published March 21, 1998
Adolescents With Attention Deficit Hyperactivity Disorder Benefit From Massage Therapy
From Adolescence, Spring, 1998 by Tiffany M. Field, Olga Quintino, Maria Hernandez-Reif, and Gabrielle Koslovsky.
Twenty-eight adolescents with attention deficit hyperactivity disorder were provided either massage therapy or relaxation therapy for 10 consecutive school days. The massage therapy group, but not the relaxation therapy group, rated themselves as happier and observers rated them as fidgeting less following the sessions. After the 2-week period, their teachers reported more time on task and assigned them lower hyperactivity scores based on classroom behavior.
Attention deficit hyperactivity disorder (ADHD) is a condition affecting as many as 3 to 6 percent of all youth, and is characterized by developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity. Overactivity is typically the most prominent feature (DSM-III-R, American Psychiatric Association, 1987; Anderson, Williams, McGee, & Silva, 1987).
Treatment is made more difficult by the comorbidity of ADHD with other disorders, such as conduct disorder, anxiety, learning disability, and depression (Biederman, Newcorn, & Spirch, 1991). Treatment usually includes drug therapy and training parents and teachers in behavior modification techniques. Drug therapy features psychostimulants, such as methylphenidate or d-amphetamine, which alter the concentration and physiology of catecholamines, namely dopamine (Barkley, 1989; Evans, Gualtieri, & Hicks, 1986). This stimulates the frontal and striatal regions of the brain, which are associated with attention, arousal, and inhibition and help regulate these processes (Evans et al., 1986). Although drug therapy improves ADHD symptoms in over three-fourths of the cases, it is not a curative measure, its effects lasting only as long as medication is taken. Another drawback of drug therapy is the occasional side effects, such as appetite loss and insomnia (Barkley, McMurray, & Edelbrock, 1990).
Behavior modification by parents and teachers involves such techniques as adjusting the time, amplitude, and frequency of consequences for the child’s actions, rearranging home and classroom settings to facilitate attention, breaking down tasks into smaller subtasks that can be completed within the child’s attention span, and setting up schedules to aid the child in overcoming organizational problems (DSM-III-R, American Psychiatric Association, 1987). Behavior modification is a way to adjust the surroundings to facilitate the ADHD child’s performance. However, as with drug therapies, behavior modification is only effective during the time that it is administered.
Alternative forms of therapy, namely massage therapy and relaxation therapy, were investigated in the present study because they have been effective with children and adolescents with attention problems. For example, relaxation therapy (Platania-Solazzo, Field, Blank, Seligman, Kuhn, Schanberg, & Saab, 1992) and massage therapy (Field, Morrow, Valdeon, Larson, Kuhn, & Schanberg, 1992) were found to reduce anxiety and activity levels in child and adolescent psychiatric patients. In addition, following massage they had more organized sleep and lower stress hormone (cortisol and norepinephrine) levels. Massage therapy has also been noted to decrease off-task behavior in children diagnosed as autistic (Field, Lasko, Mundy, Henteleff, Talpins, & Dowling, 1996). It was hypothesized here that massage therapy would lower the activity level of adolescents with ADHD.
Twenty-eight adolescents (mean age = 14.6 years) were recruited from self-contained classrooms for emotionally disturbed adolescents. All subjects were male, 90% were middle socioeconomic status, 29% were nonwhite Hispanic, and 71% were white. All were diagnosed with ADHD according to DSM-III-R criteria. They were randomly assigned to massage therapy or relaxation therapy based on a stratification procedure to ensure equivalence between groups on background variables.
Massage therapy. Fourteen subjects received a 15-minute massage after school for 10 consecutive school days. The massage consisted of moderate pressure and smooth strokes for 5 minutes in each of three regions: up and down the neck, from the neck across the shoulders and back to the neck, and from the neck to the waist and back to the neck along the vertebral column. The 15-minute sequence was composed of 30 back-and-forth strokes per region, at 10 seconds each.
Relaxation therapy. Fourteen subjects participated in 15-minute relaxation sessions after school for 10 consecutive school days. During the progressive muscle relaxation sessions, a therapist asked the adolescents to tense and relax the same body parts that were massaged in the massage therapy group.
Assessments. Pre/post therapy session measures included the Happy Face Scale, completed by the adolescents, and an assessment of fidgeting based on a behavioral observation made by an observer who was blind to the adolescents’ group assignment. The Happy Face Scale is a series of 5 drawings, ranging from unhappy to happy faces, which is used as a “barometer” to depict the adolescents’ feelings before and after the sessions. Fidgeting, one of the most characteristic problems of this group of adolescents, was rated on a 3-point scale. Interrater reliability for the fidgeting behavior was determined for one-third of the sessions (kappa = .83).
First day/last day assessments included self-report measures of depression and empathy, since depression and antisocial behavior are often comorbid with ADHD (Biederman et al., 1991). The 20-question Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) was used to rate depressive symptoms over the past week. The Empathy Scale (Bryant, 1982) required the adolescents to indicate whether they agreed or disagreed with each of 22 statements designed to tap empathy, defined as the ability to take another person’s perspective (e.g., “It’s hard for me to see why someone else gets upset”).
Teachers’ assessments included observed time on task in the classroom and the Conners Rating Scales (Conners, 1985), which were administered on the first and last days. The 10-item Conners Hyperactivity scale identifies behavior problems in children 3 to 17 years old.
