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Efficacy of peer-mediated multi-modal intervention program for ADHD students over one year
Sagar Mehta
407-628-4538
Winter Park High School
Winter Park, FL
Confirmation Number: S321593
Mentor: Devendra I Mehta MD
Assistant Professor Florida State University
407 470-6674
2
Acknowledgments
Sagar Mehta: Volunteer – Initial 6 week program in summer of 2007. Team leader - 3
weeks follow-up program in summer 2008
Dr. Devendra I Mehta MD: Mentor, Supervisor of summer 2007 and 2008 trips. Helped
with data collection and statistical analysis and editing of paper
Dr Ashok Motiwala MD: Pediatrician, New Delhi; Director, HARSH MMV Trust
Dr Swyamprabha Sharma PhD: Teacher, Najibabad Schools
Dr Naina Mehta MD: Neurodevelopmental Pediatrician, Orlando, Fl
Dr Hemant Bisht DMD: Dentist, Najibabad
Dr Vijaylakshmi Jain PhD: Principal of Najibabad schools
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Efficacy of peer-mediated multi-modal intervention program for ADHD students
over one year
Abstract:
Aim: To assess the efficacy of a 12 month peer-mediated interventional program con-
sisting of yoga, meditation, and play therapy implemented in a school in India.
Population: 69 Students between ages of 6 and 11 previously identified as having
ADHD were enrolled. Control population consisted of 66 age-matched students.
Methods: A program called Climb-Up was embedded in a school twice weekly. Local
high school student volunteers were trained to implement the program for one year. Im-
provements in ADHD symptoms and academic performance were assessed using Van-
derbilt Assessment from parents and teachers, Improvements in dental health were
scored using the DMFT score assessed by a local dentist.
Results: The mean Performance Impairment scores for ADHD students improved by 6
wks and were sustained through to 12 months in 50 (87%) students. The improvements
were highly significant (p<.0001, paired ttest). The DMFT scores of the 32 surveyed did
not improve at 6 months from baseline but by 12 months 19 (59.4%) students had im-
proved, and reached the same level as the control population. This was highly signifi-
cant compared to baseline (p<.0005, paired ttest).
Conclusion: The Climb-Up program resulted in remarkable improvements in the stu-
dents’ school performances and this was sustained throughout the year due to the local
high school volunteers’ efforts. Similarly, personal hygiene was also noted through den-
tal improvements due to dental education and increased focus. These results show
promise for a cost-effective program that could be implemented in any school.
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Introduction
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common
disorders, affecting 5.3% up to 20% of the children worldwide (Polanczyk, 2007), (Moffitt
et al., 2007). U.S. studies have shown a prevalence of 8.7% in 8 – 15 year olds
(Froehlich, 2007). We had reported a similar prevalence in a school based study in India
at 8.79%, the research project last year’s project titled: “Epidemiology of ADHD in India
and its Impact on Accident Proneness, Self Care, and Projected Economic Burden.”
Other studies in India based on hospital or outpatient clinic populations, with referral
bias suggest prevalence of 5.2% to 29.5% (Kaur , 2004, Mukhopadhyay 2003, Bhatia
1991).
The condition generally leads to poor academic performance at school and
problems with behavior at home and school. Children with this disorder often have other
problems such as anxiety, depression, and learning disabilities, and it adversely impacts
the family and community. As they reach adolescence, these children are also at
greater risk of drug and alcohol abuse and other issues such as increased rate of motor
vehicle accidents, adding a substantial cost burden to the society. In our study we had
noted an increased rate of dental decay in these children compared to controls (Figure
5). These children also suffer from higher levels of temper-tantrums, tics, and problems
with family and peer relationships that continue into adulthood and prevent the person
from achieving their maximum potential (American Academy of Pediatrics, 2001).
However, with treatment with behavioral therapy with or without medications,
most are able to do well at school and college, and become productive adults.
Multimodal behavioral program integrating play therapy, exercise, and reward systems
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using psychologists have been shown to help the majority of children with ADHD
(Jenson et al 2007). The solution we devised was a self-sustaining, low cost program
not dependent on scarce professionals that could also be embedded into the school to
ensure compliance.
