Getting Rid of Ritalin: Researchers Battle a Disorder with Biofeedback

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Given the anxiety of life in Israel, it's not surprising that many children there have problems paying attention. Now, however, there's a new method of focusing wandering minds -- courtesy of the high-pressure world of sports.

For years, Ukrainian-born researcher and sports psychologist Boris Blumenstein has studied the mind-body connection so crucial to success in athletics. Now Blumenstein, the official "mental trainer" for Israel's 2008 Olympic delegation to the summer games in Beijing, has begun using some of the ideas borne out of this research to help children with attention deficit and hyperactive disorder (ADHD).

Blumenstein wanted to use a method, originally developed to work with elite Soviet and Israeli athletes, to target impulse control in working with both competitors and kids. "I knew that stress affects an athlete's results," Blumenstein explains. During training, he often observed that although an athlete might be in prime physical condition, he or she might go blank mentally during competition. This observation led him to seek what he describes as "a goal of building optimal conditions in achieving physical targets." Not an entirely original goal for a sports trainer, perhaps, but it offered the chance to develop an original approach.

With Michael Bar-Eli and Gershon Tenenbaum, fellow scientists at Israel's Wingate Institute for Physical Education and Sports, Blumenstein created a mental-preparedness technique known as the Wingate 5-Step Approach (W5SA). (Bar-Eli and Tenenbaum left the project in 1994.) This approach incorporates biofeedback probes, computer monitors, and one-on-one sessions in five stages designed to help participants focus and use self-regulation techniques while their heart rate and muscle tension are monitored and the electrical resistance of their skin is measured.

A Gym for the Mind

The process is involved and demanding but not too rigorous for athletes determined to compete at a very high level. Each of the five stages entails ten to fifteen sessions. The Introduction stage uses guided imagery, breathing, and muscle exercises, counting or other stress-reducing activities, and focus builders to encourage self-regulation. Next, in the Identification phase, participants are connected to biofeedback devices that help them see how their heart rates, muscle tension, and breathing rise or fall in response to certain thoughts or external stimuli.

In the third phase, Stimulation, an athlete attached to biofeedback monitors undergoes simulated stress by viewing tapes of competition and of key competitors, then attempts to use previously learned focusing techniques to reduce stress levels. In Transformation, the fourth phase, the athlete goes from laboratory to field to test learned skills in low-level practices and competitions, leading to the final phase, Realization, in which the athlete applies optimal self-regulation in high-level competition.

The program's results have been proof of its impact: Blumenstein's methodology has helped Israeli athletes place highly in Olympic competition and achieve European- and world-championship titles in basketball, judo, tae kwon do, track and field, and windsurfing.

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What's Good for Jocks . . .

While working with a group of teen athletes on Wingate's campus, the psychologist and parent in Blumenstein made a connection. "I had recently been reading about children with ADHD and began thinking about the fact that kids with attention deficit problems generally have a lot of trouble regulating themselves," he says, "This was a perfect opportunity to see if the biofeedback techniques we used with athletes could also help kids."

He approached Uri Schaefer, Wingate's director-general, to gain necessary backing for expanding his work, then went back into the lab to tailor the method for students. "I cut out the final two stages -- unnecessary for nonathletes -- and, instead of simulating competition in stage three, re-created classroom pressures to induce stress: test taking, peer pressure, and even jeering. I also realized that working with a more mature set of preteens and teens would be most effective. The ideal age is over twelve, because the imagery parts of the method work best with kids after that age."

After gaining access to public schools through Israel's Education Ministry, Blumenstein went into one of Tel Aviv's toughest suburbs, Or Akiva, to work with underprivileged kids whose ADHD needs had not been adequately addressed or met by the educational system or at home.

"These were students who had been tossed out of other schools for severe behavior issues -- hyperactivity and similar problems," reports Schaefer. "Bottom line? They weren't able to control themselves at all."

And, according to Schaefer, who coordinates and often observes the institute's studies, classrooms were chaotic. A teacher might implore students to concentrate and consider it a success if they manage to pay attention for a minute or so before launching into fresh mayhem.

ADHD, as most teachers know, is a significant and growing problem here, too. According to U.S. Centers for Disease Control and Prevention statistics, about 4.4 million American children ages 4-17 have been diagnosed with ADHD. That means that in a typical classroom of 25-30, at least two children might exhibit symptoms such as impulsivity, hyperactivity, and inattention. The solution? A common approach to mediation is through medication. Figures compiled by the BioMarket Group show that 94 percent of ADHD drug sales in 2004 took place in the United States; Europe accounted for the remainder.

The Control Game

When Blumenstein began talking to kids about his work, he was initially greeted with skepticism. "But I sat down with them one-on-one," he says, "and once we got past 'Who are you, and what do you want from my life?' the changes were dramatic." When the program began, curiosity and awe at the technology took over. Dozens of teenagers, wired to monitors as they learned controlled muscle tension, breathing, counting, and other self-soothing techniques, participated avidly as computer graphs on monitors showed pulse and breathing rates sloping downward. "For them, it was like playing computer games," Blumenstein adds.

Word spread quickly, and soon long lines of kids waiting for treatment formed outside Blumenstein's door. "For some of the kids, it was also a matter of craving the attention and compliments," he said. "They had never heard anyone say 'Good job' before."

Results were encouraging. Teachers and school principals noted a nearly doubled capacity for self-regulation among biofeedback-trained students, as well as improved test scores and newfound calm in the classroom. Miriam Shabtaf, director of the Ofek school, was impressed. "What surprised me most of all was the improvement in listening and test-taking skills," she says.

Eli, one of Blumenstein's many subjects and now a high school graduate, describes himself as "basically a street kid" growing up. "When I started with Boris, it felt like a game," he says. "I would watch the monitors and think good thoughts about going to the beach -- something relaxing, like the breathing Boris showed me -- and the lines on the screen would drop."

Clinical trials in Israel continue, and psychologists and educators in other countries, including Canada, China, Germany, and Greece, have taken notice.

W5SA codeveloper Gershon Tenenbaum, now a professor of educational psychology at Florida State University, says the advantage of the method over other techniques is realtime visualization: learning to control one's body by using evidence provided by images on a monitor. "Once a child learns to regulate emotion through the computer and relax whenever he or she wants," Tenenbaum says, "learning can be improved overall."

Back in Israel, Uri Schaefer, the Wingate Institute's director-general, says he's pleased to be part of a program helping improve quality of life. "Tension and high pressure are characteristics existing in life in general," Schaefer says, "and particularly here in Israel."

Stephanie L. Freid is a writer based in Israel.