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Running head: AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES

Complementary and Alternative Therapies in children with ADHD

Na Lee Futral

Bon Secours Memorial College of Nursing

NUR 4122 Nursing Research

April 5, 2017

On my honor, I have neither given nor received any help on this work.

I Pledge. Na Lee Futral

AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 2

Abstract

The goal of this integrative review is to evaluate the literature regarding the use of

complementary and alternative therapies in children with attention deficit hyperactivity disorder

(ADHD). ADHD is a prevalent neurodevelopmental disorder that children are diagnosed with

worldwide. The efficacy of traditional medication therapy has been well researched, but there

are new ideas in the treatment of ADHD that use different complementary and alternative

therapies. The research design is an integrative review. The search for literature was conducted

using the computer-based search engines PubMed and the Cumulative Index to Nursing and

Allied Health Literature (CINAHL). The search yielded 153 research articles and 5 met

inclusion criteria. The results analysis of the articles demonstrated support for encouraging

complementary and alternative therapies to children diagnosed with ADHD. Findings showed

that these therapies could promote better attention, creativity, social skills, and reduce negative

behaviors associated with the disorder. Limitations to the review include the researchers busy

life as a nursing student and mother, the amount of time to complete the assignment, the limit on

the number of articles and a time limitation of 5 years prior to the writing of this integrative

review. The authors implicate that providers, nurses, and parents need to be open-minded in

trying different therapies, because there are benefits to using treatment other than medication.

Future research should include more trials, test different therapy modalities, and utilize larger

population sizes in studies so that there is no chance of a biased outcome in the study.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 3

Complementary and Alternative Therapies in children with ADHD

The purpose of this integrative review is to search the literature pertaining to

complementary and alternative therapies in children with attention deficit hyperactivity disorder

(ADHD). ADHD is considered to be the most prevalent neurodevelopmental disorder, with a

prevalence of 3%-7% in school-aged children (Jang et al., 2015, p. 546). This is alarming

because these children may continue to show characteristics like impulsivity, hyperactivity, and

inattentiveness that may impair their ability to be productive in school work, and in social

relationships as adults. There has been much interest in the efficacy of medication therapy that

has been researched and documented, but there is limited evidence on complementary and

alternative therapies to treat ADHD. Children with neurodevelopmental disorders may use

complementary and alternative medicine (CAM) more because of their young age, lack of

effective treatments, and greater concern about the adverse effects of traditional medications

(Huang, Seshadri, Matthews, & Ostfeld, 2013, p.746). This topic interests the researcher

because there are innovative complementary and alternative therapies that are starting to be

utilized with children with ADHD that may be beneficial for more favorable outcomes in

behavior. The proposed PICO question by this researcher is as follows: In school aged children

with ADHD, what is the effect of complementary and alternative therapies in reducing symptoms

of behavior, compared with traditional medication therapy?

Research Design, Search Methods, & Search Outcomes

The research design is an integrative review for an undergraduate senior nursing research

class. The search for research articles was conducted utilizing the computer-based search

engines PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL).
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 4

Key search terms included words like, complementary, alongside words like alternative,

treatment and ADHD. Other terms included, music, and therapy, and attention, as

well as terms like, neurodevelopmental and disorders. There were 45 results via PubMed,

and 108 results via CINAHL. The searches were limited to peer-reviewed, quantitative and

qualitative nursing research articles that were published within 5 years, from 2012-2017.

Searches were also limited to articles that were published in English and that were pertinent to

the researchers PICO question, In school aged children with ADHD, what is the effect of

complementary and alternative therapies in reducing symptoms of behavior, compared with

traditional medication therapy? Articles were chosen based on how much complementary and

alternative therapies were discussed, and its value in reducing symptoms in children with

ADHD. If the studies were written in other languages, or if the study was a meta-analysis then it

was excluded from the integrative review. This search method produced a total of 5 articles

relating to the PICO question, 1 of which was qualitative, and 4 that were quantitative.