Based on our own volunteer experiences, we reasoned school peers would be
an ideal, perpetual resource. Other studies in small settings have shown peer tutoring
does help children with ADHD (DuPaul, 1998; Plumer 2005). Peers can offer role
models, have closer associations with the children throughout school, help build self
esteem, and provide a more suitable environment for the needs of the ADHD students
(Barkley 567).
Yoga with meditation modified for children was chosen as the physical excessive
component. Yoga also needs limited space, no equipment, easy to learn, and culturally
well accepted. There is strong belief but limited evidence to show that Yoga and
Meditation helps focus and attention. Pilot studies using this as family based therapy for
ADHD in 8 boys have been reported to show promise (Jensen, 2004). Additional
theoretical basis may be the increase in dopamine release in the CNS from Yoga
(Kjaer, 2002). In ADHD, reduced dopamine levels are seen in the CNS (Swanson,
2007), and strategies to regulate these levels are suggested as possible therapies.
To evaluate the program, we chose to look at Vanderbilt Scores, which relate to
Parents and Teachers assessment of ADHD symptoms, and in terms of personal
hygiene, we chose dental disease as this was noted to be significantly worse than
controls (Figure 5), and would be amenable to changes over a one year timeline.
6
Population: The study population studied consisted of children in 2nd to 5th
grades (ages 6 yrs to 11 yrs) identified as having ADHD, attending a school in
Najibabad, a small town 400 kilometers north of Delhi. As reported previously, 80
children between ages 6 and 11 yrs were identified, using DSM IV criteria, using
Vanderbilt as the assessment tool, and a Neurodevelopment exam to exclude other
conditions. Of these, 76 agreed to enroll, and 69 stayed in the program consistently for
12 months. Of the seven, 5 moved to other schools, and 2 came intermittently and were
excluded from the data analysis. The children with ADHD were divided into age and
sex based groups of 8 to 10 each.
Population Characteristics: The town’s population is roughly 155,000 with about 55% of
the children attending the public boys or girls schools. The other 45% children attended
a Catholic or private school in the town, or boarding schools elsewhere, or did not
attend school and were not part of our survey. The population consisted of just over
50% Muslim, 48 % Hindu, in keeping with the state average. Also about 90% of the
population lived in the urban area of the town with the other 10% living in the rural area.
There are three Pediatricians and several general practitioners. There is one college,
with the nearest University in Bareilly (Central Intelligence Agency World Factbook,
2008). For the dental assessment the control population of 66 children was selected
from the same grades by random selection
.
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Method:
This program was implemented in Najibabad over a 6 week period in the
summer of 2007. As reported previously, 80 children between ages 6 and 11 yrs were
identified, using DSM IV criteria, using Vanderbilt (Appendix A) as the assessment tool,
and a Neurodevelopment exam to exclude other conditions. Of these, 76 were enrolled
after informed consent.
The interventional program was devised as part of a program called Climb-Up.
This composed of Yoga poses and simple meditation techniques using breathing
suitable for children were selected from Prekshya Dhyana taught by Jain Nuns. Games
that are used to increase attention span, while improving their memory, concentration
and social skills were translated into Hindi, with culturally appropriate modifications
made as necessary. These games ranged from “Simon Says” and “Twister” to memory
card games and board games such as “Stare”. The total cost of games and related
supplies was $75.00. With time local games with similar attributes were introduced.
Three additional high school volunteers from the US and UK were recruited and trained
over a two week period.
The children with ADHD were divided into age and sex based groups of 8 to 10
each. Morning sessions of 25 minutes of Yoga and Meditation, followed by 30 minutes
play therapy, and a 5 minute discussion/feedback from the children, twice a week per
group were established with each group having 2 volunteers delivering the program.
Attendance and level of involvement was tracked and provided graphically to give each
child feedback. In addition, tangible rewards were given each session to spur ongoing
effort. During this time 13 local high school 11th graders were recruited. These high
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school volunteers were trained over during weeks 3 and 4, and they then ran the
program for the last 2 weeks with observation and feedback from the Climb-Up team. A
Yoga and Meditation proficiency test was administered toward the end confirming all
children had reasonable skills. The volunteers carried on the program twice weekly per
group for 2 more weeks and then once weekly throughout the year except during school
breaks and examination week, as well as the first week of new term. During the winter
months, the class time switched to the last class before lunch.
