Part 3 (1/2)
GAMES, NOT PILLS, FOR ADHD.
When they see restless and agitated children, many doctors are quick to diagnose a disease called attention deficit hyperactivity disorder (ADHD). Many claim that this disorder is genetically determined and should for this reason be treated with pharmacological substances like methylphenidate (Ritalin), which alter the metabolism of a childas brain.
ADHDas estimated worldwide prevalence in people under age 19 is about 5 percent, but there is enormous variability in estimates, and the United States has an especially high rate of ADHD, with 10 percent of males and 4 percent of females diagnosed with it. Thus, according to the statistics, in every cla.s.sroom there are one or two fidgeting kids who need professional help. In recent years, many teachers and parents have arrived at the conclusion that ADHD is an innate disorder affecting the metabolism of the brain. But to this day there is no scientific method of telling the brain of a normal child from the brain of a child who is said to have ADHD.
Only with the aid of arbitrary criteria can a preschool child or young student be given the ADHD label. But the symptoms (aeasily distracted,a adoesnat sit stilla) are so random that they can be seen in a variety of forms among most children. It appears impossible to draw an objective line between a healthy temperament and disturbed behavior.
Methylphenidate was first synthesized in 1944 by a chemist, Leandro Panizzon, with the company Ciba.8 He swallowed the substance in an experiment on himself but did not experience much from it. His wife, Margueritea”known as Ritaa”tried it, too, and felt a quite inspiring effect. From this time on Rita would consume the substance occasionally when she was getting ready for a tennis match, and it was named after her: Ritalin.
At first, Ritalin was given to adults only to treat depression, mental fatigue, and disorientation among elderly people. The disease that would make Ritalin famous, and notorious, had not yet been invented. It was not until the 1960s that research became public showing that methylphenidate, and a similar substance called dexedrine, had a quieting effect on children with learning difficulties. By now, methylphenidate is marketed in specific doses, some lasting 8 to 12 hours. The children who are told to take this drug at breakfast spend the full day under medication.
As the consumption of methylphenidate has exploded in industrialized countries, teens and young adults in the United States take the drug for additional reasons: as an appet.i.te suppressant or to stave off the urge to sleep. They crush the tablets and snort the powder to get high. Youngsters have little difficulty obtaining methylphenidate from cla.s.smates or friends with prescriptions. The U.S. Drug Enforcement Administration has posted a drastic warning: aMethylphenidate, a Schedule II substance, has a high potential for abuse and produces many of the same effects as cocaine or the amphetamines. The abuse of this substance has been doc.u.mented among narcotic addicts who dissolve the tablets in water and inject the mixture. Complications arising from this practice are common due to the insoluble fillers used in the tablets. When injected, these materials block small blood vessels, causing serious damage to the lungs and retina of the eye. Binge use, psychotic episodes, cardiovascular complications, and severe psychological addiction have all been a.s.sociated with methylphenidate abuse.a9 To this day, it is not known what methylphenidate actually does in the still-developing brain of a preschool or kindergarten child. Nora Volkow, now director of the National Inst.i.tute on Drug Abuse in Rockville, Maryland, found that the substance, by blocking certain transporting proteins, increases the level of the neurotransmitter dopamine in the synapses, thus acting much like cocaine.10 However, methylphenidate does not appear to be as addictive, given that it is ingested in pill form. It takes hold much more slowly than cocaine and does not create such a high.
Even when properly prescribed by a doctor, the consumption of the drug comes with a whole range of side effects: agitation, fear, sleeping problems, and paranoia. If the drug is dropped after a long-term treatment, there may be withdrawal symptoms. The drug can spoil a childas appet.i.te.
Yet many parents are relieved when their child is diagnosed with ADHD because it unburdens them: If my childas problems are caused by an innate defect of brain chemistry, the thinking goes, the way we are raising our children is not involved. The label ADHD, however, has serious repercussions for children, who learn to think: I can only be tolerated by my parents and teachers when I take my drugs.
aThe medication with regulating substances might be advisable for correcting some deficits or for starting an integral therapy,a says Christina Hahn at the Inst.i.tute of Sport and Sport Science of the University of Heidelberg, Germany. aAs a child-oriented, long-ranging treatment, however, medication is by no means the only solution of the problem.a11 Among children diagnosed with the syndrome, a familiar pattern appears. More than half of these children not only have problems concentrating but are conspicuously awkward; they are bad at balancing and have difficulties timing their movements. This could mean that exercises in improving coordination might be useful to improve concentration and attention.