Findings/Results

The findings and results of the five reviewed studies indicate an overall positive effect on

complementary and alternative therapy on children with ADHD (Carpente, 2014; Hodgkins,

Shaw, Coghill, & Hechtman, 2012; Huang et al. 2013; Jang et al., 2015; Roden et al., 2014). A

synopsis of the articles are presented in Appendix 1. The articles that did not support the PICO

question were not used in this integrative review. The researcher framed the review according to

the following categories: complementary and alternative therapy treatment, and improved social

behavior.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 5

Complementary and Alternative Therapy

In 3 out of 5 studies, there was commonality in the idea that complementary and

alternative therapies in children with ADHD, showed significant improvement in reducing

symptoms of the disorder (Carpente, 2014; Huang et al.; 2013, Roden et al.; 2014). In the

qualitative study conducted by Carpente (2014), the study seeks to look at the efficacy of music

therapy and assessment to help psychologists and other health professionals to determine what

skills and therapies will improve neurodevelopmental disorders like ADHD. This study only had

one participant, who was a 12 year-old boy diagnosed with ADHD. He participated in a 30-

minute IMCAP-ND assessment session facilitated by a board certified music therapist. This

session was video recorded and analyzed using the Musical Emotional Assessment Rating Scale

(MEARS), the Musical Cognitive /Perception Scale (MCPS), and the Musical Responsiveness

Scale (MRS). The data collected was utilized to clinically-musically guide the therapist in

working with the client, as well as providing information to other disciplines working with the

client. This study showed that complementary and alternative therapies, like music therapy,

requires the ability to abstract, differentiate, assimilate, and demonstrate creativity (Carpente,

2014), which may be beneficial for children with ADHD.

Huang et al. (2013), conducted a cross-sectional, quantitative study that investigated

parent satisfaction with complementary and alternative medicine (CAM) compared to

satisfaction with traditional medication therapy in children with ADHD. Categorical data were

analyzed by chi-square or Fisher exact tests. The results were significant in showing that parents

were interested in the benefits of seeking more CAM for their children with ADHD, to reduce

symptoms of the disorder. Some of the treatments that were looked at were dietary supplements,

sensory integration, facilitated communication, kinesiology and behavior modification. The

AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 6

researchers noted that there was a trend toward more CAM therapy use by the children who did

not use prescribed medication. This study showed that parents like CAM therapy because it

helps prevent serious adverse effects from medication in their young children.

Roden et al. (2014), conducted a quasi-experimental, quantitative, longitudinal study.

The purpose of this study was to investigate if children who were exposed to music training had

better attention, processing speed, and cognitive music ability, compared to children in the group

who received extended education in natural sciences. The sample was comprised of 345

children, 192 children participating in the instrumental training program, and 153 children being

given extra education in natural sciences. The researchers used written cognitive ability tests as

well as standardized paper questionnaires. They used the d2 Test of Attention and the Zahlen-

Verbindungs-Test (ZVT) to measure the information processing speed. The level of statistical

significance set by the researcher was at an alpha level for KL, which was the efficiency of

concentration, at 0.93. This study found evidence for significant improvement of verbal

memory and auditory working memory for the music group only (Roden et al., 2014, p. 554).

There are so many children who have difficulty focusing and processing information in schools,

and the authors showed that complementary and alternative therapy like music lessons may be a

solution for helping children with ADHD improve these cognitive abilities and reduce symptoms

of the disorder.

Improved Social Behavior

In 2 out of the 5 of the research studies, the authors discussed the efficacy of

complementary and alternative therapies on improved social behavior (Hodgkins et al., 2012;

Jang et al., 2015). In the randomized, quantitative study conducted by Hodgkins et al., the

researchers sought out to find a comprehensive strategy aimed at optimizing treatment for the
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 7

benefit of an individual with ADHD and their family members or caregivers. In this study, 125

treatment-nave children, were randomly assigned to receive either Methylphenidate (MPH) or

Amfetamine (AMH) alongside intensive behavioral therapy. The Conners Teacher Rating Scale

(CTRS) and the Conners Parent Rating Scale-Revised (CPRS-R), were used to statistically

compare these two groups. In the CTRS-R, there was a statistically significant difference (MPH

effect minus AMF effect) in favor of MPH in treatment-induced improvements in conduct

problems, and hyperactivity factor. This article found that multimodal treatment, combining

medication and behavioral therapy, showed benefits in aggression, internalizing symptoms,

social skills, and parent-child relations (Hodgkins et al., 2012, p. 488). This article showed that

complementary and alternative therapies alongside medication therapy would yield the best

result for more positive social behavior.