After 6 months of enrollment, another UK volunteer visited and introduced
changes in the program. This consisted of new games, partly devised with input from
the high school volunteers, and new Yoga postures to maintain interest and pose new
challenges, as well as continue to engage the volunteers.
The children were screened for ADHD using the Initial Teacher Vanderbilt
Assessment (American Academy of Pediatrics, 2001) in May 2007 toward the end of
their school year. Follow up Teacher and Parent version were subsequently completed
after 6 weeks of the program implementation, and then by parents at 6 months, and
teachers at the beginning of the next school year. The Vanderbilt captures symptoms
relating to inattentiveness or hyperactivity, and generates a combined or raw score. The
Vanderbilt questionnaires were translated into Hindi by trained teachers. The parents if
needed, asked teachers not directly teaching their child to help complete the
questionnaire. Though not specifically validated in India, this score system has been
used in other countries (Wolraich, 2003). These completed forms were then mailed to
us and data entered onto excel spreadsheets. The scores are generated for
Hyperactivity and Inattentiveness, and these are combined to give the Vanderbilt Raw
9
Score. Performance Impairment Scores on the questionnaire are based on 8 areas:
reading, mathematics, written expression, relationship with peers, following directions,
disrupting class, assignment completion, and organizational skills. Each category is
scored from a 1 to 5 with a 4 or 5 indicating impairment, and abnormal scores
(American Academy of Pediatrics, 2001). The number of areas of impairment are then
tallied (maximum 8) to give the Performance Impairment Score.
During that summer, a dental evaluation of the ADHD children and control
students was performed by a dentist in town to determine the number of decayed,
missing, or filled teeth. This produces the DMFT score (WHO Global InfoBase: India). A
dental survey was also conducted to determine brushing habits, use of toothpaste, and
unhealthy dietary habits such as eating sweets before bed. In addition, the children
were educated in oral hygiene and taught the proper methods to brushing and the
amount it should be done. They were also given supplies to carry on healthy brushing
habits.
At the 6 month interval, a dental evaluation was also conducted by the same
dentist, and the children were exposed to dental education again to reinforce oral
hygiene. Again after a year the students’ dental health was re-assessed by the same
dentist.
All the information was collected using excel and Epi Info Database. Analysis
was performed using descriptive statistics, and paired t-test for each time point.
Significance was determined as P value < .05.
10
Time Table
Assessments May 2007 July 2007 Dec 2007 July 2008
Parents X X X
Teachers X X X
Dental X X X
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Results:
Performance impairment is assessed by the teachers only (Figure 1). The follow-
up performance impairment scores were completed in July 2007 and July 2008. The
average score decreased remarkably from 5.7 at baseline May 2007 to 1.4 in July 2007
(p<0.001, 2 tailed paired ttest). This improvement from baseline was sustained with the
score in July 2008 of 1.5 sd (p<.0001, 2 tailed paired ttest). From the Baseline
assessment in May 2007 to July 2008, 7 (12%) students had scores remain the same or
worsen and 50 (87%) of the students showed improvement. A total of 19 students still
had significant symptoms of ADHD according to the teacher evaluations.
In terms of gender, the mean improvement score was 3.24 for females and 4.93 for
males. However, when compared with their baseline, the improvement from baseline for
females was 76% and for males 75%.
The Teachers’ follow-up Vanderbilt raw score assessments were completed in
July 2007 and July 2008 and are shown in Figure 2. At baseline May 2007 the average
score was 12.4 SD 3.8. In July 2007, after 6 weeks of twice weekly intervention the
average improved to 5.4 SD 4.7 (p<0.000 2 tailed ttest). One year later in July 2008,
after once weekly sessions, the improvement was sustained with an average score of
4.7 SD 5.8.
The parents’ follow-up assessments were completed in July 2007 and Dec 2007
and are shown in Figure 3. At baseline May 2007, the average score was 9.3 SD 4.6. In
July 2007 the average improved significantly to 6.8 SD 5.2 (p<0.001 2 tailed ttest). In
December 2007 this average was still significantly lower at 5.8 SD 4.4 then at baseline
(p<0.001 2 tailed ttest). The July 2007 and December 2007 scores were not statistically
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different. 63 of the 69 students had assessments completed at both dates. According to
the parent reports, by Dec 2007, 14 (22%) students had ADHD symptoms that
remained the same or worsened and 49 (78%) had improved from baseline. In terms of
parent and teacher concordance, agreement in direction of change was seen by both at
6 weeks in 54 (78%), and disagreements in 12(17%).
