TAI CHI FOR ATTENTION DEFICIT HYPERACTIVITY DISORDER 
Attention Deficit Hyperactivity Disorder Benefits from Tai Chi

Maria Hernandez-Reif, Tiffany M. Field and Eric Thimas
Touch Research Institute University of Miami School of Medicine
Acknowledgements
The authors thank the children and teachers who participated in this study. This research was supported by an NIMH Research Scientist Award (#MHO0331) and an NIMH Research Grant (#MH46586) to Tiffany Field, and a grant from Johnson and Johnson to the Touch Research Institute. Correspondence and requests for reprints should be sent to Dr. Tiffany Field, Touch Research Institute, University of Miami School of Medicine, P.O. Box 016820, Miami, FL 33101
Abstract
Thirteen adolescents with ADHD participated in Tai Chi classes twice a week for 5 weeks. Teachers rated the adolescents' behaviors on the Conners Scale during the baseline period, after the 5 week Tai Chi period and two weeks later. After the 10 Tai Chi sessions the adolescents displayed less anxiety, daydreaming behaviors, inappropriate emotions and hyperactivity and improved conduct. These changes persisted over the two-week follow up (no Tai Chi) period.
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Attention Deficit Hyperactivity D'isorder Benefits from Tai Chi
Attention Deficit Hyperactivity Disorder (ADHD) is characterized by cognitive and behavioral deficits including inattention, impulsivity and hyperactivity levels inappropriate for age and gender (DSM-III-R, American Psychiatric Association, 1987). Although short-term improvements have been reported in academic and social functioning ~lit.h drug therapy such as methylphenidate or Ritalin (Schachar & Tannock, 1993; Swanson et aI, 1995), side-effects such as motor tics, insomnia, headaches, and social withdrawal make this treatment controversial (Handen, Feldrnanm Gosling, Breaux et al., 1991; Parraga & Cochran, 1992).
Non-pharmacological treatments include counseling, parent/family training in behavior modification techniques, relaxation and massage therapy. Counseling treatments have received little empirical attention and reports are mostly anecdotal (Schwiebert, Sealander & Tollerud, 1995). Behavior modification techniques have attempted to facilitate the child's performance and attention by including scheduling changes, rearranging home and classroom settings, and training teachers, parents and siblings in differential reinforcement techniques (Blakemore, Shindler & Conte, 1993). Although some studies have shown that behavioral modification is effective (Damico & Armstrong, 1996), one study showed that ADHD adolescents had a weak behavioral inhibition system (Iaboni, Douglas & Blaine, 1997), which made them poor candidates for behavioral programs. Although relaxation therapy has alleviated depression in adolescents (Platania-Solazzo, et al, 1992), it has had limited effects in treating ADHD (Field, Quintino & Hernandez-Reif, 1997) perhaps because of the demands relaxation therapy places on concentration. Massage therapy, in contrast, has been effective in increasing time spent on task, reducing fidgeting, improving mood and lowering hyperactivity scores in adolescents with ADHD (Field, Quintino & Hernandez-Reif, 1997).
Tai Chi has been effective with adults by reducing stress and stress hormones (Jin, 1992), anger and confusion, and improving, mood (Brown, Wang, Ward, Ebbeling, Fortlage, Puleo, Benson & Rippe,
1995; Wolf, Barhhart, Kutner, McNeely, Coogler & Xue, 1996). In addition, Tai Chi results in lower blood pressure (Channer, Barrow, Barrow, Osborne & Ives, 1996) and improved balance (Wolfson, Whipple, Derby, Judge, King, Amerman, Schmidt & Smyers, 1996). The present study examined the effects of Tai Chi on anxiety, mood, hyperactivity and conduct in adolescents with ADHD.
Method Participants
Thirteen adolescents (11 males), with a mean age of 14.5 years, (R = 13-16) and a DSM-IIIR diagnosis of ADHD were recruited from a remedial school for adolescents with developmental problems. The adolescents carne from middle class f~ilies (~= 2.2 on Hollingshead Two Index Factor) and were ethnically distributed 70% Caucasian, 15% Hispanic and 15% African American.
