Gym as treatment for ADHD?

An article in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry about the role of exercise in treatment of ADHD gives me hope that there is some movement in the direction of non-pharmacological treatment of problems of regulation of emotion, behavior, and attention. ( I do not use the term "ADHD" for as readers of my blog know, I believe that ADHD as defined by DSM is an oversimplified, artificial construct.)

However, the accompanying editorial entitled "Gym for the Attention Deficit/ Hyperactivity Disorder Brain?" gives me concern that this idea represents yet another oversimplification. The editorial calls for "empiric support" from "well- designed studies." Our culture has a love of "evidence-based medicine."  I hope that before embarking on these studies, there is consideration given to what a colleague referred to as "medicine-based evidence," or research based on what we have learned from both clinical experience as well as other disciplines.

Primarily what we have learned is that its not just "exercise" or "gym," but a very specific use of the body to help the brain with the task of self-regulation. In fact, for a child who is overwhelmed by sensory input and easily dysregulated, as many of the children carrying the "ADHD" label are, traditional "gym" may be a disorganizing experience.  I described this concept in detail in a previous post, Emotional Regulation in Children: Using the Body to Help the Brain. It preceded my Boston.com blog so I have re-posted it below:

I recently heard a great story from a parent in my behavioral pediatrics practice. Their son was very active and had a hard time settling down to learn, and so, before an early morning tutoring session, a very resourceful teacher suggested he ride a scooter down the empty halls to the room where a group of kids with reading difficulties met. To make it fair, the teacher allowed all of the students in the group to ride scooters to class. The kids lay on their stomachs and used their arms to propel them down the long hall. Interestingly, not only this boy, but also all of the kids in the class began to do better!

One of the best weekends of the Infant-Parent Mental Health Post-Graduate Certificate Program that I have been attending and writing about over the past year, was with child psychiatrist Bruce Perry. He spoke of the importance of what he referred to as "rapid alternating movements' in achieving emotional regulation. Dr. Perry's ideas grew out of his frustration with the traditional model of psychiatric care, where children who have experienced significant trauma are expected to sit and talk with a therapist about their experience( and of course are also medicated.) His model of intervention is based on knowledge of brain development and is termed the "Neurosequential Model of Therapeutics.'

While it is not my intention to describe the model in detail, one of the main messages, which has relevance not only to traumatized children, is that in order to think, learn and process experience, one must first feel calm. A range of activities can achieve this calm. Dr. Perry does therapy sessions with very troubled children while going on walks. Horseback riding, martial arts, drumming and dance are other activities that can serve to achieve this kind of calm. A group of fellows from the program got to try out the theory. After a long, very stimulating (and also somewhat dysregulating) day of learning with Dr. Perry, we went ice-skating. Not only was it a lot of fun, but it worked wonders in helping us to process the experience.

Often when kids are struggling in school, teachers express concern that they are "over-scheduled." But if extracurricular activities are carefully planned and well thought out, they can be considered an essential part of treatment. It is best to have some kind of a calming activity interspersed with homework, tutoring or therapy. These can be tailored to a child's particular talents and interests. Many know the story that Michael Phelps struggled terribly with ADHD. Swimming can be a very regulating activity, but some kids with learning and behavior problems also have sensory processing difficulties and can't stand to have their head under water. Clearly swimming isn't the right choice for them.

The more children I see with a range of "behavior problems," the more I recognize the importance of using the body to help the brain. Occupational therapy for young children can accomplish this goal. But as children get older, and can learn to express their feelings, parents can help them identify what works for them. This same boy on the scooter, several years later, learned to recognize that when he was feeling overwhelmed, going down to the basement to play his drums helped him to regroup. This kind of awareness, both of mind and body, can serve kids well not only in childhood, but over the course of a lifetime as they learn to adapt to their particular vulnerabilities.

Central to this notion of using the body to help the brain is that movement take place in relationships. We know that children develop the capacity for emotional regulation in the context of relationships. Things like martial arts, horseback riding and swimming involve intimate relationships with teammates, coaches and instructors.

So I hope that before psychiatrists head down the road in search of "evidence" that "gym" is good for ADHD, there is sufficient thought and attention to what kind of physical activity, how and when it occurs, and if it occurs in the context of meaningful relationships.