The Effects of Yoga on Attention, Impulsivity and Hyperactivity in Pre-school Age Children
Condition: ADHD
MeSH terms: Hyperkinesis; Impulsive Behavior
Study type: Interventional

Summary: 
      This pilot project will evaluate yoga as an intervention to improve attention and reduce
      challenging behaviors such as hyperactivity and impulsivity, rated by parent and teachers, in
      preschool age children with or "at risk" for attention-deficit hyperactivity disorder (ADHD).
      "At Risk" for ADHD will be defined as four or more hyperactive/impulsive and/or inattentive
      symptoms on the ADHD Rating Scale IV-Preschool Version as rated by parents or teachers. Using
      a randomized wait-list controlled experimental design, the investigators will explore the
      efficacy of practicing yoga for 6 weeks on behavioral symptoms, attentional control using a
      computer based tasks of attention, and heart rate variability (HRV), which is a measure of
      self-regulatory capacity. The investigators hypothesize that practicing yoga for six weeks of
      will improve ADHD and other behavioral symptoms based on parent and teacher rating scales,
      which will correlate with improvements in scores on the computer based task of attention as
      well as with improvements in HRV.
    

Detailed description: 
      Background: Symptoms of attention-deficit hyperactivity disorder (ADHD) are often observable
      by preschool age and can be associated with similar behavioral, social, and cognitive
      impairments as seen in older children with ADHD. Seventy to eighty percent of preschoolers
      with symptoms of ADHD continue to display these symptoms in elementary school. Behavioral
      therapies are recommended as first line treatments in this age group. There have been some
      small but promising studies looking at yoga as an intervention for school age children with
      ADHD, but none have looked specifically at yoga as an intervention for preschool age children
      with ADHD symptoms (Birdee et al, 2009).

      Objective: To determine if yoga improves hyperactive/impulsive symptoms and attention in
      preschool age children with or "at risk" for ADHD.

      Study design: A randomized wait-list controlled trial exploring whether 6 weeks of children's
      yoga improves behavioral symptoms, task-related scores of attention, and increases heart rate
      variability in preschool age children "at risk" for or diagnosed with ADHD. The investigators
      plan to enroll a total of 30 children ages 3-5 years old. "At risk" for ADHD will be defined
      as four or more inattentive or hyperactive/impulsive symptoms rated by parents and teachers
      on the ADHD Rating Scale-IV Preschool Version.

      Procedures: The investigators will evaluate the efficacy of yoga for improving ADHD and other
      behavioral symptoms using parent and teacher rating scales (ADHD Rating Scale-IV Preschool
      Version; Strengths and Difficulties Questionnaire), as well as objective measures including
      computer based tasks of attention and executive function (KiTAP, Test of Attentional
      Performance for Children), and heart rate variability (HRV), a physiologic measure of
      self-regulatory capacity. HRV will be assessed during an active, attention computer task
      (using the emWave ® desktop device), as well as during a relaxed state, in a breathing
      exercise paired with verbal affirmations. The protocol includes baseline, post-treatment and
      3 month follow-up assessments. The intervention consists of school and home yoga sessions.
      School sessions will be held twice a week at Triumph Center for Early Childhood Education,
      which is a local preschool associated with University of California, Davis. The school based
      yoga classes will be lead by trained child yoga instructors using a manualized yoga protocol
      that is 30 minute long. Home session will include use of a children's yoga video featuring
      the same protocol to practice at home on the days that the children do not participate at
      school. The goal is for daily yoga practice during the 6 week intervention period. Home yoga
      practice will be documented daily by parents completing a brief online survey that is emailed
      to them. Generalization of the skills learned during the yoga sessions to
      behaviorally-challenging situations will be specifically developed by teaching the parents
      and teachers to "cue" the children to integrate skills learned in the yoga sessions into
      their daily routine. The goal is for the children to learn to use breathing practices and
      affirmations to help regain calmness and focus when their behaviors become challenging. A
      questionnaire will assess parent and teacher perception regarding the use of yoga in the
      children's daily life, its effect on challenging behaviors, and their satisfaction with the
      intervention. Optional focus groups will also be done with the parents and teachers of the
      children who participate in the study in order to gather qualitative data about the yoga
      intervention.

      Statistical Methods and Power Analysis: Outcome distributions will be visualized and, if
      necessary, log-transformed to reduce skewness or stabilize variances. For this wait-list
      design, the primary assessment of treatment effects will be estimated by comparing treatment
      and control groups on baseline-adjusted mean outcomes at the first follow-up and reported
      with 95% Confidence Intervals. Between- and within-group contrasts involving outcomes at the
      2nd follow-up time will permit exploration of treatment durability. The primary index of HRV
      will be the standard deviation of beat-to-beat intervals, but other time- and
      frequency-domain indices will be evaluated in exploratory analyses. Assuming pre/post
      correlations of 60%, our target sample size of 30 subjects will permit estimating treatment
      effects with margins of error of 0.41 standard deviations and provide 80% power (with 2-sided
      alpha=5%) to detect between-group effects as small as 0.59 standard deviations.

      Gaps in knowledge: The majority of the studies on yoga for children with ADHD have been
      conducted in school aged children, and only one was completed in the United States. None have
      looked specifically at yoga as an intervention for ADHD symptoms in preschoolers. In
      addition, none of these studies included physiologic measures such as vagal tone, which has
      been shown to increase in adults who practice yoga. Physiologic measures are valuable because
      they are an objective measure of treatment response, may give evidence to support the role,
      and perhaps mechanism by which yoga may affect change in ADHD. The investigators will assess
      heart rate variability (HRV), a measure of the beat-to-beat changes in heart rate, which
      reflects the activity of the vagus nerve, a key component of the parasympathetic nervous
      system, which mediates changes in heart rate. Reduced HRV is associated with increased
      morbidity and mortality, while increased HRV is associated with physiologic resiliency, the
      ability to self-regulate and improved performance on tasks of executive function. Compared to
      healthy controls, children with ADHD have higher mean heart rates, and unmedicated children
      have significantly decreased HRV. In adults, HRV has been found to increase in response to
      both exercise and biofeedback. A study in children with ADHD evaluated the use of biofeedback
      using HRV coherence, synchronization of the heart rhythm pattern, and found that it improved
      cognitive function and behaviors. HRV has not been evaluated in relation to yoga training in
      young children with ADHD symptoms.

      Innovation: This project is novel in its subject population, preschoolers, teaching of yoga
      at the school, use of manualized treatments, objective measures and wait-list randomized
      control methodology. While there are many studies in exercise, yoga and meditation for
      children, many lack sophisticated methodology to guide clinical practice. The proposed
      methods are not highly innovative, but they are critical to moving the field forward and
      providing direction to clinicians, parents and teachers in need of research to guide their
      clinical decision-making.
    

Intervention name(s): Children's Yoga
Intervention type(s): Behavioral
Intervention description(s): Trained children's yoga instructors will guide the children through 30 minute yoga classes (in-person and on the yoga video), using a manualized curriculum from If I Was a Bird Yoga ™ with child centered themes. Each class will have a similar structure, set of poses, and breathing exercises, but the theme of the class will change every two weeks. The themes for the classes are "ocean yoga adventure", "jungle yoga adventure" and "outer space yoga adventure". The study participants will spend two weeks practicing the same theme at home and at school before moving on to the next theme.
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Attention; Hyperactivity; Impulsivity; Yoga; Preschool