Though problems with motor activity are not the main symptoms of ADHD, autism, and dyslexia, it is eye-catching that these problems appear so often along with impaired coordination. Adele Diamond concludes: aMotor development and cognitive development may be much more interrelated than has been previously appreciated. Indeed, they may be fundamentally intertwined.a12 But physical training is nearly never prescribed; the rule instead is to give children medication. On any given day, hundreds of thousands of children are served tablets for breakfast to calm them down and make them attentive. In about 20 minutes the substance takes hold, and the children show a different behavior.
By contrast, prescribing sports programs for children with ADHD appears to be a much gentler and longer-lasting approach. Only a few researchers have developed specific exercise programs for inattentive children, and Gerd Hlter at the University of Dortmund, Germany, is one of them. In one trial, therapists, children, and their parents met once a week for three months in a swimming pool. While educators coached the parents, the children played in the water and tried things like diving for rings. After encouraging results, Hlter plans to expand his program by adding games in a gym. He says: aMore exercise and behavioral therapy and less Ritalina”this is our concept.a13 In the meantime, Hahn has already gathered scientific data doc.u.menting the beneficial influence of exercise on children diagnosed with ADHD. More than 90 children, mostly boys with an average age of eight and a half, partic.i.p.ated in the study. At first, researchers tested motor skills and the ability to concentrate on problems. Some children were actually taking methylphenidate, and their parents were asked not to change the medication during the study so that the results would not be distorted.
The children were randomly a.s.signed to three groups. Members of the first one played ball games most of the time, soccer and field hockey, learning techniques and tactics. That way, the researchers aimed to simulate how children played in the 1950s and 1960s when it was normal for them to spend summer days outside, playing in yards and fields. The partic.i.p.ants of the second group rode mountain bikes, learned in-line skating, and took climbing lessons. Both sports programs lasted 90 minutes and took place twice a week. The third group was used as a control, with 37 ADHD-diagnosed children who did not play any sports at all.
Six months later, Hahn and her colleagues retested the motor skills and concentration abilities of the children. The sedentary children had largely the same results as at the beginning of the study, and there was even further deterioration to be seen, possibly an adverse effect of the methylphenidate some of the children continued to take. The drugs slow down the natural desire to move and thus impair the motor skills all the more.
By contrast, the children in both sports groups did much better. Although their motor skills were markedly subpar at the beginning of the study, they improved dramatically and even reached the lower range of what is considered normal. Their ability to concentrate also improved greatly. These budding athletes solved more cognitive problems than the controls in a given time.14 These results confirm what the findings of the neuroscientists suggest: If we train our motor abilities by exercising, at the same time we strengthen regions of the brain that are important for paying attention and other cognitive capabilities. Playing sports makes us smarter, and all children can benefit from this effecta”whether they are diagnosed with an attention disorder or not.
10.
Lifting the Spirit.
A BLEAK MIND AND A LIFE FULL OF ACTIVITY? THESE TWO THINGS DO not seem to match. Sedentary people tend to have a heavy heart, and sad people are often physically inactive. The correlation is so stable and widespread that it has been demonstrated in many epidemiological trials. Study after study has shown that the more we utilize our muscles, the more positive feelings develop in our heads. This also applies to latecomers to exercise: if a person gets going in advanced age, the risk of developing depression drops to the low levels enjoyed by people who have been active from early on in life. The reverse strategy cannot be recommended. Formerly active people who refrain from using their muscles in middle age have a higher likelihood of developing psychiatric problems.
Although this relations.h.i.+p has been known since the 1980s, psychiatrists and psychologists have just started to use the healing power of exercise in the treatment of mental disorders. In contrast to cardiologists, they largely disregarded the influence of regular exercise on mental well-being.1 Some psychiatrists believe it is high time to alter this att.i.tude: aThe clinical psychiatry of the recent past and present with its focus on psychotherapy and pharmacotherapy regards sports and games rather as simply a fine pastime and doesnat so far attribute any specific therapeutic effectiveness to it.a2 The reservations shown by many psychologists and psychiatrists in this regard are even more astonis.h.i.+ng given that there is now a wealth of data indicating specifically that people suffering from depression and anxiety disorders benefit from physical exercise. Multiple studies also show that more than just psychiatric impairments can be successfully treated with training. Neurodegenerative disorders like Alzheimeras disease, characterized by dramatic losses of brain ma.s.s and nerve cells, are being studied in relation to physical activity. These diseases, once they develop, are curable with neither tablets nor training. Yet exercise appears to be one of the best means to prevent them from developing in the first place.
