Investigation of the Effect of Yoga on Balance, Reaction Time and Agility in Children With ADHD
Condition: Yoga; ADHD; Balance; Children, Only
Study type: Interventional

Summary: 
      Purpose: To determine the effect of 8-week kids yoga training on balance, reaction time and
      agility on children diagnosed with attention deficit hyperactivity disorder (ADHD).

      Method: A randomized controlled trial. The intervention (kids yoga) was an 8-week program
      administered to children attending a special education center by a yoga instructor
      occupational therapist. Outcomes included Pediatric Balance Scale, Bruininks-Oseretsky Motor
      Proficiency Test-Short Form, and Microgate Witty SEM System assessed at baseline and at the
      end of 8th week.
    

Detailed description: 
      Introduction According to the fifth revision of the diagnostic and statistical manual of
      mental disorders (DSM-5), attention deficit and hyperactivity disorder (ADHD) is a
      heterogeneoud disorder that causes behavioral problems in at least two domains of life,
      lasting at least 6 months. Behavioral disorders usually manifest themselves in the school
      period and are characterized by hyper-motor skills, increased distractibility and attention
      disorders, impulsivity, and psychosocial adjustment disorders.

      It is known that many children with ADHD have impairments in executive functions such as
      working memory, attention, emotion regulation, and inhibitory control. In addition to the
      cognitive function problems that are widely known and frequently emphasized in the
      literature, it is known that children with ADHD also have difficulties in activities that
      require motor coordination, such as handwriting. Several studies have found that children
      with ADHD perform poorly on motor skills tests assessing fine and gross motor areas.

      Cho et al. (2014) stated that 30-70% of children with ADHD have motor control problems and
      these problems cause problems in their neurobehavioral development. School-age children with
      motor problems may face many problems such as the desire to avoid physical activity, obesity,
      lack of concentration, low self-esteem, school performance and inadequacy in social
      relations. Motor impairment, which causes problems with cycling, dressing, tying shoelaces
      and/or writing, may cause problems in children's social participation, peer relationships,
      and adaptation in daily life. Therefore, early detection and intervention of motor delay can
      reduce feelings of inadequacy, depression, frustration, and anxiety in children with ADHD and
      prevent long-term negative effects on social development and academic achievement.

      The most commonly used treatment options for ADHD are pharmacological and psychosocial
      interventions. Parents may not prefer pharmacological methods because of their stimulating
      effect on the general health of their children. It is known that the effects of behavioral
      interventions cannot be generalized to non-target environments and behaviors. Considering
      these limitations, there is a trend towards different complementary methods for the treatment
      of ADHD. Among the complementary treatment options, there are methods such as meditation,
      yoga, massage, homeopathy, acupuncture, neurofeedback, nutritional supplements, and few foods
      diet.

      In recent years, yoga programs for children have been widely used as a mind-body supplement
      and alternative medicine intervention to improve physical and mental health conditions, as
      the benefits of yoga practice in promoting general health are recognized. Yoga has many
      comprehensive types, and child yoga, one of them, is a fairly new type of yoga that can
      increase children's mental focus by providing mind, soul and body awareness, improve their
      enjoyment of life, social relationships, self-esteem and self-confidence levels. Kids yoga
      consists of compositions such as games, stories, postures, breathing exercises, imitations of
      living things in nature, memory games. While physical exercises (asanas) can increase the
      physical flexibility, coordination and strength, breathing practices and meditation are used
      to increase awareness and reduce anxiety and improve children's quality of life. Other
      beneficial effects include reduction of blood pressure, and improvements in endurance, mood,
      and metabolic regulation.

      Yoga practiced in childhood mainly improves balance as well as proper postural alignment,
      musculoskeletal strength and endurance. In addition, the literature suggests that yoga
      training can improve motor planning, execution, reaction time, and agility. Studies conducted
      in many parts of the world have revealed the results on the effects of yoga in children, and
      various studies are carried out on the effect of yoga on short-term heart rate variability in
      children with autism, physical fitness in school-aged asthmatic children, psychomotor skills
      in mentally retarded children, and quality of life in children with hemophilia. In addition,
      there are studies on the effects of yoga on impulsivity, hyperactivity, attention and
      behaviors, executive functions and cognitive motor functions in children with ADHD. Yoga
      remains an investigational therapy, but more research is needed on its possible uses for this
      population. In this study, it was aimed to examine the effect of yoga on balance, reaction
      time and agility in children with ADHD.

      Methods Study Design The present investigation is a cross-sectional study planned to examine
      the effect of yoga on balance, reaction time and agility in children with ADHD. An 8-week
      randomized controlled trial design following Consolidated Standards of Reporting Trials
      (CONSORT) recommendations was used in the study.

      The study was carried out in accordance with the Declaration of Helsinki and was approved by
      the Ethics Committee of Non-Invasive Clinical Researches of Hacı Bektaş Veli University (No.
      2100082713).

      After the power analysis using G*Power version 3.1.9.4 software, it was calculated that 16
      individuals with ADHD should be included in the study with a 5% type 1 error rate to reach
      0.80 power. The minimum estimated sample was 15 participants, allowing for an estimated 15%
      dropout at follow-up.

      Individuals were randomly divided into the intervention and control groups using
      computer-assisted online randomization application and simple randomization method in equal
      probability and in equal numbers, and kids yoga was applied to the intervention group.
      Participants were randomly numbered from 1 to 20, and the randomization of numbers under kids
      yoga (n=10) and control groups (n=10), without repeating the same number, using the online
      randomization application at https://www.randomizer.org/ appointed with. A total of 20
      children were recruited and agreed to participate in the study. Because the individuals in
      the control group give education a rest, 3 participants left the study voluntarily.

