Intervention Summary

HeartMath: Coherence Training in Children With ADHD

HeartMath: Coherence Training in Children With ADHD (attention-deficit/hyperactivity disorder) is designed for use with youth ages 8-14 who have a diagnosis of ADHD. The intervention aims to help these youth reduce stress, control impulses, and improve academic focus (e.g., word recognition, memory, attention, problem solving) by gaining and maintaining self-control over their emotional responses to stressful events.

HeartMath, which can be implemented by educators, clinicians, or parents, usually consists of 6-12 sessions, although more sessions can be conducted as needed. Sessions are brief to help participating youth sustain attention. Participants learn coherence-building techniques for emotional self-regulation, which teach them to focus on the physical area of the heart through deep, rhythmic breathing while thinking of positive feelings. This process is supported by emWave technology, and using an ear or finger sensor connected to a USB port on a computer running the emWave Desktop software, participants can view, on the computer screen, the different coherence levels and wave patterns produced by their heart rhythms (an indicator of physiological activity) in response to stressful and nonstressful thoughts. This visualization allows participants to monitor their pulse rates during different activities and learn how to self-regulate their emotions and maintain the breathing and heart rhythm pattern that is associated with nonstressful thoughts. The software also includes three age-appropriate games, of varying length, which help participants to practice coherence-building techniques. Throughout the sessions, implementers have opportunities to assess the progress of the youth.

Descriptive Information

Areas of Interest	Mental health treatment
Outcomes	1: Internalizing and externalizing problems 2: Accuracy of new word recognition
Outcome Categories	Education Social functioning
Ages	6-12 (Childhood)
Genders	Male Female
Races/Ethnicities	Non-U.S. population
Settings	School
Geographic Locations	Urban
Implementation History	HeartMath: Coherence Training in Children With ADHD was first implemented during the school year in Liverpool, England. Since then, it has been implemented in all 50 States and in Australia, Austria, Canada, China, France, Germany, Indonesia, Italy, Mexico, the Netherlands, Saudi Arabia, South Africa, South Korea, Spain, and the United Kingdom. The intervention has been implemented in approximately 2,000 school sites and in numerous private agencies and homes. It is estimated that more than 5,000 educators and clinicians have used the emWave technology with children with ADHD or related conditions.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: No Evaluated in comparative effectiveness research studies: No
Adaptations	The emWave technology is available in Chinese, Dutch, French, Japanese, and Spanish.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Lloyd, A. Investigating the impact of HeartMath techniques for children with ADHD (Unpublished doctoral dissertation). Liverpool John Moores University, Liverpool, UK.

Lloyd, A., Brett, D., & Wesnes, K. Coherence training in children with attention-deficit hyperactivity disorder: Cognitive functions and behavioral changes. Alternative Therapies in Health and Medicine, 16(4), 34-42.

Supplementary Materials

Goodman, R. Psychometric properties of the Strengths and Difficulties Questionnaire. Journal of the American Academy of Child and Adolescent Psychiatry, 40(11), 1337-1345.

Wesnes, K. Psychometric documentation for the Cognitive Drug Research test battery.

Wesnes, K. A., Pincock, C., Richardson, D., Helm, G., & Hails, S. Breakfast reduces declines in attention and memory over the morning in schoolchildren. Appetite, 41(3), 329-331.

Wesnes, K. A., Ward, T., McGinty, A., & Petrini, O. The memory enhancing effects of a Ginkgo biloba/Panax ginseng combination in healthy middle-aged volunteers. Psychopharmacology, 152(4), 353-361.

