
relative effect of SYM as an alternative or complementary treatment
for ADHD. However, the indications are that SYM has a potential to
offer families an effective management tool for family-oriented
treatment of childhood ADHD.
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Acknowledgements
The authors
gratefully acknowledge the contribution of Alice Bhasale, Robert
Hutcheon, Kim Pearce, Liallyn Fitzpatrick, Ione Docherty, and other
Sahaja Yoga instructors who provided training for the participants
on a voluntary basis. We also thank the Royal Hospital for Women,
University of New South Wales, for providing facilities for running
the meditation clinic. Sarah Yates’ help with data entry is
gratefully acknowledged.
Table 1. Changes in Child ADHD Symptoms during the Meditation
Program by Medication Status for Study 1 and 2 Combined
Sample
Commencement
Final Point Symptom Change
(Week 1) (Week
6) (Week 1 to 6) ANOVA
_____________________________________________________________________________________________________________
Medication
Status a
n
Mpre
SD n
Mpost
SD n
Mreduction
SD
F ratioc
df
No medication 14
21.50 4.86 6 14.50 1.52 6 7.83 5.15 0.00 1,25
Receiving
medication 31 23.16 4.08 20 14.65 5.86 20 7.95 4.97
---------------------------------------------------------------------------------------------------------------
Reduced
dosage b
11
24.00 4.90 11 13.81 7.11 11 10.18 4.79 6.31*
1,19
No change of dose 9 20.89 3.33 9 15.67 4.03 9 5.22 3.83
______________________________________________________________________________________________________________
Notes:
*
p
<
.05
a
Medication
status information was only available for 45 of the 48 children who
began the program; 3 parents did not answer this
question.
b
Data
is presented for the 20 children who completed the 6-week program
and were receiving medication at Week 1
c
ANOVA tests were
conducted to compare group means for Commencement, Final Point, and
Symptom Change scores. The first analysis compared mean scores for
the group receiving medication versus the group not receiving
medication, F(1,25)
= 0.00, ns.
The second analysis compared mean scores for the group who reduced
dosage versus the group who had no change of dosage,
F(1,19)
= 6.31, p
=
.022. No other ANOVA comparison achieved significance.
Table 2. Changes in Child Outcomes and Parent-Child Relationship
Quality during the Meditation Program for Study 1
Sample
Commencement
Mid-Point Final Point Paired Samples t-tests
(Week 1) (Week
3) (Week 6) Time 1-3 Time 1-6
__________________________________________________________________________________________________________
Measure
M SD M SD M
SD t t
1.
Child Outcomes
Parent-rated
ADHD symptoms
22.62 4.06 15.94 4.99 16.25 5.48 5.81***
5.65***
Indicators of
self-esteem 3.24 0.78 3.69 0.37 3.73 0.48 -3.06**
-3.62**
Child
self-report
Rating of
self-esteem 4.28 0.43 4.24 0.63 0.43
2.
Parent-Child Outcomes
Child-parent
relationship 3.06 0.45 3.35 0.42 -3.34**
Conflict
subscale 3.37 0.81 2.94 0.73 3.08**
Warmth subscale
3.93 0.38 4.00 0.39 -0.82
Open subscale 3.55 0.71 3.71 0.70 -1.20
___________________________________________________________________________________________________________
Notes:
***
p
<
.001; **
p
<
.01
Authors’ Biographical Statements
Dr
Linda Harrison
Has worked in teacher education and developmental psychology for 15
years, specialising in children's attachment relationships with
parents and teachers and how these explain socio-emotional
adjustment over time. Currently involved in the design and
implementation of large research projects investigating family
and child care predictors of children's development, health, and
wellbeing, including the Longitudinal Study of Australian Children,
the Sydney Family Development Project, and the New South Wales
Child Care Choices study.
Dr Katya Rubia
Work has focused on cognitive neuroscience of
executive and attention functions and in determining the
neurobiological basis of ADHD by use of functional magnetic
resonance imaging (fMRI). Currently investigating the
neurobiological basis of executive dysfunctions in major
developmental disorders such as ADHD, conduct disorder,
obsessive-compulsive disorder, depression and
autism.
Dr Ramesh Manocha
Presently involved in
clinical trial evaluation of natural and complementary therapies.
Has a special interest in scientific assessment of meditation
techniques. Ongoing involvement in assessment of health
professional knowledge of natural medicines and issues relating to
their appropriate application, safety and manufacture. Recipient of
Bernard Lake Memorial Prize for complementary medicine
research.