Analyses of variance with pre/postsession and first/last day of treatment as repeated measures were performed. Table 1 reveals that (1) the massage therapy group selected happier faces after the sessions on both the first and last days of the treatment; (2) the massage therapy group demonstrated less fidgeting after the sessions; and (3) no significant pre/postsession changes were noted for the relaxation therapy group. Repeated measures analyses of variance yielded the following first day/last day changes: (1) the massage therapy adolescents averaged more time on task in the classroom as observed by their teachers; (2) the massage therapy group received significantly better scores on the Conners scale; (3) no significant changes were noted on the depression or empathy scales; and (4) no changes were noted on any of the measures for the relaxation therapy group.
While drug therapy and behavior modification techniques are commonly employed to treat ADHD, two alternative therapies, relaxation and massage therapy, were investigated here. The positive effects of massage therapy were perhaps not surprising inasmuch as that intervention has helped reduce depression and anxiety levels as well as stress hormones in child and adolescent psychiatric patients (Field et al., 1992) and has enhanced on-task behavior in autistic children (Field et al., 1996). Although the comorbid problems of depression and lack of empathy were not altered in this study, the adolescents reported feeling better (happier) after their massage sessions, and they were observed to fidget less. Longer term effects were reported by their teachers, including more time on task in the classroom and lower Conners Hyperactivity scores.
Since hyperactivity, not depression, is the salient problem in ADHID, it is interesting that hyperactivity was uniquely reduced in this study. Although the underlying mechanism for the massage therapy/lesser activity relationship is not known, increased serotonin levels noted in other studies of massage (Field et al., 1996; Ironson et al., 1996) might help modulate elevated dopamine levels noted in ADHD youth (Rogeness, Javors, & Pliszka, 1992). Future studies might assay dopamine levels as well as its known regulators, norepinephrine and serotonin.
Although relaxation therapy has also been effective with depressed adolescents (Platania-Solazzo et at, 1992), no changes were noted in the present study. The lack of effects may relate to the fact that several adolescents reported not enjoying the relaxation therapy. This more active form of therapy was called “hard work” by those who complained.
Massage therapy could become an important tool in the management of ADHD, in conjunction with currently used therapies. It may, for example, potentiate methylphenidate and other drugs or complement behavior modification. In cases where present therapies are not effective or are accompanied by undersirable side effects, massage therapy could be a substitute treatment for children and adolescents diagnosed with ADHD.
This research was supported by an NIMH Research Scientist Award (#MH00331) and an NIMH Basic Research Grant (#MH46586) to Tiffany Field.
Olga Quintino, Maria Hernandez-Reif, and Gabrielle Koslovsky, Touch Research Institute, University of Miami School of Medicine.
Reprint requests to Tiffany Field, Ph.D., Touch Research Institute, University of Miami School of Medicine, P.O. Box 016820, Miami, Florida 33101.
Anderson, J. C., Williams, S., McGee, R., & Silva, P. A. (1987). DSM-III disorders in preadolescent children: Prevalence in a large sample from the general population. Archives of General Psychiatry, 44, 69-76.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.
Barkley R. A., McMurray, M. B., & Edelbrock, C. 1990 side effects of methylphenidate in children with attention deficit hyperactivity disorder: A systematic, placebo-controlled evaluation. Pediatrics, 86, 184–192.
Barkley, R. A. (1989). Attention deficit hyperactivity disorder. In E. J. Mash & R. A. Barkley (Eds.), Treatment of childhood disorders (pp. 39-72). New York: Guilford Press.
Biederman, J., Newcorn, J., & Spirch, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 148, 564–577.
Bryant, B. K. (1982). An index of empathy for children and adolescents. Child Development, 53, 413–425.
Conners, C. K. (1985). The Conners Rating Scales: Instruments for the assessment of childhood psychopathology. Unpublished manuscript, Children’s Hospital National Medical Center, Washington, DC.
Evans, R. W., Gualtieri, C. T., & Hicks, R. E. (1986). Substrate for stimulant drug effects in hyperactive children. Clinical Neuropharmacology, 9, 264–281.
Field, T., Lasko, D., Mundy, P., Henteleff, T., Talpins, S., & Dowling, M. (1996). Autistic children’s attentiveness and responsivity improved after touch therapy. Journal of Autism and Developmental Disorders, 27, 329–334.
Field, T., Morrow, C., Valdeon, C., Larson, S., Kuhn, C., & Schanberg, S. (1992). Massage reduces anxiety in child and adolescent psychiatric patients. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 124–131.
Ironson, G., Field, T. M., Scafidi, F., Kumar, M., Patarca, R., Price, A., Goncalves, A., Hashimoto, M., Kumar, A., Burman, I., Tetenman, C., & Fletcher, M. A. (1996). Massage therapy is associated with enhancement of the immune system’s cytotoxic capacity. International Journal of Neuroscience, 84, 205–218.
Platania-Solazzo, A., Field, T., Blank, J., Seligman, F., Kuhn, C., Schanberg, S., & Saab, P. (1992) Relaxation therapy reduces anxiety in child/adolescent psychiatry patients. Acta Paedopsychiatrica, 55, 115–120.
Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.
Rogeness, G. A., Javors, M. A., & Pliszka, S. R. (1992). Neurochemistry and child/adolescent psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 765–781.
COPYRIGHT 1998 Libra Publishers, Inc.