In the quantitative, open label study conducted by Jang et al. (2015), researchers

investigated the clinical effects of equine-assisted activities and therapy (EAA/T) for treating

ADHD. The researchers wanted to implement a psycho-exercise program to improve attention,

inhibit impulsivity, and improve social behavior in children. They studied 20 participants after

using exclusion criteria and identifying any other comorbidities that did not qualify other

children for this study. Investigators administered ADHD rating scales (ARS-1), the Clinical

Global Impressions Scale (CGI), and the Gordon Diagnostic System (GDS) to measure ADHD

symptom improvement. Pre- and post-EAA/T scores were compared, by using the paired t-test to

assess EAA/T effectiveness. At the end of the study, researchers were able to show that 2

patients were very much improved, 15 patients had a score of 2 indicating much improved

and only 3 patients minimally improved (Jang et al., 2015). The ARS-I total score and the

inattention and hyperactivity/impulsivity subscale scores decreased significantly. CGI-S scores

AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 8

decreased significantly, and the effectiveness ratio on the GDS increased from 0.73-0.78. The

researchers state that, animal-assisted activities help children improve social thinking and social

skillsAnimals can facilitate a trusting alliance between the therapist and child and relieve

tension and anxiety while helping the child learn social skills (Jang et al., 2015, p. 547). The

results of this study showed that alternative therapies can improve social behavior in children

with ADHD without the use of medication.

Discussion/Implications

The findings of the integrative review, addresses the effects of complementary and

alternative therapies in children with ADHD. The review findings supports the researchers PICO

question, which specifically looks at complementary and alternative therapies in reducing

negative symptoms of behavior, and helps promote more positive behavior in children. The

qualitative study by Carpente (2014), and the two other quantitative studies by Huang et al.

(2013), and Roden et al. (2014), brought up good points about collaboration in care between the

child, healthcare professionals, parents, and therapists to find the most optimal form of treatment

with the best results even though it may be untraditional and unconventional. The two

quantitative studies by Hodgkins et al. (2012) and Jang et al. (2015), showed that complementary

and alternative therapies give children the opportunity to interact with others more, and practice

using skills like focusing and concentrating that they would not get with traditional medication

treatment.

The implications of the findings suggest the potential to treat children with ADHD

worldwide with other modalities of treatment by using more complementary and alternative

therapies. The studies implicate that pediatricians and nurses should be more aware and more

educated in helping parents explore complementary an alternative therapies in treating children

AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 9

with ADHD. The authors of these various studies also implicate that providers and parents need

to be open-minded in trying different therapies, because there are benefits to using treatment

other than medication. Recommendations for future research should include more trials, utilize

other treatment modalities, and include bigger population sizes, especially in the study with

equine assisted therapy by Jang et al. (2015), and in the study from Carpente (2015), where there

was only one participant.

Limitations

There are numerous limitations acknowledged by the researcher that have influenced this

integrative review. This literary review is due at an inopportune time near the end of the

semester, and the researcher is a full-time nursing student, with two children, and a part-time job.

This is the researchers first time writing an integrative review. The review was limited to 5

journal articles within the last 5 years. The sample size was inadequate in a few of these studies,

and could have influenced a biased outcome.

Conclusion

The findings of this integrative review give validity to the idea that complementary and

alternative therapies can reduce negative behaviors, and help promote more focus, control, and

social behaviors in children who are diagnosed with ADHD. Beneficial findings from this

review include, children diagnosed with ADHD who can practice self-control, creativity,

listening skills, and improved communication with the use of complementary and alternative

therapies. The results of this study show that alternative therapies can reduce symptoms of

ADHD without the use of medication. Some of these therapies may improve not only ADHD

core symptoms but also social problems as well.

AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 10

References

Carpente, J. A. (2014). Individual music-centered assessment profile for neurodevelopmental

disorders (IMCAP-ND): New developments in music-centered evaluation. Music

Therapy Perspectives, 32(1), 56-60. doi:10.1093/mtp/miu005

Hodgkins, P., Shaw, M., Coghill, D., & Hechtman, L. (2012). Amfetamine and methylphenidate

medications for attention-deficit/hyperactivity disorder: complementary treatment

options. Eur Child & Adolescent Psychiatry, 21(9), 477-492.

doi:10.1007/s00787-012-0286-5

Huang, A., Seshadri, K., Matthews, T. A., & Ostfeld, B. M. (2013). Parental perspectives on use,

benefits, and physician knowledge of complementary and alternative medicine in

children with autistic disorder and attention-deficit/hyperactivity disorder. The Journal of

Alternative and Complementary Medicine, 19(9), 746-750. doi:10.1089/acm.2012.0640

Jang, B., Song, J., Kim, J., Kim, S., Lee, J., Shin, H., Joung, Y. (2015). Equine-assisted activities

and therapy for treating children with attention-deficit/hyperactivity disorder. The

Journal of Alternative and Complementary Medicine, 21(9), 546-553.

doi:10.1089/acm.2015.0067

Roden, I., Knen, T., Bongard, S., Frankenberg, E., Friedrich, E. K., & Kreutz, G. (2014).

Effects of music training on attention, processing speed and cognitive music abilities-

findings from a longitudinal study. Applied Cognitive Psychology, 28(4), 545-557.

doi:10.1002/acp.3034
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Running head: AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES
Appendix 1: Qualitative and Quantitative Article Table of Evidence

First Author John Carpente, 2014, the Rebecca Center for Music Therapy and Center for Autism and child
(Year)/Qualifications Development, Molloy College, Rockville Centre.
Background/Problem There has been an increased interest in looking at alternative therapies to treat neurodevelopmental
Statement disorders like ADHD, but there are not a lot of assessment tools to help clinicians utilize and understand
the efficacy of these therapies. This study seeks to look at the efficacy of music therapy for Jason, using
the IMCAP-ND to determine what areas his ADHD were affecting his social behavior.
Conceptual/theoretical The theoretical framework of this study is based around the Music Therapy Communication and Social
Framework Interaction scale (MTCSI) which was developed to assess communication and social interactive behaviors
of children during music therapy.

Design/ This is a qualitative study that explores the efficacy of using music therapy and assessment to help
Method/Philosophical psychologists and other health professionals determine what skills and therapies will improve
neurodevelopmental disorders like ADHD. This study only had one participant, and he was tested by a
Underpinnings music therapist, using the IMCAP-ND assessment.
Sample/ Setting/Ethical This study looks at a 12-year old boy diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). He
Considerations participated in a 30-minute IMCAP-ND assessment session facilitated by a board certified music therapist.
The session was video recorded and analyzed using the MEARS, MCPS, and MRS. There was no
mention of ethical considerations for this study.
Major Variables Studied There were 3 variable studied using the IMCAP-ND assessment. Scale 1: Musical Emotional Assessment
(and their definition), if Rating Scale (MEARS) is designed to assess each clients musical-social-emotional capacities in musical-
play, Scale II: Musical Cognitive/Perception Scale (MCPS) is used to assess each clients ability to react,
appropriate focus, recal, follow, and initiate five musical elements, and Scale III: Musical Responsiveness Scale (MRS)
is designed to assess each clients preferences, efficiency, and ability to self-regulate in musical play.
Measurement Tool/Data The IMCAP-ND is made up of three quantitative scales that assess the clients developmental capacities to
Collection Method engage in relational musical making. The therapist improvised music to engage the client while assessing
specific targeted musical responses in order to identify his musical resources, challenges, and preferences.
The assessment process involves coding video recorded sessions in one-minute intervals while observing
the childs ability to engage in instrument play, vocalization, movement, as well as display social-emotional-
behaviors like gestures, eye contact, joint attention, etc.
Data Analysis The data collected was utilized to clinically-musically guide the therapist in working with the client, as well
as providing information to other disciplines working with the client. The rating scales were used as pre-
and post-test measures to evaluate client progress.
Findings/Discussion The assessment, from the lower areas of the MEARS, showed Jasons difficulties of sustaining and
maintaining attention and expressing affect. This is developmentally impacting his ability to initiate,
differentiate, bridge ideas, and be creative. Music therapy could focus primarily on providing children with
musical opportunities that foster sustained musical attention, adaptation, and engagement.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 12

Appraisal/Worth to This was a well-written and informative article, but it lacks substantial credibility because it is written only
practice about one child. It did however raise good points about encouraging pediatricians, and nurses to
encourage alternative therapy for children with ADHD like music therapy.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 13