Procedure
Tai Chi. The adolescents engaged in Tai Chi postures for 30- minute sessions twice a week for 5 weeks. Each mid-afternoon session began with slow raising and lowering of the arms in synchrony with breathing exercises for 5 minutes. The adolescents were then taught to perform slow turning and twisting movements of the arms and legs, shifting body weight from one leg to the other, rotating from side to side and changing directions in a sequence of Tai Chi forms.
An A1B1A2 design was used consisting of a baseline phase (without Tai Chi) (A1) , as-week Tai Chi phase (B1), and a two week follow up phase without Tai Chi (A2). At the end of each phase, the teachers, who were not aware of which adolescents were receiving Tai Chi at what time completed the Conners Teacher Rating Scale.
Conners Teacher Rating Scale - Revised (CTRS-R; Goyette, Conners & Ulrich, 1978). This 28 item teacher rating scale yields a total hyperactivity score in addition to the subcategories of anxiety, asocial behavior, conduct, daydreaming, emotion and hyperactivity. Test-retest reliability coefficients of .97 have been reported over a one-week period for this scale (Goyette, Conners & Ulrich, 1978).
Results Repeated measures analyses of variance were performed on the subcategories and total hyperactivity score of the Conners. As can be seen in Table 1, repeated measures effects were obtained for all but the asocial scale.
Insert Table 1 about here
Bonferroni t-tests suggested the following baseline to Tai Chi therapy changes: 1) less anxiety, 2) improved conduct, 3} less daydreaming, 4} less inappropriate emotions, and 5} less hyperactivity during Tai Chi versus before Tai Chi (see Table I). Bonferroni t-tests also revealed that these improved scores persisted over the two-week follow-up (no Tai Chi) period.
DISCUSSION
The results of this study and our earlier massage therapy study (Field, Quintino & Hernandez-Reif, 1997) suggest that at least two non-drug therapies are effective for adolescents with ADHD. The positive effects of Tai Chi on the adolescents with ADHD parallel the positive effects for adults including reduced mental and emotional stress (Jin, 1992) and improved mood (Jin, 1989).
Although stress hormone levels were not assayed in this study, the adolescents were perceived by their teachers as being less anxious, emotional and hyperactive following Tai Chi. The adult literature has reported reduced stress hormones (cortisol) with Tai Chi (Jin, 1992) .
Tai Chi research on adults has identified changes in cardiovascular, respiratory, electroencephalographic, and biochemical levels (e.g., lower cortisol stress hormone levels) (Brown, Mucci, Hetzler, & Knowlton, 1989; Jin, 1989). Reduced sympathetic activity, or enhanced parasympathetic activity, has been considered a potential underlying mechanism (Hsu, Wang & Kappagoda, 1985). This mechanism might also account for the marked behavioral changes observed in the adolescents in this study and our earlier ADHD massage study (Field, Quintino & Hernandez-Reif, 1997). The lower stress hormones (cortisol) observed following at least the massage therapy in our other studies (Field, et al, in press, Field; Seligman, Scafidi & Schanberg, 1996; Ironson, et al, 1996) is consistent with a mechanism of enhanced parasympathetic activity.
Future studies might compare Tai Chi and massage therapy effects on the reduction of stress hormones (e.g., salivary cortisol or urinary catecholamines) in ADHD adolescents. The comorbidity of ADHD with other psychiatric disorders, such as depression and anxiety, and the potential side effects of a multidrug therapy makes Tai Chi and massage therapy attractive alternative treatments. In addition to little or no side effects, especially appealing are the documented effects of Tai Chi and massage therapy on reducing anxiety and hyperactivity, the major and most difficult symptoms in ADHD children.

Several studies have shown that regular tai chi practice has benefits:
It can reduce falls in the elderly or those with balance disorders — sometimes dramatically. In one 1996 Atlanta study, elderly people who practiced tai chi for 15 weeks reduced their risk of multiple falls by 47.5 percent. Falls are a particular danger for elders and others with brittle bones, or osteoporosis. For such people, falls frequently result in broken bones

Tai Chi for Older People Reduces Falls, May Help Maintain Strength
Thursday, May 2, 1996

Public Information Office 
(301) 496-1752

Tai Chi, a martial arts form that enhances balance and body awareness through slow, graceful, and precise body movements, can significantly cut the risk of falls among older people and may be beneficial in maintaining gains made by people age 70 and older who undergo other types of balance and strength training. The news comes in two reports appearing in the May 1996 issue of the Journal of the American Geriatrics Society.

The two studies are the first involving Tai Chi to be reported by scientists in a special frailty reduction program sponsored by the National Institute on Aging (NIA).

In the first study, Steven L. Wolf, Ph.D., and colleagues at the Emory University School of Medicine, Atlanta, Ga., found that older people taking part in a 15-week Tai Chi program reduced their risk of falling by 47.5 percent. A second study, by Leslie Wolfson, M.D., and colleagues at the University of Connecticut Health Center, Farmington, found that several interventions to improve balance and strength among older people were effective. These improvements, particularly in strength, were preserved over a 6-month period while participants did Tai Chi exercises.

The projects are among several in the NIA's Frailty and Injuries: Cooperative Studies of Intervention Techniques, or FICSIT, initiative, launched in 1990 to improve physical function in old age.

Research from these and other FICSIT trials has demonstrated the benefits of strength training for older people and the value and cost-effectiveness of targeted, fall prevention programs for the elderly. It is estimated that each year falls are responsible for costs of over $12 billion in the U.S., and the costs due to physical frailty are much higher.

The news on Tai Chi is a reminder that relatively "low tech" approaches should not be overlooked in the search for ways to prevent disability and maintain physical performance in late life. "The FICSIT studies have shown that a range of techniques, from the most sophisticated medical interventions to more 'low tech' methods, can help older people avoid frailty and falling," says Chhanda Dutta, Ph.D., Director of Musculoskeletal Research in the NIA's Geriatrics Program. "We must make sure that we look at every approach, especially relatively inexpensive ones like Tai Chi," says Dutta. "People can do this at home and with friends once they have had the proper training."

The Wolf study included 200 participants age 70 and older. The participants were divided into groups for Tai Chi, computerized balance training, and education. In addition to 15 weekly sessions in which they progressed to more complex forms of Tai Chi, the participants were asked to practice at home at least 15 minutes, twice daily. Another group received balance training using a computer-operated balance platform in which participants tried to improve control of their body sway under increasingly difficult conditions. The education group was asked to not change any of its current exercise regimens, and took part in weekly meetings on a variety of topics with a nurse gerontologist.

Wolf's group compared several factors before and after the interventions, and found improvements in certain key areas. The most notable change involved the reduction in the rate of falling for the Tai Chi group. The groups receiving computerized balance platform training did not have significantly lower rates of falling. The Tai Chi participants also took more deliberate steps and decreased their walking speed slightly compared to the other groups. Fear of falling also was reduced for the Tai Chi group. After the intervention, only 8 percent of the Tai Chi group said they feared falling, compared with 23 percent before they had the training.

"The Tai Chi group seemed to have more confidence," says Wolf, noting that "they had an increased sense of being able to do all that they would like to do." Wolf notes that almost half of the Tai Chi participants chose to continue meeting informally after the study was finished.

The Connecticut FICSIT site used sophisticated techniques for balance and strength training. Some 110 participants, averaging age 80, received training for 3 months. They were divided into four groups: one group received balance training in 45-minute sessions three times per week, including a computerized balance platform (of a different type than the one used in the Wolf study) as well as low-tech balance exercises; another took part in resistance training and weight lifting three times a week to improve strength; a third group did both balance and strength training, and a fourth "education" group participated in sessions on fall prevention and stress management. Everyone in the study took part in weekly Tai Chi classes for 6 months following the intensive training period.

The people in the study were evaluated before undergoing any training, immediately after the training, and after a 6-month follow-up Tai Chi program. The interventions of major focus in the study -- intensive balance and strength training -- produced marked effects. Participants had a 25 to 50 percent improvement in three different measures of balance after completing balance training, while strength training resulted in a 17 percent improvement in strength. Some of the gains immediately following the balance and strength training were lost after 6 months of the Tai Chi follow-up program. However, the participants tested significantly higher than they had before the interventions began.

Without a comparable group who did not receive Tai Chi training after exercise training, it is difficult to know for certain whether the Tai Chi contributed to maintaining gains in strength and balance. Wolfson noted that study participants might have done even better at the end of the maintenance phase had they continued the more intensive balance and strength training, but he also suggested that Tai Chi might be further studied as a less intensive way to hold onto the benefits of prior strength and balance training.

The NIA, part of the National Institutes of Health, leads the Federal effort conducting and supporting research on the aging process and the diseases and disabilities that accompany advancing age. The Institute's program focuses on biomedical, clinical, and social and behavioral research, and supports the Claude D. Pepper Older American Independence Centers at medical centers across the U.S., whose research is aimed at maintaining healthy function well into old age.

Research into the effects of chi gong and tai chi are constant in Chinese hospitals

Shanghai hospital #2
Study for respiratory function in pulmonary Tuberculosis:
This was a two group study (double blind) in patients with similar illness where the chi gong group had a remarkable improvement in respiratory lung function.

Bronchial asthma:
22 cases received training in chi gong. Over a 10 day training period the patients diaphragmatic movement increase by and average of 1 - 2.5 centimeters with respiratory rhythm and frequency becoming deeper and slower. Some patients reported and were found to no longer exhibit asthmatic symptoms anymore and were able to return to work. 10 of the workers suffered fewer fits with symptons and signs significantly less.

Pregnancy study in China

Study using 196 pregnant women before and after chi gong exercise found that the heart rate of the foetus either slowed or increased with any congestion in the mothers breathing alleviated and the blood vessels in the mother's limbs becoming dilated. Chi gong may contribute to natural labour as observations show that women who practice chi gong before they give birth do not tend to suffer from difficult or premature labour. This is because abdominal respiration diaphragmatic function is improved this has a massage effect on the organs in the viscera which could increase blood circulation around the body and to the foetus, the muscles of the diaphragm also become stronger and are more within the control of the mother during labour improving the chance of being able to give a good strong push at the right time

Tai Chi Boosts Immunity to Shingles Virus in Older Adults, NIH-Sponsored Study Reports
FOR IMMEDIATE RELEASE
April 6, 2007

Tai Chi, a traditional Chinese form of exercise, may help older adults avoid getting shingles by increasing immunity to varicella-zoster virus (VZV) and boosting the immune response to varicella vaccine in older adults, according to a new study published in print this week in the Journal of the American Geriatrics Society. This National Institutes of Health (NIH)-funded study is the first rigorous clinical trial to suggest that a behavioral intervention, alone or in combination with a vaccine, can help protect older adults from VZV, which causes both chickenpox and shingles.

The research was supported by the National Institute on Aging (NIA) and the National Center for Complementary and Alternative Medicine (NCCAM), both components of NIH. The study’s print publication follows its online release in March. The research was conducted by Michael R. Irwin, M.D., and Richard Olmstead, Ph.D., of the University of California at Los Angeles, and Michael N. Oxman, M.D., of the University of California at San Diego and San Diego Veterans Affairs Healthcare System.

“One in five people who have had chickenpox will get shingles later in life, usually after age 50, and the risk increases as people get older,” says NIA Director Richard J. Hodes, M.D. “More research is needed, but this study suggests that the Tai Chi intervention tested, in combination with immunization, may enhance protection of older adults from this painful condition.”

“Dr. Irwin’s research team has demonstrated that a centuries-old behavioral intervention, Tai Chi, resulted in a level of immune response similar to that of a modern biological intervention, the varicella vaccine, and that Tai Chi boosted the positive effects of the vaccine,” says Andrew Monjan, Ph.D., chief of the NIA’s Neurobiology of Aging Branch.

The randomized, controlled clinical trial included 112 healthy adults ages 59 to 86 (average age of 70). Each person took part in a 16-week program of either Tai Chi or a health education program that provided 120 minutes of instruction weekly. Tai Chi combines aerobic activity, relaxation and meditation, which the researchers note have been reported to boost immune responses. The health education intervention involved classes about a variety of health-related topics.

After the 16-week Tai Chi and health education programs, with periodic blood tests to determine levels of VZV immunity, people in both groups received a single injection of VARIVAX, the chickenpox vaccine that was approved for use in the United States in 1995. Nine weeks later, the investigators did blood tests to assess each participant’s level of VZV immunity, comparing it to immunity at the start of the study. All of the participants had had chickenpox earlier in life and so were already immune to that disease.

Tai Chi alone was found to increase participants’ immunity to varicella as much as the vaccine typically produces in 30- to 40-year-old adults, and Tai Chi combined with the vaccine produced a significantly higher level of immunity, about a 40 percent increase, over that produced by the vaccine alone. The study further showed that the Tai Chi group’s rate of increase in immunity over the course of the 25-week study was double that of the health education (control) group. The Tai Chi and health education groups’ VZV immunity had been similar when the study began.

In addition, the Tai Chi group reported significant improvements in physical functioning, bodily pain, vitality and mental health. Both groups showed significant declines in the severity of depressive symptoms.

“This study builds upon preliminary research funded by NCCAM and we are delighted to see this rigorous trial of Tai Chi for varicella zoster immunity come to fruition,” said Ruth L. Kirschstein, M.D., NCCAM Acting Director.

Shingles, or herpes zoster, affects the nerves, resulting in pain and blisters in adults. Following a case of chickenpox, a person’s nerve cells can harbor the varicella-zoster virus. Years later, the virus can reactivate and lead to shingles.