FROM THE COUCH TO THE TREADMILL.
Only a few patients who suffer from depression become healthy again by taking drugs. About 65 to 75 percent of those patients who do so are not cured and have to face recurring depressive episodes: they are sad, easily agitated, and have problems sleeping and concentrating. This is due not only to the fact that drugs have little effect, but it is also because up to 60 percent of patients are believed to stop following their prescriptions after three weeks. Others refuse to take antidepressants in the first place for fear of being stigmatized.
In the face of all these problems, some doctors started to wonder whether there might be a better alternative. Ideally this would be a remedy that is effective, has no adverse side effects, and is socially accepted. Older studies among healthy subjects had indicated that physical exercise is an ideal candidate to fit this description. Endurance training had been found to lighten moods, reduce fears, and increase the capacity to cope with stress. In one study, groups of active and sedentary people were followed for eight years, with the conclusion being that inactive people developed a depression rate twice that of their active counterparts.
Other trials included patients suffering from mild to severe depression. In one study, 40 patients were encouraged either to partic.i.p.ate in a running program for eight weeks or to try strength training for eight weeks. Tests before and after the program revealed improved symptoms in both groups.3 Does that mean exercise beats pharmaceuticals in terms of effectiveness? The research group of James Blumenthal at Duke Medical Center in Durham, North Carolina, set out to answer this question.4 They randomly a.s.signed 156 elderly patients, who suffered from major depression, into three groups: those exercising, those taking antidepressants (in this case sertraline hydrochloride, which is an antidepressant of the selective serotonin reuptake inhibitor cla.s.s), and those trying both. The exercise session lasted for 30 minutes, three days per week.
After 16 weeks, the partic.i.p.ants were reexamined. In all three groups, the patientsa health had significantly improved, and about 60 percent of each group were no longer depressed.
Therefore the program relying solely on physical activity was as effective as state-of-the-art antidepressants.
Over time, the effect of exercise became more p.r.o.nounced. The partic.i.p.ants were examined after six months, and those on exercise regimens had significantly fewer relapses than the drug-takers. The long-lasting effect of activity can be explained by the fact that many of the partic.i.p.ants liked exercising so much that they continued to be active even after the official end of the study. That way, they overcame their depressions. Knowing that they were capable of fighting their illnesses might have further enhanced their success. Blumenthal concludes: aSimply taking a pill is very pa.s.sive. Patients who exercised may have felt a greater sense of mastery over their condition and gained a greater sense of accomplishment. They felt more self-confident and had better self-esteem because they were able to do it themselves, and attributed their improvement to their ability to exercise.a5 As impressive as this result seems, the study could not completely determine if the results were simply a consequence of the social aspect of the workouts because the partic.i.p.ants exercised together. During these sessions, everyday worries seemed to be forgotten, and people made small talk and laughed. Perhaps the new friends.h.i.+ps and the collective experience were the main reasons for the improved mood.
In order to exclude this possibility, researchers at the Cooper Inst.i.tuteas Science Research Center in Golden, Colorado, initiated a further study.6 They encouraged 80 men and women who were sedentary, depressive, and not on medication to partic.i.p.ate in a sports program that lasted eight weeks, with three to five sessions per week. They either walked on a treadmill or pedaled on a stationary bike, and were alone (except for gruff a.s.sistants who checked on them to make sure n.o.body was secretly resting).
Half the partic.i.p.ants tried an easy program and in one week burned just three kilocalories per pound of bodyweight. Though their symptoms improved, the effect was small and thus could have been a chance finding.
The members of the second group burned eight kilocalories per pound. This consumption corresponds to moderate exercise, like a brisk 30-minute walk on most days of the week. The symptoms in this group decreased by 47 percent, and in 42 percent of the patients the symptoms disappeared completely. This confirms that physical exercise is as effective as antidepressants and psychotherapy. Interestingly, it did not matter if the patients worked out for three or five days per week. Burning the recommended amount of kilocalories in a week is the main objective.
PLAYING AGAINST PANIC.
