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mind brain the journal of psychiatry research article adhd brain functioning and transcendental meditation practice 1 2 2 3 frederick travis sarina grosswald and william stixrud 1 2 affiliations director ...

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                                MIND & BRAIN, THE JOURNAL OF PSYCHIATRY                                                                   RESEARCH ARTICLE
              ADHD, Brain Functioning, and Transcendental Meditation
              Practice
                              1,2                    2                      3
              Frederick Travis  ,  Sarina Grosswald and William Stixrud
                           1                                                                                                               2
              Affiliations: Director, Center for the Brain, Consciousness, and Cognition, 1000 North 4th Street, Fairfield, IA 52557, USA; Maharishi University of Management
                                                                              3
              Research Institute, Maharishi Vedic City, IA 52557, USA and Department of Psychiatry, George Washington University School of Medicine and Health Sciences,
              Washington, DC 20057, USA
                                                                                   ABSTRACT
                This random-assignment pilot study investigated effects of Transcendental Meditation (TM) practice on task performance and brain
              functioning in 18 ADHD students, age 1114 years. Students were pretested, randomly assigned to TM or delayed-start comparison groups,
              and posttested at 3- and 6-months. Delayed-start students learned TM after the 3-month posttest. Three months TM practice resulted in
              significant decreases in theta/beta ratios, increased theta coherence, a trend for increased alpha and beta1 coherence, and increased Letter
              Fluency. The delayed-start group similarly had decreased theta/beta ratios and increased letter fluency at the 6-month posttest, after they
              practiced TM for 3 months. Also, all students significantly improved on five ADHD-symptoms over the six months of the study, as reported in
              the parent’s survey. These findings warrant additional research to assess the impact of TM practice as a nondrug treatment of ADHD.
                 Keywords: ADHD, brain, Transcendental Meditation, coherence, theta/beta ratios, learning disabilities
                 Correspondence: Frederick Travis, PhD, Director, Center for the Brain, Consciousness, and Cognition, 1000 North 4th Street, Fairfield, IA
              52557, USA. Tel/Fax: 641 472 1209; e-mail: ftravis@mum.edu
                Attention-deficit/hyperactivity disorder (ADHD)*character-                          and is thought to block out irrelevant stimuli during memory
              ized by inattentiveness, impulsivity, and hyperactivity*is                            processing.23 In ADHD subjects, greater theta activity may
              diagnosed in 8% of children age 417 years.1 Factors                                  block out relevant as well as irrelevant information.
              associated with increased risk of ADHD include unhealthy                                Another brain marker of ADHD is EEG coherence, a
              maternal lifestyle (drinking and smoking), premature birth                            measure that reflects the number and strength of connections
                                                                                  24                                                     24
              and low birth weight, and poor early childhood care.                    Some          between different brain areas.           Adults diagnosed with ADHD
              researchers also theorize that there is a genetic factor                              are reported to have lower alpha coherence,25,26 and in
                                                57
              associated      with ADHD.              Studies     identify     imbalances           children diagnosed with ADHD coherence in all frequencies
              in dopaminergic and noradrenergic systems in ADHD                                     is reported lower.27,28 The brain processes indexed by alpha
              children,8,9     along with developmental abnormalities in
              fronto-striatal circuits that lead to maladaptive response to                         coherence have an important role in attention and conscious-
              environmental challenge. These abnormalities include (1)                              ness. They coordinate the selection and maintenance of
              lower frontal metabolic rates as measured by PET10 and by                             neuronal object representations, which are reflected in beta
                                                                                                                               29,30
              MRI,11 (2) lower myelination in frontal-striatal circuits,12 and                      and gamma activity.                Thus, lower alpha coherence in
              (3) lower cortical volume in left frontal and temporal                                ADHD populations could document disrupted working
              areas.11,13                                                                           memory and attention.