First Author Paul Hodgkins, 2012, worked as an employee of Shire PLC Pharmaceuticals in Basingstoke, UK.
(Year)/Qualifications
Background/Problem Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders
Statement among school-aged children. It is highly symptomatic and associated with significant impairment in
inattention and hyperactivity/impulsivity. The purpose of this investigation is to seek a comprehensive
strategy aimed at optimizing treatment for the benefit of an individual with ADHD and their family members
or caregivers.
Conceptual/theoretical Evidence-based guidelines agree that each patient with ADHD is unique, and individual treatment
Framework strategies that incorporate both drug and non-drug treatment options should be sought.
Design/ Randomized, quantitative study that seeks to examine the role of stimulant medications as part of a
Method/Philosophical multimodal treatment strategy in children and adolescents with ADHD. In the United States, the American
Academy of Child and Adolescent Psychiatry Practice Parameters recommend that treatment plans consist
Underpinnings of psychopharmacotherapy and/or behavioral therapy.
Sample/ Setting/Ethical 125 treatment-nave children, ages 5-15, were randomly assigned to receive either MPH or AMF. The
Considerations study included children and adolescents from schools in Australia. There was no mention of ethical
considerations.
Major Variables Studied The variables studied were short and long-acting formulations of the stimulants, Amfetamine (AMF) and
(and their definition), if Methylphenidate (MPH) alongside intensive behavioral therapy.
appropriate
Measurement Tool/Data The Conners Teacher Rating Scale (CTRS) and the Conners Parent Rating Scale-Revised (CPRS-R)
Collection Method were used to statistically compare these groups.
Data Analysis In the CTRS-R, there was a statistically significant difference (MPH effect minus AMF effect) in favor of
MPH in treatment-induced improvements in conduct problems (difference 3.31, 95% Cl 1.11-5.50, p<0.01),
hyperactivity factor (difference 2.78, 95% CI 0.70-4.86, p<0.01). Data was collected after 2 weeks of
treatment.
Findings/Discussion This study favored MPH as the statistically superior stimulant. Concurrent non-drug treatments, including
behavioral therapy, should be considered as part of a multimodal treatment strategy. For those patients or
caregivers who prefer not to take stimulants or for whom stimulant are contraindicated, non-stimulant drug
options are available, though generally less effective. This study also discussed the issue of non-
adherence with medication being an issue with children. Children with both therapies had better behavioral
outcomes.
Appraisal/Worth to This was a well-organized and well written study, but it was a little lengthy and redundant at times. This
practice study is important in healthcare practice because it encourages the importance of medication compliance
along with CAM to generate the best results in children diagnosed with ADHD.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 14

First Author Angela Huang, 2013, MD at the Department of Pediatrics, Division of Developmental-Behavioral Pediatrics
(Year)/Qualifications at Texas Tech University Health Sciences Center School of Medicine in Amarillo, TX.
Background/Problem Complementary and alternative medicine (CAM) use appears to be increasing in children with
Statement developmental disorders. It is not clear whether parents perceive their healthcare providers as resources
who are knowledgeable about CAM therapies and are interested in further developing their knowledge.

Conceptual/theoretical Theoretical framework based on the idea that CAM are not considered to be part of conventional medicine,
Framework and few pediatricians feel very knowledgeable about CAM. This study sought to explore the willingness of
parents and pediatricians to utilize CAM in the treatment of ADHA and ASDs.