Psychiatrists report regularly on patients and cases in which physical training was found to help people suffering from anxiety. Yet only a few trials have been initiated to look into this phenomenon. In one study, 46 individuals with claustrophobia, affective panic disorder, or both partic.i.p.ated in a ten-week program and were asked to jog a distance of 3.1 to 3.7 miles on three or four days of the week. The patients of a second group were inactive and received either standard medication (the antidepressant clomipramine) or a placebo. Compared to the placebo, the medication significantly improved the symptoms. Exercise was also better than placebo, though not as effective as the medication.
In the treatment of alcoholics and drug addicts, moderate training programs are by now quite widespread in Germany, although there are few studies about whether this actually affects the addiction. On the contrary, members of soccer and handball clubs often consume amazing numbers of cigarettes as well as alcoholic beverages like beer and schnapps. It might shock American readers, but in lower-level German soccer leagues, it is not too uncommon for subst.i.tute players to smoke while watching their peers play. After the game, players and their families often gather and open a keg of beer. People with addiction problems might do better to avoid such crowds and pick up healthy ways of exercising like walking and jogging. Andreas Broocks of Helios Kliniken in Schwerin, Germany, is among the leaders in the field of sports therapy in psychiatry, and he concludes: aRegular endurance training substantially improves the self-confidence and self esteem of addicted patients and thus could help them to stay abstinent.a7 Individuals with schizophrenia are also often in a condition for which physical exercise is much needed. Many such patients are heavy smokers, have an unhealthy diet, and hardly move their bodies. A training regimen would not only improve their physical shape but also help work against the psychiatric disorders that can accompany schizophrenia. According to one study, about 50 percent of all schizophrenic people also have symptoms of panic, obsessive-compulsive disorder, and depression. Although the possible benefit of exercise has not been studied until now, some physicians are discovering its potential. Inspired by good experiences with patients, many clinics are now trying to treat patients with schizophrenia with exercise as therapy.8 SOUND BODY FOR A SOUND MIND.
It is thanks to the Roman poet Juvenal that we believe a sound mind (mens sana) resides in a sound body (corpore sano).9 This proverb has spread for centuries, but it was not until recent times that neuroscientists have found enough evidence to rea.s.sure us that the ancient claim can be taken literally. Researchers have now acc.u.mulated evidence showing that exercise can stave off mental decline and the onset of widespread Alzheimeras disease, which leads to the loss of critical brain functions.
Alzheimeras is a disease that strikes with age. Among people aged 70 to 74, it is estimated that fewer than 3 percent are affected; among those older than 90, about one-third are affected. And because people in the United States and other industrialized nations live longer and longer, Alzheimeras is considered one of the most pressing health-care problems of the near future. An estimated 4.5 million Americans have Alzheimeras disease. That number has more than doubled since 1980 and is projected to reach 11.3 to 16 million by the year 2050.
Besides age, there are other risk factors. It may not be a good omen when family members have suffered from Alzheimeras because that suggests a genetic preposition to it. Alzheimeras also relatively frequently afflicts people with low education levels. These factors are hard to change once a person has reached adulthood, but there is another way to postpone the onset of the disease or to prevent it altogether: activities such as brisk walking or bicycle riding.
Results from lab trials indicate that exercise can protect the brain.10 Mice held in cages with treadmills acc.u.mulate fewer harmful molecules in their brains than sedentary animals. These peptides, called amyloid beta, are usually found in demented mice and lead to plaque formation.
Even when this peptide is already spreading in the brain, exercise appears to help stall the progression of dementia. In a study published in the Journal of Neuroscience, researchers at the Inst.i.tute for Brain Aging and Dementia at the University of California, Irvine, took mice that were predisposed to develop Alzheimeras disease and gave them running wheels for exercise. After several months of exercise, the mice showed improved cognitive behaviors and less amyloid-beta plaque. aWhat we found is that levels of the amyloid in these exercising mice went down,a said the princ.i.p.al investigator, Carl Cotman. aInstead of a drug, it was a natural behavior that translated to a reduction of Alzheimeras-like pathology developing in the brain.a11 A similar picture emerges when researchers try to correlate the lifestyles of people and their risk of developing Alzheimeras disease. Chinese researchers studied more than 1,000 elderly inhabitants of Beijing for three years. Those who hardly left their apartments developed dementia more often than was average.