      The research team consisted of an occupational therapist who was blinded to the group
      distribution for assessments, an occupational therapist with a certificate of yoga training
      who conducted the yoga sessions, and physiotherapist and occupational therapist researchers
      who analyzed the evaluation results. The data were collected at 2 time points (baseline
      [April 2022] and post-test [June 2022]).

      Participants The children who were diagnosed with ADHD by a child and adolescent psychiatrist
      according to DSM-V diagnostic criteria and were educated at Ankara Special Education Center
      were included in the study.

      Inclusion criteria for the study were (1) the participants were between the ages of 6-10 and
      (2) received an occupational therapy treatment program. Exclusion criteria were (1)
      participants had a different diagnosis such as autism spectrum disorder, asperger's syndrome,
      pervasive developmental disorder, (2) had an additional psychiatric problem, (3) had a
      serious medical condition (for example, severe cerebral palsy) or intellectual disability (IQ
      < 70), (3) sought specialist help for sleep problems was determined as having a positive
      screening test for obstructive sleep apnea and (4) had excessive behavioral disorders
      incompatible with group participation.

      Children who agreed to participate and met the inclusion criteria and their parents/guardians
      were informed about the aims of the study and their written informed consent was obtained.

      Interventions The kids yoga was applied to the intervention group for 8 weeks, once a week (8
      sessions), 40 minutes per session, by a yoga instructor occupational therapist.

      Kids yoga training included: 5-minute warm-up consisting of jogging, jumping, stretching,
      relaxation exercises; 20 minutes of asanas (positions) consisting of standing, sitting,
      prone, supine postures and pranayamas (breathing exercises) consisting of vigorous
      inspiration and expiration, slow and rhythmic alternating nostril breathing; 10-minute yogic
      games about balance, reaction time and agility; meditation with focus for 5 minutes with
      resuscitation techniques.

      Instruments Sociodemographic Information Form The sociodemographic information of the
      children was recorded in the information form. In the form, information such as date of
      birth, age, gender, school class, number of siblings, and parental marital status were
      obtained from the families of the children.

      Pediatric Balance Scale (PBS) The Pediatric Balance Scale is an assessment that is used to
      assess functional balance skills in school-aged children. The scale consists of 14 items that
      are scored from 0 points (lowest function) to 4 points (highest function) with a maximum
      score of 56 points. The scale consists of sitting to standing, standing to sitting,
      transfers, standing unsupported, sitting unsupported, standing with eyes closed, standing
      with feet together, standing with one foot in front, standing on one foot, turning 360
      degrees, turning to look behind, retrieving object from floor, placing alternate foot on
      stool, reaching forward with outstretched arm. In the study; ın the pedıatrıc balance scale
      standing with one foot in front, standing on one foot, turning 360 degrees, and placing
      alternate foot on stool sub-scales was applıed.

      Bruininks-Oseretsky Test of Motor Proficiency-Short Form (BOT-SF) BOT-SF, which was developed
      to measure the motor functions of individuals between the ages of 4-21, is applied to the
      participants individually. The test materials, consisting of eight subtests and a total of 46
      items, are a comprehensive motor proficiency indicator and measure both gross and fine motor
      skills.

      BOT-SF materials are designed to attract children's attention, provide a uniform application
      opportunity, and facilitate application and evaluation. It consists of eight domains: running
      speed and agility, balance, bilateral coordination, endurance, arm-hand coordination,
      reaction speed, visual motor control, arm speed and manual dexterity. The highest score is
      243 points. In our study, the response speed, running speed and agility sub-parameters of
      BOT-SF were used. In the BOT-SF running speed and agility sub-parameters, the score
      corresponding to the time in the distance run was recorded.

      Microgate Witty SEM System The reaction time was recorded using the photocell system
      MICROGATE. The Witty SEM diagnostic system consists of eight photocells arranged in rows on a
      mat, 10 cm apart. Participants are asked to react as quickly as possible with their dominant
      hand to the green photocells that light up 20 times in sequence. In this test, visual stimuli
      are created immediately after each response. The best overall reaction time is recorded after
      two trials.

      Statistical Analyses Statistical analyses were performed using SPSS software version 22. The
      variables were investigated using visual (histograms, probability plots) and analytical
      (Kolmogorov Simirnov/Shapiro Wilk test) methods to determine whether or not they are normally
      distributed. Descriptive analyses were presented using medians and interquartile ranges (IQR)
      for the non-normally distributed and ordinal variables. Since the data of children's age,
      balance scores, agility scores and reaction speed scores were not normally distributed,
      non-parametric tests were conducted to compare these parameters. The Mann-Whitney U test was
      used for pairwise comparisons for the intervention group and the control group. Wilcoxon
      Signed Rank Test was used to analyze pre- and post-measures for all variables. An overall 5%
      type-I error level was used to infer statistical significance.
    

Intervention name(s): kids yoga
Intervention type(s): Other
Intervention description(s): The kids yoga was applied to the intervention group for 8 weeks, once a week (8 sessions), 40 minutes per session, by a yoga instructor occupational therapist.
Kids yoga training included: 5-minute warm-up consisting of jogging, jumping, stretching, relaxation exercises; 20 minutes of asanas (positions) consisting of standing, sitting, prone, supine postures and pranayamas (breathing exercises) consisting of vigorous inspiration and expiration, slow and rhythmic alternating nostril breathing; 10-minute yogic games about balance, reaction time and agility; meditation with focus for 5 minutes with resuscitation techniques.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A Randomized Controlled Trial
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment