Integra Mindfulness Martial Arts as an effective treatment tool in comorbid ADHD and learning disabilities

Christine Lackner, MSc

PhD Candidate, Brock University

Dr. Karen Milligan, C. Psych.

Assistant Professor, Ryerson University

November 3, 2014

LD & ADHD relationship

� LDs and ADHD are HIGHLY comorbid

� 40-80%

� Tabassam & Grainger (2002)

� Interrelated disorders along a continuum?

� Mayes, Calhoun, & Crowell (2000)

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Learning Disabilities (LD)

� Individuals of average to above average average to above average average to above average average to above average intelligence

� Impairments in specific areas of cognitive processing

� Affect the ability to take in, understand, remember or express information

� Impact on academic performance

� Neurobiological in basis & lifelong

� Not due to cultural or educational factors, impairments in hearing or vision, or other neurological conditions

(Büttner & Hasselhorn, 2011; LDAC, 2002)

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ADHD - DSM-IV-TR CRITERIA

� Diminished sustained attention and high impulsivity in child

or adolescent compared to what is expected

� Three types: Combined Type, Predominantly Inattentive

Type, and Predominantly Hyperactive-Impulsive Type.

� Some symptoms onset before 7 years, present in two

settings

� Social, occupational, and/or academic functional

impairment

� Symptoms not better accounted for pervasive

developmental disorder, schizophrenia, any other mental

disorder

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DSM-IV-TR CRITERIAInattention

� Often has difficulty sustaining attention in tasks

� Often fails to give close attention to details/ makes mistakes in schoolwork, work, and other activities

� Often does not seem to listen when spoken to directly

� Often does not follow through on instructions and fails to finish schoolwork, chores or duties in work

� Often has difficulty organizing tasks and activities

� Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

� Often loses things necessary for tasks or activities

� Often easily distracted by extraneous stimuli

� Often forgetful in daily activities

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DSM-IV-TR CRITERIA

Hyperactivity� Often leaves seat in class/ situation where staying seated is expected

� Often fidgets with hands or feet or squirms in seat

� Often runs about/climbs excessively in situations where it is inappropriate

� Often has difficulty playing/engaging in leisure activities quietly

� Often on the go or acts as if driven by a motor

� Talks excessively

Impulsivity� Often blurts out answers before questions have been completed

� Often has difficulty waiting to take turns

� Often interrupts or intrudes on others

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Similar BRAIN-BASED processing weaknesses

associated with LDs underlie many mental health

disorders

E.g., Executive Functions

� ADHD (Mattison & Mayes, 2012; Pennington & Ozonoff, 1996)

� Autism (Zingerevich & Patricia, 2009)

� Behavior disorders (Morgan & Lilienfield, 2000)

E.g., Processing Speed

� Depression

E.g., Attention

� Depression, Anxiety, ADHD

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Integra Mindfulness Martial Arts (MMA)

� Developed in 2002 at Integra by

Paul Badali MSW & Integra staff

� Integrates:

� Mindfulness

� Cognitive therapy

� Behaviour therapy

Martial

arts

training

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Integra MMA

� 20 sessions

� 1.5 hours

� 8-10 youth

� 1 Sensei with training in martial arts and mindfulness

and a volunteer

� Multi-modal learning, in the moment feedback,

repetition

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Session Components

Brief Meditation

The Skill

The Case

The Application

• MMA Yoga Warm-Up

• Mixed Martial Arts

Meeting with Youth & Parent

Home practice

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Mindfulness Treatments for Youth

� Externalizing behaviour� Bogels, Hoogstad, Van Dun, De Schutter, & Restifo, 2008; Singh,

Lancioni, Singh et al., 2007; Singh, Lancioni, Manikam et al., 2011

� Anxiety � Semple, Reid & Miller, 2005; Semple, Lee, Rosa, & Miller, 2010

� ADHD� van der Oord, Bogels, & Peijnenburg, 2012; van de Weijer-Bergsma,

Formsma, de Bruin, & Bögels, 2012; van Oord et al., 2012

� Autism Spectrum Disorder � Singh, Lancioni, Manikam et al., 2011; Singh, Lancioni, Singh et al., 2011;

Singh, Lancioni, Winton et al., 2011

� Executive functions, such as impulsivity, attention and flexibility in children � Flook et al., 2010

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Exercise treatments for youth� Behaviourally:

� ↓ negative behaviors

� oppositional behavior, lack of achievement

� hyperactivity and classroom behavioral disturbance

� ↑ positive behavior, and better impulse control

Azrin et al. (2006); Etscheidt & Ayllon (1987); Parish-Plass & Lufi

(1998); Tomporowski et al. (2003); Wendt (2000)

� Physiologically:

� Acute exercise induces changes in catecholamine response

� Wigal, Nemet, Swanson, Regino, Trampush, ... Cooper (2003)

� Changes in spontaneous eye blink rate and motor impersistence

� Tantillo, Kesick, Hynd, & Dishman (2002)

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Martial Arts Interventions...

Martial Arts� Decreased aggression

� Ziven et al. (2001), Adolescence

� Improved:

� Attention

� Self-regulation

� Social relationships� Lakes & Hoyt (2004), Journal

of Applied Developmental

Psychology

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Integra Mindfulness Martial Arts

MMA Goals:

↑Self-awareness

↑Impulse control

↑Flexibility

↑Self-confidence

↑Social interaction

↑Martial arts skill (mastery)

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Research on Integra MMA

� 4 Studies – LD+MH

� Group design study on behavioural

outcomes (LD+MH)

� Cohort study examining executive functions

� Qualitative study of the experience of

youth/parents in MMA

� Changes in EEG and HR measures of emotion

regulation and executive functions

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Study #1 -- MMA: Impact on Behavioural Outcomes

� Quasi-experimental design study of MMA

� 65 adolescent boys aged 12-15 with LD + Self-Regulation Disorders

� Approx ½ waitlist

� Key Results:

� LD + ADHD – significant improvement on externalizing behaviour, oppositional behaviour, and conduct problems (CBCL)

� LD + elevated hyperactive/impulsive or inattention –significant decrease in social problems (CBCL)

� LD + anxiety – decrease in anxiety (YSR)

(Haydicky, Wiener, Badali, Milligan, Ducharme, 2012)

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Study #2 - Integra MMA: Impact on Executive Functions

� N = 20 (3 girls, 17 boys), age 12-16

� LD + significant attention and/or impulsivity/hyperactivity symptoms on Conners 3 (65% taking medication for ADHD)

� Improved impulse control pre- to post-treatment (TOVA)

PRE 74.58 (24.7) POST 92.58 (21.0) p=0.002

� Improved processing speed pre- to post-treatment (range 8-12)

Visual Scanning 7.1 8.8 p= 0.007

Number Seq. 7.4 8.9 p = 0.06

Letter Seq. 7.8 9.4 p = 0.008

Milligan & Phillips (in prep)

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Study #3 --Qualitative results

� Youth are motivated to engage in treatment

� Development of mastery and pride

� “It is a good way of getting therapy without your kid really understanding. They think they’re coming and they’re punching and they’re kicking and they’re doing all this and they are, but at the same time, they don’t really get that they’re getting therapy.” – Parent

� Promotes a sense of calmness, tolerance, and acceptance of distress

� “I’ve been getting a lot of homework lately and MMA kind of calms you down so it’s easier just to like sit down and do your work…I’ll be more calm so I’m more focused on my work and that makes it easier to do the work in the first place.” -- Youth

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Mechanism??

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Attentional control

� Top down and bottom up mechanisms

� Early selection versus late correction

� ERP evidence of attentional differences in ADHD and LD populations

� ADHD, the novelty P300, and the late negativity

� Gumenyuk et al., (2005)

� Adult trait impulsivity and frontal P300 amplitudes

� Carlson, Thai, & McLarnon, (2009)

� Selective language impairment and frontal N1-like amplitudes

� Stevens, Sanders, & Neville (2006)

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• Negative deflection 100 mspost-stimulus

• Diminished for

unattended/irrelevant stimuli

• Amplified for

relevant/attended stimuli

N1d

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Courtney Stevens and Helen Neville’s work

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Self-regulation and selective auditory attention

� Active selective auditory attention paradigm

� 2 channels

� 2 types of tones of 200 ms in duration

� One frequent (88%)

� One deviant (12%)

� 600 to 800 ms ISI

� Pay attention to one ear only and respond

with a button press to the deviant tones

� 48 typically developing 12-14 year olds

� Parent-report BRIEF

Lackner et al., (2013).

Biological Psychology,

93(2), 325-333

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Stevens et al.

Note: +ve is ↓

Lackner et al.

Note: +ve is ↑

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Lackner et al. (2013). Biological Psychology, 93(2), 325-333.

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Lackner et al. (2013). Biological Psychology,

93(2), 325-333.

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Study #4 -- Is MMA Associated with Brain-Based Changes in Attention?

� N = 12 treatment (9 LD + ADHD)

� 9 controls (7 LD + ADHD)

� 4 ERP assessments – baseline, during treatment, immediately following, & follow-up

� Selective auditory attention� Two approaches

� Traditional peak scored ERPs

� Single –subject analysis using bootstrapping of single data points

� Using techniques of Wilcox (2005)

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Approach #1 – Peak scored ERPs

0

100

200

300

400

500

600

700

Time 1 Time 3

Me

an

La

ten

cy

Timepoint

P3 Pz Mean Latency

TX AT

TX UNT

Ctrl AT

Ctrl UNT

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Grand average

Single subject across sessions

Approach #2 – Single subject statistics

� 9/12 treatment participants showed an increased

ability to discriminate between attended and

unattended tones over time

� Control – 2/7

� χ2 = 3.909, p =.04

� Tx - at least 23% of effects maintained over time

� Ctl – 0 effects maintained over time

� Idiosyncratic effects

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Heart Rate Variability (HRV)

� Variability in beat-to-beat intervals associated with parasympathetic function

� Mediated by Vagus Nerve

� Respiratory Sinus Arrhythmia (RSA)

� Slight ebb and flow of HR during normal respiration

� Behavioural flexibility & autonomic adaptability

� RSA � Ability to adapt effectively to environmental changes/demands

R RR R

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Examples of High and Low Resting Heart Rate Variability

High resting/baseline RSA(High Vagal Tone)•Lots of parasympathetic

influence on the heart•Healthy & adaptive

High variability in beat to beat intervals

Low variability in beat to beat intervals Low resting RSA(Low Vagal Tone)•Very little

parasympathetic influence on the heart

•Not healthy or adaptive

� HRV increases from pre-MMA to 3 month follow-up in treatment group with no changes in the control group (Borges, Schmidt et al., in prep.)

� MMA as leading to better autonomic flexibility and therefore behavioural flexibility?

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Treatment grp Waitlist grp

Session 1

6.19(1.42) 7.22(1.04)

Session 4

6.83(1.33) 7.62(1.24)

Summary

� Good evidence that MMA leads to improvement in problematic behaviour

� Engages an otherwise difficult population

� Leads to electrophysiological change

� Leads to improvements in HRV

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Thank you!

Support:� Mitacs- Accelerate Grant (2013)� Centre of Excellence in Child and Youth Mental Health, Doing

Grant (2010-2011)� SSHRC (J. Wiener)� NSERC Queen Elizabeth II Graduate Scholarship (C. Lackner)

Co-investigators & Collaborators:

M. Phillips, Integra

J. Wiener, U of T

J. Haydicky, U of T

T. McKeough, Intega

D. Jurasek, Integra

S. Craig, Integra (RA)

F. Spiroiu, Ryerson (RA)

S.J. Segalowitz (Brock)

L.A. Schmidt (McMaster)

J. Desjardins (Brock)

L. Wilkins (Ryerson)

C. Borges (McMaster)

A. Sibalis (U of T, RA)

J. Doige (Ryerson, RA)

Integra MMA youth & families, and Integra staff!

RSA work

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RSA work