j.a.panese researchers conducted a diligent study in which they monitored 828 citizens older than age 65 for seven years and inspected their brains using CT scans and other methods. More than 200 partic.i.p.ants died in the course of the study, but most of their brains were examined after death. And the result showed again that sedentary seniors were more p.r.o.ne to become ill with Alzheimeras disease.12 Fortunately, there is no need for strenuous activities to stave off this notorious atrophy of the brain. Older men aged 71 to 93 who walk at least two miles every day cut the risk of Alzheimeras in half, compared to people the same age who walk only a quarter of a mile per day.13 The more intense the dose of exercise, the bigger the effect against dementia. This direct correlation was revealed by a five-year trial of elderly women. The most active women had a risk reduction by 50 percent, and a 60 percent reduction specifically for Alzheimeras.
One of the most extensive studies has been carried out by researchers at the Aging Research Center of the Karolinska Inst.i.tute in Stockholm. In 1972 they began studying the leisure-time exercise habits of nearly 1,500 people.14 Those who exercised at least two days per week during midlife lowered their risk of developing Alzheimeras by 50 percent.
For people around age 40, this implies that if they start now on moderate exercise programs, like bicycling and walking, they might be rewarded on some not-too-distant day. The neurologist Miia Kivipelto, senior author of the study, said: aThese findings may have wide implications for preventive healthcare; if an individual adopts an active lifestyle in youth and at midlife, this may increase their probability of enjoying both physically and cognitively vital years later in life.a Apart from these epidemiological findings, brain-imaging studies also indicate that exercise influences the risk for Alzheimeras disease. These images show that physical activity slows down the type of brain atrophy that usually comes with age. Between our 30th and 90th birthdays, approximately 15 to 25 percent of the brainas gray matter is lost, and the areas in charge of learning and memorizing shrink the most.
The psychologist Arthur Kramer of the University of Illinois in Urbana-Champaign was able to demonstrate the presence of this atrophy when he looked at the brains of 55 healthy elderly persons, using magnetic resonance imaging (MRI). But Kramer also had good news, at least for those people who had always been active. They were not only in good shape, but on average their brain atrophy was not as p.r.o.nounced as that in sedentary people. Furthermore, they had specifically retained structures in the lateral and frontal areas of the brain, which are most important for complex cognitive functions.
After this finding, Kramer and his colleagues wanted to check whether moderate exercise might even reverse the usual course of brain atrophy. Healthy but sedentary volunteers aged 60 to 79 partic.i.p.ated in an aerobic training program for six months (consisting of one-hour sessions, three days per week). To provide a comparison, other volunteers of the same age also met three days per week in the gym. But instead of true exercising, they just did some stretching.
The astonis.h.i.+ng result has been published in the Journal of Gerontology.15 Parts of the brain actually increased in size for aerobic exercisers! The enlarged areas were primarily located in prefrontal and temporal cortices, the same regions often reported as showing substantial age-related deterioration. Declines in these areas are linked to a broad array of clinical symptoms including Alzheimeras disease. In the group that just did some stretching, such enlargements could not be found.
If this novel and intriguing finding is further confirmed, it will have profound repercussions for the prevention of neurodegenerative diseases. The results suggest that brain volume loss is not an inevitable effect of advancing age and that relatively minor interventions can halt or slow down this loss. Moderate exercise not only helps stave off the onset of cognitive decline, but it might have the potential to halt and even reverse the loss of brain structures in old age! These implications did not escape the attention of the researchers. They conclude that their results adirectly bear on issues of public policy and clinical recommendations in that they suggest a rather simple and inexpensive mechanism to ward off the effects of senescence on human brain tissue.a16 Responsible doctors are prudent enough not to raise hopes that Alzheimeras patients will have effective drugs available to them in the foreseeable future. At the same time, surveys show that more than 40 percent of adults who are 50 or older are afraid of losing control of their minds someday because of Alzheimeras disease. Science has rarely provided us with better arguments to start moving.
TRAINING IS THE BETTER PILL.
As soon as we start sweating, we help our brains. As we saw, growth factors and neurotransmitters start circulating in higher numbers through the brain. Next, the number and length of connections between the nerve cells increase. One could say that the whole brain becomes jazzed up from inside, making it more malleable and more plastic than before. Yet there is an even more astonis.h.i.+ng rejuvenator, which we will discuss in the following chapter; exercise appears to promote the growth of new nerve cells in old brains.