Dental Results:
Attrition rates for dental evaluation were as follows: all 69 were evaluated at baseline,
and at 6 months in Dec 2007, 52 were reassessed. At 12 months in July 2008, only 32
of the students were present at follow-up dental examination as monsoon rains
hampered the local dentist travel; therefore the analysis is limited to this subset. The
average DMFT score in July 2007 for the whole group of 69 was 2.42 SD 2.3, and the
subset of 32 with completed follow-up was 2.27 SD 2.4 (n.s.). This similarity and the
unplanned circumstances leading to a smaller final sample should minimize any risk of
sampling bias. The follow-up assessment in Dec 2007 reported an average score of
2.12 and in July 2008, the average score was 1.03 (Figure 4) (p<.0005, 2 tailed paired
ttest). From July 07 to July 08, 4 (12.5%) had scores worsen, 9 (28.1%) had scores
remain the same, and 19 (59.4%) had scores improve. Figure 5 shows our previous
baseline data for percentage of children with ADHD with a score greater than 2 on the
DMFT scale, compared with age matched controls from the same classes. The one
year follow-up DMFT scores are similar to controls.
13
Figure 1:
MAY2007 JUL2007 JUL20080
1
2
3
4
5
6
7
8
Performance Impairment Score
Date of Assessments
Mea
n Sc
ore
(SD=
bar)
* *
Figure 1: Shows the teachers’ performance impairment scores with SD for the months of May 2007, July 2007, and July 2008. “*” represents the difference between the baseline value (May 2007) and all the fol-low up assessments and is significant at p < .0001.
14
Figure 2:
MAY2007 JUL2007 JUL20080
2
4
6
8
10
12
14
16
Teacher Raw Vanderbilt Scores
Date of Assessments
Mea
n Sc
ores
**
Figure 2: Shows teachers’ raw Vanderbilt scores assessing the ADHD. The mean values and SD are shown for month May 2007, July 2007, and July 2008. “*” represents the difference between the baseline and July 2007 and July 2008 for the teachers and is significant at p<.0001
15
Figure 3:
MAY2007 JUL2007 DEC20070
1
2
3
4
5
6
7
8
9
10
Parent Raw Vanderbilt Scores
Date of Assessment
Mea
n Sc
ore
(SD
=Bar
)
*
Figure 3: Shows parents’ raw Vanderbilt scores assessing the ADHD. The mean values and SD are shown for month May 2007, July 2007, and Dec 2007. “ * ” represents the difference between the baseline value (May 2007) and all the follow up assessments for the parents is significant at p < 0.005.
*
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Figure 4:
JUL '07 DEC '07 JUL '080
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5 Change in DMFT Score After 1 year
Year
DMFT
Sco
re (S
D=Ba
r)
Figure 4: Shows the Change in DMFT scores of the ADHD Children from July 2007 to Dec 2007 to July 2008. The change from July 2007 to July 2008 is significant at p < .0005. The change from July 2007 to Dec 2007 is not significant at p >0.5. The change from Dec 2007 to July 2008 is significant at p < .005
17
Figure 5:
Control ADHD baseline ADHD 1 year f/u0
5
10
15
20
25
30
35
40
45
Percent of Children with ADHD at Baseline,One Year Follow up, and Controls with DMF scores >2
Figure 5: Shows the percentage of control or ADHD students with a DMFT score of more than 2. The dif-ference is statistically significant at P < 0.01 (Chi Sq.) with a relative risk of 1.5 between control and ADHD baseline. One year follow up for ADHD is similar to control children (p>0.5 Chi q)
%
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Discussion:
The improvement in the performance impairment score confirms the efficacy of
the program for ADHD children. This constitutes improvement in the academic
performance, social and peer interactions and ability to follow instructions. Likewise,
these improvements were seen in the parents and teachers raw Vanderbilt scores
which show a statistically significant decrease in the scores. Both report improvements
in the child’s ability to pay attention in class, organizational skills with homework, and
decreased impulsive behavior. The teacher evaluations confirm the positive results
were maintained from July 2007 through to the following July 2008. This was also
achieved after the original Climb-Up team members left and the local high school
student volunteers carried on the program. These results show that a two-week training
course was enough to transfer the program successfully to local high school volunteers.