                The EEG studies report decreased activation in ADHD                                 DRUG TREATMENTS OF ADHD
              populationsinparietalcross-modalmatchingareasthatweave                                  Most drug treatments of ADHD contain methylphenidate or
              sensory input into concrete perception,14 higher density and
              amplitude of theta activity,15,16 and lower density and ampli-                        amphetamines that increase dopamine and noradrenalin in
                                                      17                                            the synapse by either increasing the release of neurotrans-
              tude of alpha and beta activity.           Theta/beta power ratios are
              highly correlated with severity of ADHD symptoms.18,19                                mitters or blocking their reuptake. However, up to 30% of
              Normal adolescents exhibited theta/beta ratios from 2.5 to                            ADHDchildren either do not respond to, or do not tolerate,
              3.5 in one study20; and 3.0 to 3.5 in another.16 The ADHD                             treatment with stimulants.31,32 Even for children who do
                                                                                    18,19                                                                                    2
              populations exhibit theta/beta ratios greater than 5.                        In       respond to medication, often the effect is modest.                          In
              normal adolescents, theta rhythms gradually increase in                               addition, in some patients drug treatments result in disrup-
              memory tasks a few seconds before an anticipated response                             tions in sleep and appetite and increases in apathy and
                                                                              21,22                 depression, which significantly affect physiological, cogni-
              and reach a peak immediately after the response.                      During
              memory tasks, theta EEG is generated in the hippocampus                               tive, and behavioral functioning.33
              www.slm-psychiatry.com                                                           73                                                   M&B2011; 2:(1). July 2011
        Mind & Brain, the Journal of Psychiatry
        BEHAVIORAL INTERVENTIONS FOR ADHD                                       using a random-assignment delayed-start design to assess
          Since ADHD may reflect a lag in natural brain devel-                  effects of TM practice on performance on standardized
                 1113                                                          measures of executive functioning and on brain wave patterns
        opment,       can stalled brain development be jump-started in          (EEG) during a computer-administered choice reaction time
        someway?Braincircuits are highly plastic and are continually            task. In this study we hypothesized: If TM practice activates
        sculpted with each experience.3437 Thus, behavioral inter-
        ventions that activate frontal-striatal circuits could potentially      and strengthens frontal executive circuits, then ADHD
        facilitate brain development in ADHD populations and so                 students who practice the TM technique, compared to
        improve executive function and cognitive performance during             delayed-start students, should exhibit (1) lower theta/beta
        tasks.                                                                  power ratios, indicating greater brain activation during tasks;
                                                                                (2) higher frontal, parietal, and anterior/posterior coherence,
          As mentioned, the key brain circuits that are underdeve-              indicating greater communication between brain areas during
        loped in ADHD populations include frontal areas (major                  a visual-motor task; and (3) improved performance on
        integrative centers), cingulate gyri (attention switching),             executive functioning tests.
        parietal areas (concrete experience centers), and striatum
        (motor activation). One class of behavioral interventions               METHOD
        exercise the motor node in this circuit. For instance, the
        Interactive Metronome, which involves matching a computer-                This is a pilot test of effects of TM practice on ADHD
        generated beat, would exercise motor circuits. This interven-           symptoms.It tests whether middle school students diagnosed
        tion, however, has had limited benefits on reducing ADHD                with ADHD can learn and practice the TM technique, and it
        symptoms in clinically controlled studies.38 Neurofeedback is           investigates effects of TM practice on executive functioning
        another nondrug intervention that teaches children to control           and brain functioning in these students.
        theta and/or beta brain activity by interacting with a computer         Subjects
        game. Although requiring many training sessions*45
        sessions lasting 40 minutes each*neurofeedback is reported                All students attended an independent school for children
        to reduce ADHD symptoms39 and reduce amplitude of theta                 with language-based learning disabilities in Washington, DC.
        EEG with no effect on beta amplitude.40                                 All students received two clinical diagnoses. First, licensed
                                                                                psychiatrists identified students with ADHD according to the
        Meditation as a Behavioral Intervention                                 DSM IV-TR criteria and recommended that they attend this
          Meditation practices activate distinct brain areas, which             school. Second, professionals in the school verified the
        makes these areas progressively more available during tasks             clinical diagnoses and placed them into their school system.
        after meditation.4143 For instance, Mindfulness Meditation,            The curriculum at the school is designed to help students
        in comparison with mental math, leads to increased blood                with ADHD and other learning disabilities.
        flow in prefrontal areas,44 and to thickening of brain areas              Twenty-four families responded to an information letter
        involved with attention switching and perception of bodily              about the study and volunteered to participate. Twenty-three
        states.43 Preliminary research investigated effects of mind-            chose to participate in the study; the 24th student learned TM
        fulness training on 24 adults and 8 adolescents diagnosed               but did not participate in assessments. Four students were
        with ADHD, who received an 8-week mindfulness-training                  not part of the randomized study, because their parents asked
        program involving 2.5 hour sessions once/week and 45-min                that they learn the TM technique immediately. The remaining
        daily meditation sessions at home. Seventy-five percent of              18 students were stratified by age, and randomly assigned to
        these individuals finished the 8-week program. After the                learn TM immediately (TM group: 6 boys, 3 girls, average age
        mindfulness training, both adults and adolescents exhibited             12.991.3), or learn TM in 3 months (delayed-start group:
        significant decreases in inattention and hyperactivity. Only            7 boys, 2 girls, average age 13.091.6).