Design/ Quantitative study. Families of children with a diagnosis of ADHD or autism spectrum disorders (ASDs)
Method/Philosophical were surveyed regarding the frequency of use of traditional treatment and CAM, parental perceptions of the
helpfulness of each therapy, parental perceptions regarding physicians knowledge level about CAM, and
Underpinnings physician interest in continuing education.
Sample/ Setting/Ethical 378 were recruited from among the parents/caregivers of the patient panel of Kapila Seshadri, MD,
Considerations Associate Professor of Pediatrics in the Division of Child Neurology and Neurodevelopmental Disabilites at
the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. Each
survey was accompanied by a cover letter explaining the purpose of the study and emphasizing that
participation was voluntary and anonymous. No identifiers were associated with returned surveys.
Caregivers were informed in the cover letter that in completing and returning the survey, they were giving
consent for their responses to be used in the study.
Major Variables Studied The major variables studied were the use of CAM (dietary supplements, sensory integration, facilitated
(and their definition), if communication, music therapy, intravenous secretin, kinesiology, behavior modification, and vision
therapy), compared to the use of traditional therapies (medication, special education,
appropriate speech/physical/occupational therapy, early intervention).
Measurement Tool/Data Questionnaires were mailed to participants for this cross-sectional study. Of the 378 surveys, 135 were
Collection Method completed and returned. Of these 41 were from parents who reported that their child had a diagnosis of
ADHD.
Data Analysis Data were categorized by patient diagnosis as reported by the parent. Because all questionnaires were
de-identified, diagnosis and treatment were not independently corroborated. Categorical data were
analyzed by chi-square or Fisher exact tests. A two-tailed p-value of 0.05 was considered to represent a
statistically significant difference.
Findings/Discussion Perceived helpfulness of medication was 92% for children with ADHD and 60% for children with ASD.
CAM was used for 19.5% of children with ADHD and 82% of children with ASD. Perceived satisfaction for
any form of CAM in the children with ADHD was at an individual patient level. Satisfaction for two of the
most commonly used CAM treatments in children with ASD ranged from 50% to 78%. In children with ASD
(the diagnostic group with the highest use of and satisfaction with CAM), physicians perceived knowledge
of CAM was lower, as was perceptions of the physicians interest in learning more.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 15

Appraisal/Worth to This article was clearly written and well organized, but it lacked a lot of background research on the efficacy
practice of CAM. There was not a literary review of other research studies pertaining to this topic. The study is
helpful though in encouraging healthcare professionals to be more aware and more educated in helping
parents explore CAM with children with ADHD and ASDs instead of just prescribing medication to children.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 16

First Author Byongsu Jang, 2015, MD at Hae-sol Psychiatric Clinic in Seoul, Korea.
(Year)/Qualifications
Background/Problem Attention Deficit Hyperactivity Disorder (ADHD) is considered to be the most prevalent neurodevelopmental
Statement disorder with a prevalence of 3%-7% in school-aged children. The efficacy of medications for treating
ADHD is well established, but some patients treated with medication do not improve adequately or cannot
tolerate the side effects. Although medications can improve core ADHD symptoms, there is less
improvement in peer relationship problems or social problems. This study investigates the clinical effects
of equine-assisted activities and therapy (EAA/T) for treating attention-deficit/hyperactivity disorder (ADHD)
in children age 6-13 years old.
Conceptual/theoretical Theoretical framework is based on the idea that non-pharmacologic options to treat ADHD are needed.
Framework Psychosocial treatments include cognitive training, neurofeedback, behavioral treatment, and physical
exercise. Among the psychosocial treatments, physical exercise promotes calmness in children with
ADHD and improves attention. Motion stimulation also improves ADHD symptoms. In particular, animal-
assisted activities help children improve social thinking and social skills. EAA/T strengthens motor planning,
sequencing, and timing, which may have a role improving the capacity to attend.
Design/ This was a quantitative study that was a 12-week, prospective, open-label trail which included equine-
Method/Philosophical assisted activities and therapy (EAA/T). All patients received EAA/T, and there was no placebo or control
group. The program was based on a psycho-exercise program to improve attention and inhibit impulsivity.
Underpinnings It consisted of unmounted activities like putting a halter and saddle on a horse, leading the horse from
stables to the riding arena, and grooming and feeding a horse. It also included hippotherapy sessions twice
per week for 12 weeks (total of 24 sessions). Twenty minutes of unmounted activities was assigned, 10
minutes before and after 40 minutes of therapy on a horse.
Sample/ Setting/Ethical Twenty participants (19 boys and 1 girl) completed 12 weeks of EAA/T. This study took place at the Child
Considerations and Adolescent Psychiatry Service Unit at Samsung Medical Center in Seoul, Korea. The institutional
review board of Samsung Medical Center approved the study. All participants and their parents provided
signed informed consent and assent.
Major Variables Studied Equine-assisted activities and therapy (EAA/T) was the only variable that was tested on the children.
(and their definition), if Methylphenidate or atomoxetine was not permitted during EAA/T in order to reduce the effect of
confounding factors.
appropriate
Measurement Tool/Data The patients received an initial comprehensive evaluation (visit 1) to determine study eligibility. The
Collection Method patients were given a 30-day period before visit 2. All study measures were administered during visit 2.
After EAA/T, all study measures were readministered (visit 3) within 2 weeks. Assessments included the
investigator-administered ADHD-Rating Scale (ARS-I), Clinical Global Impressions (CGI)-Severity Scale,
Clinical Global Impressions-Improvement Scale (CGI-I), Dordon Diagnostic System, Korea-Child Behavior
Checklist (K-CBCL), Self-Esteem Scale, Second edition of the Bruininks-Oseretsky test of motor
proficiency (BOT-2), and quantitative electroencephalography. The primary efficacy measure was the
response rate.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 17

Data Analysis Researchers analyzed the data from various assessment tools and surveys. The primary efficacy measure
was the response rate. Response was defined as follows: (1) a 30% reduction in the pre-treatment ARS-I
score after 12 weeks of EAA/T or (2) a CGI-I score of 1 or 2 after 12 weeks of EAA/T.
Findings/Discussion The EAA/T resulted in significant improvement in the social problems and in the manual dexterity, bilateral
coordination, and total motor composite subscales of the BOT-2. The patients learned to control their initial
emotions through rapport with the horse. The physiologic mechanisms that promote reciprocal responses
of patients to the horse during EAA/T may play a role in improving motor function.
Appraisal/Worth to This was a well-organized and well thought out study. The results of this study showed that alternative
practice therapies can reduce symptoms of ADHD without the use of medication. EAA/T may improve not only
ADHD core symptoms but also social problems. This can also encourage healthcare workers to encourage
children to play outside and exercise since, physical exercise is thought to influence the improvement in
ADHD symptoms.
AN INTEGRATIVE REVIEW: COMPLEMENTARY THERAPIES 18

First Author Ingo Roden, 2014, Department of Music, School of Linguistics and cultural Studies at Carl von Ossietzky
(Year)/Qualifications University of Oldenburg.
Background/Problem Background looked at musics effect on attention, processing speed, and musical abilities and audiation.
Statement Examined how processing speed affected intelligence, how music demands high attention and processing
speed, and how these processes help develop distinguishing skills in noticing variances in music. The
purpose of this investigation was to investigate the effects of music lessons on cognitive mechanisms in
primary school children.
Conceptual/theoretical Theoretical framework was based on effects of music on memory and intelligence, but the authors felt like
Framework they were the first to investigate the long-term effects of classroom-based music programs.
Design/ Quasi-experimental, quantitative, longitudinal study that explores the effects of music lessons on cognitive
Method/Philosophical mechanisms like music abilities, visual attention, and processing speed abilities in primary school aged
children over a period of 18 months.
Underpinnings
Sample/ Setting/Ethical 345 children, ages 7-8, that were recruited from 25 primary schools located in Germany. 192 children
Considerations participated in an instrumental training program and 153 children were recruited from primary school
emphasizing natural science skills. Consent was obtained from the school administration, parents, and
children. No discussion about protecting the children from harm or ethical considerations, and
confidentiality.
Major Variables Studied Two groups of children were studied; one group received weekly school-based music lessons on a musical
(and their definition), if instrument of their choice, and the other group of children received extended education in natural science
topics.
appropriate
Measurement Tool/Data Data assessed and analyzed at three different points. Researchers used a written cognitive ability test as
Collection Method well as standardized paper questionnaires. Also used the the d2 Test of Attention and the Zahlen-
Verbindungs-Test (ZVT) to measure information processing speed.

Data Analysis Research assistants were trained in administering the tests and also ran the data collection. The level of
statistical significance set by the researcher was at an alpha level for KL, which was the effiency of
concentration at 0.93.
Findings/Discussion The natural science group scored better than the music group. They were correct that information
processing speed was better in children in the music group. The results showed a superior effect on the
children in the music group. School-based instrumental music training affects cognitive skills positively and
music shows improvement in verbal memory and auditory working memory.
Appraisal/Worth to Study was well thought out, excellently researched, organized, cohesive and well executed. Limitation to
practice study was the excessive amount of variables being explored. There are many children who have difficulty
focusing and processing information in schools, and the authors showed that music lessons may be a
solution for helping children improve these cognitive abilities.
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