Furthermore the data proves that the interventional program had more than just a short-
lasting beneficial impact and the efficacy was self-sustained over the year. Indeed the
program is still being carried on with newly trained volunteers in 2008 suggesting this
could be perpetuated in a peer to peer fashion.
The children as well as the peers enjoyed the meditation and yoga and were
particularly interested in the play therapy. It was clear another relationship was
developing between the peers and the students having an impact on the child’s self
esteem. Although difficult to evaluate, this may have been one important factor in the
program’s success
Another element of the program that could contribute to the improvement was the
use of tangible rewards. Each week the children were scored on the behavior and the
19
child with the most marks would receive a choice of a toy from a gift bag. This inspired
the children to improve their behavior and maintain this improvement. Also, the 12
graduating students were presented with awards for successfully completing the
program and were recognized by the Principal and School Chairmen. A similar idea was
used for the local high school volunteers to give them motivation for their work.
Depending on the amount of hours volunteered, these students were given a certain
amount of dress material, and also recognition by the Principal and School Chairmen.
At first the school principal had been hesitant concerning the volunteer involvement idea
as this was the school’s first exposure to Community Service and Volunteer activities.
But once it was carried out, the program helped raise community awareness and by the
next year there were a multitude of new students eager to volunteer.
Figure 5 shows the July 2007 DMFT scores of greater than 2 between the
control group and the ADHD group. The increased prevalence in untreated ADHD
children is statistically significant and shows the negative impact that ADHD has on oral
hygiene. This led to the idea of Dental education sessions for the students. In
December 2007 the dentist re-evaluated the children’s teeth and found that the mean
DMFT score decreased from 2.3 to 1.8. This is not statistically significant and a reason
for this could be that 6 months is not enough time for the dental education and the
assessment of its effects. However a repeat dental evaluation in July 2008 revealed that
the mean score had decreased to 1.0, which is statistically significant. Indeed, in Figure
5, the percent of children with DMFT scores greater than 2 improved from baseline to
control values after 1 year for the ADHD children. Unfortunately, only 32 children had
complete assessments over the three time points, so this may lead to sampling bias.
20
The dentist was not always able to stay for a long enough time to assess each child,
and the July timeline proved to be inconvenient because of monsoon rains. Out of these
32, 4 children (12.5%) had worse scores by the end, 9 (28.1%) had scores remain the
same, and 19 (59.4%) had improved scores. The results prove that the ADHD children’s
oral hygiene can be improved with dental education and enforcement of healthy dietary
habits.
These results show a remarkable consistency in response to both the peer
mediated program, as well as dental education. While some of the effects may be
credited to initial enthusiasm and attention, the fact that improved performance in school
was sustained for the majority after one year of intervention by school volunteers is
impressive. Further work would be needed to assess which part of the program has the
greatest efficacy. One recent study pilot study from Arizona shows preliminary evidence
of efficacy of Transcendental Meditation in ADHD in 11 children (Grosswald et al 2008),
reaffirming potential role of Yoga with Meditation. Likewise, further attention should be
given to the children who failed to improve. One approach being followed is to increase
the number of sessions to twice weekly and to engage their parents to make sure they
continue to do yoga and meditation at home.
To assess whether these responses seen can be generalized, we have started a
program in an elementary school in Orange County, Florida. Using the success of the
program in India, we were able to convince the School Board to establish a program in
the morning. It already appears Yoga and Meditation has universal appeal, and every
other aspect of the program is enjoyable and inexpensive. Currently one other high
21
school volunteer assists me, and if we show success here, widespread use would be
feasible.
22
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APPENDIX A