        the adults also showed significant reductions in depression               Table 1 presents the DSM-IV clinical diagnoses and medica-
        and anxiety.45                                                          tion use for the 18 randomized students. Comorbidities
          Another form of meditation, the Transcendental Meditation             included General Anxiety Disorder (3 subjects), Obsessive
        (TM) technique, is reported to lead to increased cerebral               Compulsive Disorder (1 subject), and Autism (3 subjects). In
        metabolic rate in frontal and parietal attentional areas in a           each group, five of the nine subjects were on ADHD
        PET study46; greater activity in prefrontal executive circuits          medication.
        and anterior cingulate attention circuits in a MEG study47;               As seen in this table, random assignment placed more
        and higher frontal alpha1 power and coherence and higher                subjects with comorbidities in the TM group (4) than in
        beta1 power in EEG studies.48 Preliminary research with a               the delayed start group (1). Subjects with comorbidities may
        single group design with 10 ADHD children age 1114 years               be more resistant to change. Thus, this was a conservative
        reported that 3 months of TM practice resulted in significant           test of effects of TM practice on brain and executive
        reductions in anxiety and depression and significant im-                functioning in an ADHD population.
        provements in executive function and behavior regulation.49
                                                                                  Written informed consent was obtained from the parents
          The current study extends the preliminary findings of the             and students before pretesting. The Maharishi University of
        effectiveness of TM practice on reducing ADHD symptoms by               Management IRB approved the research.
        M&B2011; 2:(1). July 2011                                           74                                            www.slm-psychiatry.com
                                                                                                                 ADHD and TM Practice
           Table 1. DMV-IV Diagnoses and Medication Use for the TM and Delayed Start Groups
                                              TMGroup                                             Delayed Start Group
                                          Subjects on ADHD                                          Subjects on ADHD
            ADHDType      ADHDType            Medication        Comorbidity     ADHDType               Medication           Comorbidity
            Inattentive       3                   1                  1               1                     0                     0
            Hyperactive       2                   1                  1               2                      1                    0
            Combined          4                  3                   2               6                     4                     1
            Totals            9                  5                   4               9                     5                     1
                                                                           number of responses and number of correct responses in
           Procedure                                                       each trial.
            Students were pretested, and then stratified by age and
           ADHD symptoms and randomly assigned to a group*                 Tower of London
           immediate start TM or delayed-start*using blind drawing
           of names. Certified teachers of the TM technique went to the      The Tower of London measures higher order problem
           school to instruct the students in TM practice*four con-        solving. Subjects are shown a configuration of colored balls
           secutive days*and then for follow-up meetings once a            stacked on pegs. The subject executes a sequence of moves
           month. The students were instructed in the standardized         that transforms his or her board to match the displayed
           format to learn the TM technique, as described below. Four      configuration with the balls arranged on designated pegs.
           teachers at the school learned the TM technique and             This analysis yields total correct score, total initiation time,
           meditated with the children morning and afternoon.              total move score, total execution time, total time score, and
                                                                           total time violation. It has a reliability coefficient of .80 and
            Students were given paper-and-pencil tests in the school       loads on a principle component analysis with other tests of
           during class time, and made individual appointments for         executive planning/inhibition.53
           performance tests and EEG recordings. All students were
           posttested at 3 months and 6 months. The delayed-start          Self-Report Instruments
           students learned TM after the 3-month posttest.                   Twoself-report instruments were administered at the end of
                                                                           the study*one to the children and one to their parents. The
           Psychological Test Measures                                     first one asked the children: ‘‘How much do you like your TM
           Delis-Kaplan Executive Function System (D-KEFS) Verbal          practice?’’ on a 7-point Likert Scale*1 (Not At All) to 7 (Very
           Fluency                                                         Much). The second scale asked parents how their children
            The D-KEFS tests executive functions such as flexibility of    had changed on five ADHD-related symptoms. There were
           thinking, inhibition, problem solving, planning, impulse        asked: ‘‘Compare your child before learning the Transcen-
           control, concept formation, abstract thinking, and creativity   dental Meditation technique to now. Indicate the degree of
           in both verbal and spatial modalities.50 It has been standar-   change you have observed in the following areas: (a) ability to
           dized and used in both clinical groups and as a research tool   focus on schoolwork, (b) organizational abilities, (c) ability to
           for increasing knowledge of frontal-lobe functions.51 The       work independently, (d) happiness, and (e) quality of sleep.’’
                                                                           Responses were along a 11-point Likert Scale from 5 (Strong
           Verbal Fluency subscale was considered appropriate because      Negative Changes) to 5 (Strong Positive Changes).
           the school specializes in teaching students with language-
           based learning difficulties. The Verbal Fluency test provides   Other Psychological Tests
           information about the student’s word fluency and language-        Four other tests were administered. However, because there
           related concept fluency. It also assesses the ability to shift  were incomplete data for these four measures, these data are
                                         52
           from one concept to another,     a difficulty associated with   not interpretable. Thus, they will not be reported. The test
           ADHD. The measure also includes an Alternate Form, thus         and the corresponding number of completed forms were:
           reducing practice effects at posttest.                          Spielberger’s  State  and Trait Anxiety scale (TM4,
            Theanalysis of the Verbal Fluency test yields four measures:   Delayed6), SNAP IV (TM5, Delayed5), the Teacher
           Letter Fluency, Category Fluency, Category Switching, and       BRIEF (TM3, Delayed5), and the Youth Self-Report
           Total Switching Accuracy. Letter Fluency is the total number    (TM7, Delayed5).
           of words the student can think of that start with a specified
           letter, in three 60-sec trials. Category Fluency is the number  EEG Recording Protocol
           of words the student can say that belong to a designated          The EEG was recorded during a computer-administered
           semantic category (eg, animals, fruit) in two 60-sec trials.    paired choice reaction-time task to calculate theta/beta ratios
           Category Switching evaluates the student’s ability to alternate (Cz) and patterns of EEG coherence. The task began with a
           between saying words from different semantic categories         one- or two-digit number (300 ms duration), a 1200 ms blank
           within a 60-sec trial. Total switching accuracy includes the    screen, and another one- or two-digit number (300 ms
           www.slm-psychiatry.com                                       75                                      M&B2011; 2:(1). July 2011
        Mind & Brain, the Journal of Psychiatry
        duration). Subjects were asked to press a left- or right-hand     Statistical Analysis
        button to indicate which number was larger in value. This           The primary analysis was a between comparison of
        task was chosen because performance on this task discrimi-        differences from baseline to the 3-month posttest between
                                                               54
        nated meditating and nonmeditating college students.              groups. The TM group had been practicing the TM technique
         The BIOSEMI ActiveTwo system was used to record EEG              for 3 months along with the curriculum at the school; the
        from 32 locations over the scalp, following the 10-10 system.     delayed-start comparison group had only been receiving the
        Signals from the left and right ear lobes were recorded for       curriculum at the school. This analysis is the strongest test of
        later re-referencing as a linked-ears reference. All signals      the hypothesis. In this analysis, two repeated measures
        were digitized on line at 256 points/sec, with no high or low     MANOVAs were conducted*psychological and performance
        frequency filters, and stored for later analyses using the Brain  variables in one and coherence in the other. An ANCOVA of
        Vision Analyzer.                                                  theta/beta ratio difference scores, covarying for pretest
                                                                          scores, was also conducted.
         The data during the task were visually scanned and any
        epochs with movement, electrode, or eye-movement artifacts          Analpha level of .05 was used for these three initial tests. If
        were manually marked and not included in the spectral             significant interactions were found, then further F-tests were
        analysis. The artifact-free data were digitally filtered with a   used for subanalyses. An alpha level of B.025 was used for
        250 Hz band pass filter and fast Fourier transformed in          further tests. Partial eta squared (h2), the power statistic
        2-sec epochs, using nonoverlapping Hanning windows with a         reported for F-tests by SPSS, is reported for all analyses.
                                                                          Partial eta squared is the variance accounted for, similar to r2.
        10% onset and offset.
         Power (uV2/Hz) was calculated from 2 to 50 Hz at the 32            A secondary within analysis assessed changes in the
        recording sites. To investigate theta/beta ratios, power at Cz    delayed-start students comparing differences from baseline
        during the task was averaged into theta (47.5 Hz) and beta       to the 3-month posttest, when these subjects were not yet
        (1320) bins and theta/beta ratios were calculated.19             meditating, to differences from the 3-month to the 6-month,
                                                                          when these subjects were meditating. This analysis is an
         Coherence patterns during the computer task were averaged        exploratory analysis, since it is a single group design.
        into 11 intra- and interhemispheric frontal coherence pairs, 11   However, we expect to see a similar pattern of change as in
        intra- and interhemispheric parietal coherence pairs, and five    the primary analyses.
        anterior/posterior coherence pairs. The 11 frontal pairs
        included: AF3-AF4, F3-F4, FC1-FC2, F7-F3, AF3-F3, AF3-
        FC1, F3-FC1, F8-F4, AF4-F4, AF4-FC2, F4-FC2; the 11 parietal      RESULTS
        pairs included: CP1-CP2, P3-P4, PO3-PO4, P7-P3, CP1-P3,           Feasibility of the Intervention
        CP1-PO3, P3-PO3, P8-P4, CP2-P4, CP2-PO4, PO4-P4; and the            All students in the TM group and, later, all students in the
        five anterior/posterior pairs included: F3-P3, FzPz, F4-P4,       delayed-start group were able to learn the TM technique and
        AF3-PO3, AF4-PO4. Averaged coherence was analyzed in              practice it successively. This was evidenced in their daily
        theta (47.5 Hz), alpha (812 Hz), beta1 (12.520 Hz), and        group TM practice, which was done in the morning and
        gamma bands (20.550 Hz).                                         afternoon in groups at the school. Also, a questionnaire was
        Intervention: The Transcendental Meditation Program               administered at posttest to assess how the students felt about
                                                                          their TM practice. This questionnaire used a 7-point Likert
         The Transcendental Meditation (TM) technique is a mental         scale*1 Not-At-All to 7 Very-Much*to quantify the re-
        technique practiced for 10 min (for these students) sitting in a  sponse. Students reported that the TM technique was
        chair with eyes closed. During TM instruction, the student        enjoyable and easy to do (average5.39.9). They may have
        learns how to let the mind move from active focused levels of     been able to learn and practice this meditation technique,
        thinking to silent, expanded levels of wakefulness underlying     because TM does not involve concentration or control of the
        thoughts.55,56 Certified teachers taught these students the TM    mind*a challenge for anyone with ADHD. (For a detailed
        technique using the standardized teaching format of four 1-       discussion of mechanics during TM practice see Travis &
        hour meetings over 4 days, followed by knowledge and                    57
                                                                          Shear ).
        experience meetings every other week for the first few months
        to assure correct practice. (See Travis & Shear57 for a more      Changes in Brain Functioning
        detailed description of the TM technique.)                        Theta/Beta Ratios
         After personal instruction, students meditated in a group at       The ANCOVA of theta/beta difference scores, covarying for
        school at the beginning and at the end of the day with a          pretest scores yielded significant decreases in theta/beta ratios
        school teacher, who was trained to lead the meditation. A         of EEGrecordedatCzintheTMgroup(F(1,17)4.7,p.05,
        certified TM teacher met with students as needed to discuss       h2.24).Figure1presentsthemeansandstandarderrorsfor
        experiences, verify correct practice, and answer questions        the theta/beta ratios at pretest and the two posttests. At
        about their TM practice. The group practice allowed easy          pretest, both groups were well above the average for theta/beta
        logging of compliance*as long as students were not absent,        ratios in normal populations. At the 3-month posttest, theta/
        they practiced TM.                                                betaratiosincreasedslightlyinthedelayed-start group(dotted
        M&B2011; 2:(1). July 2011                                     76                                         www.slm-psychiatry.com
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...Mind brain the journal of psychiatry research article adhd functioning and transcendental meditation practice frederick travis sarina grosswald william stixrud affiliations director center for consciousness cognition north th street fairfield ia usa maharishi university management institute vedic city department george washington school medicine health sciences dc abstract this random assignment pilot study investigated effects tm on task performance in students age years were pretested randomly assigned to or delayed start comparison groups posttested at months learned after month posttest three resulted significant decreases theta beta ratios increased coherence a trend alpha letter fluency group similarly had decreased they practiced also all significantly improved five symptoms over six as reported parent s survey these findings warrant additional assess impact nondrug treatment keywords learning disabilities correspondence phd tel fax e mail ftravis mum edu attention deficit hyper...

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