Outcomes

Outcome 1: Internalizing and externalizing problems
Description of Measures	Internalizing and externalizing problems were assessed with the Strengths and Difficulties Questionnaire (SDQ). The SDQ is composed of five scales that yield scores for strengths (positive attributes) and difficulties (negative attributes) in a student's psychological development. Internalizing and externalizing problems were determined from the difficulties score, which was produced from items in four of the five scales: the emotional symptoms scale (e.g., "I worry a lot"), the conduct problems scale (e.g., "I usually do as I am told"), the hyperactivity/inattention scale (e.g., "I am easily distracted"), and the peer relationship problems scale (e.g., "I have one good friend or more"). Using a 3-point Likert scale ranging from "not true" to "certainly true," students and their teachers rated each item.
Key Findings	Students were recruited from three secondary and two primary schools in England, and those who met the DSM-IV criteria for an ADHD diagnosis were randomly assigned to the intervention group or the wait-list control group. Students in the intervention group received instruction in emotional self-regulation techniques through HeartMath, and those in the control group used LEGO bricks to build models of the student's choice during each session. All students received a baseline assessment and a 6-week assessment (after the 6-week intervention and LEGO sessions). Students in the wait-list control group subsequently were offered HeartMath. From baseline to the 6-week assessment, students in the intervention group had a greater improvement in self-reported (p = .044) and teacher-reported (p = .001) internalizing and externalizing problems compared with students in the control group.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 2: Accuracy of new word recognition
Description of Measures	Accuracy of new word recognition was assessed with the word recognition task of the Cognitive Drug Research (CDR) test battery. The CDR test battery is composed of 10 tasks that assess an aspect of cognition: immediate word recall, picture presentation, simple reaction time, digit vigilance, choice reaction time, spatial working memory, numeric working memory, delayed word recall, word recognition, and picture recognition. Using a notebook computer, school staff trained by the developer administered the measure to participants, who recorded their response to each item by clicking one of two buttons corresponding to "no" or "yes."
Key Findings	Students were recruited from three secondary and two primary schools in England, and those who met the DSM-IV criteria for an ADHD diagnosis were randomly assigned to the intervention group or the wait-list control group. Students in the intervention group received instruction in emotional self-regulation techniques through HeartMath, and those in the control group used LEGO bricks to build models of the student's choice during each session. All students received a baseline assessment and a 6-week assessment (after the 6-week intervention and LEGO sessions). Students in the wait-list control group subsequently were offered HeartMath. From baseline to the 6-week assessment, students in the intervention group had a greater improvement in new word recognition accuracy (p < .01) compared with students in the control group.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.8 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	6-12 (Childhood)	89.7% Male 10.3% Female	100% Non-U.S. population

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Internalizing and externalizing problems	3.5	3.5	2.0	3.8	2.8	2.5	3.0
2: Accuracy of new word recognition	3.0	3.0	2.0	3.8	2.8	2.5	2.8

Study Strengths

Evidence of test-retest reliability and face validity was presented for both the SDQ and the CDR test battery, and evidence of internal consistency, interrater reliability, and criterion validity was presented for the SDQ. No missing data were reported, and the small amount of attrition that was reported was adequately addressed. Some strategies were put in place to minimize confounding variables, including double-blind randomization and use of an active control group. The statistical analysis was appropriate.

Study Weaknesses

A number of variables may have presented confounds, including varying levels of teacher familiarity with the students they rated with the SDQ, varying time for daily intervention sessions, and effects of the administration of ADHD medication. The sample size was small, and there was no evidence that a power analysis was conducted.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Institute of HeartMath. emWave Desktop personal stress reliever [Hardware]. Boulder Creek, CA: Quantum Intech.

Institute of HeartMath. emWave Desktop software kit with Coherence Coach tutorial. Boulder Creek, CA: Quantum Intech.

Institute of HeartMath. Using emWave technology with young adolescent children diagnosed with ADHD: A guide for implementation and application. Boulder Creek, CA: Author.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.3	3.3	3.0	3.2

Dissemination Strengths

The implementation guide is well organized and appropriate for a variety of users, with clear, step-by-step instructions on how to incorporate the emWave technology into practice and implement the program. The program Web site provides a wealth of information and resources to support implementation. Coaching and consultation are available through weekly bridge calls, and topics of discussion are based on the callers' needs. The technology itself, along with simple provider checklists, can be used to contribute to overall quality assurance.

Dissemination Weaknesses

Limited information is provided to support organization-level implementation readiness. Although the program Web site contains a number of resources, it is challenging to find all of the implementation, training, and evaluation support materials, including those for interpreting data to improve program delivery or client outcomes.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
emWave Desktop (includes hardware, software, and manual)	$249	Yes
Using emWave Technology With Young Adolescent Children Diagnosed With ADHD: A Guide for Implementation and Application (includes emWave Desktop Proficiency Checklist and emWave Learning Checklist)	Free	No
2-day, off-site Institute of HeartMath Training	$1,500	No
Training programs targeting specific audiences, including educators, clinicians, parents, nonprofit agencies, and government agencies	Contact developer for detailed information	No
Weekly conference calls to support implementation of emWave technology	Free	No
Phone-, email-, or Webinar-based coaching and consultation	Free	No