Depression and anxiety are common mental health problems that significantly affect children in the modern society. In western countries, up to 14% of preschool-age children were found to have clinical levels of depression and anxiety1,2. In a study involved over 1300 primary school children in Hong Kong, about 10% were reported to have major depressive disorders3. From 2012 to 2013, The Child Assessment Service (CAS) of the Department of Health of Hong Kong diagnosed 570 new cases with anxiety disorders / problems, which accounted for 3% of the total referral cases in the Department4. A more recent study showed the prevalence rate of children with anxiety disorders in Hong Kong was 27.5%5. The prevalence and incidence of having depression and / or anxiety are expected to be even higher in children with learning difficulties and / or neurodevelopmental disorders, given they encounter more daily challenges at learning and living. For instance, the numbers of children with Attention-Deficit and/or Hyperactivity Disorder (ADHD) who are comorbid with another mental disorder were doubled compared to typically developing children5. Given the appearance of depression and anxiety symptoms in early childhood were associated with later negative outcomes in middle childhood6, it is essential to offer early interventions to children who are at high risk of mental illness, i.e. children with learning difficulties and / or neurodevelopmental disorders. Educational kinesiology, also called Brain Gym, is one potential treatment to tackle this problem. From here after, educational kinesiology will be referred to as Brain Gym.
Paul Dennison and Gail Dennison developed Brain Gym in 1969 as one of the potential treatment/interventions for children7. Due to the simplicity and easy-to-follow activities, it is popular among educators and is a training scheme that is particularly suitable for managing stress-induced problems including anxiety. Brain Gym emphasized on facilitating whole-brain learning through different movements, which is a bottom-up approach8. In this approach, Dennison and Dennison proposed that the change of body movement could result in the alteration of brain functions8. The theoretical framework behind Brain Gym is that due to the imbalanced body-and-mind coordination could hinder an individual to learn8. Therefore, Dennison and Dennison developed 26 simple body movements (e.g. Cross Crawl, the Think of an X, the Lazy Eights and the Neck Rolls, etc.) to link up the body with specific brain functions for reducing this imbalance8. According to Dennison and Dennison8, these movements can be categorized into three dimensions, they are: Laterality, Focus, and Centering. Each of these three dimensions are proposed to target different brain areas and different functioning. For instance, movements in laterality dimension enhance the coordination between the left and right hemispheres’ functioning, which helps to facilitate one’s ability in reading, writing, listening, speaking, and the ability in synchronizing movement and thinking; movements in focus dimension synchronize the anterior and posterior portions of the brain, which facilitate comprehension skills, and improve attention; movements in centering dimension coordinates the dorsal and ventral parts of the brain, which helps balance rational thoughts and emotions8.
Brain Gym is especially popular among teachers and educators. Stephenson9 performed an internet search study using terms ‘Braingym’ or ‘Brain Gym’, and ‘School’ and found 4,290 website hits. The first 200 sites were visited to check if they are targeting teachers and educators in Australia as audiences. Thirty of which were found explicitly promoting Brain Gym to teachers and educators. All of them included some levels of support to teachers and educators if Brain Gym was chosen to be used in school, and most of them recommended Brain Gym as a form of professional development.
In the past decades, different studies attempted to examine the effectiveness of Brain Gym exercises in various aspects. For instance, a study showed a positive effect of Brain Gym on learning to play musical instruments in a small group of college students7. Another study demonstrated positive effects of Brain Gym on reading performance, maths performance, maladaptive behaviors, and adaptive behaviors in 30 at-risk primary school students10. Likewise, results from another recent study showed that Brain Gym could improve academic performance of children aged 10 – 12 years old11. These studies suggest some positive effects of Brain Gym on learning across different age groups. Nevertheless, scientific evidence that supports the claimed beneficial effects of Brain Gym remains limited, making it hardly become an evidence-based practice.
There is limited research exploring the effectiveness of Brain Gym on the improvements of mental health, and findings from the previous studies were inconsistent. For instance, Azizah and colleagues12 showed an improvement in perceived levels of psychological distress in elderly people after Brain Gym intervention. Effendy and colleagues13 also examined the effects of Brain Gym on anxiety and quality of sleep in 68 elderly people and they found that 8-week of Brain Gym training could improve sleeping quality and reduce anxiety symptoms in the studied cohort. On the other hand, Voss14 found no effect of Brain Gym on the level of perceived stress in a group of school-age children. It is therefore necessary to readdress the effectiveness of Brain Gym on mental health.
One approach to assess psychological stress is by measuring the level of stress biomarkers in saliva samples, which provides accurate objective data in scientific studies. The use of stress biomarkers can avoid bias generated by the assessor and reporter in the commonly used self-reported method. This approach is well adopted in psychological and clinical studies because of its non-bias and non-invasive nature. Among various stress markers, cortisol and oxytocin are most studied in stress science.
Cortisol is a stress hormone regulated by the hypothalamic-pituitary axis (HPA), which is one of the main components in the stress system15. A meta-analysis in 2004 reviewed 208 laboratory results showing that psychological stressors increased cortisol levels, especially when the task involved uncontrollability and social evaluation16. Furthermore, multiple studies’ findings support that salivary cortisol is a useful measure of the stress response that can be used to evaluate intervention effectiveness17, 18, 19. Being widely considered as a consistent measure of stress, studies also examined the change in salivary cortisol in preschoolers in response to stress tasks20, 21, which further supports salivary cortisol to be a validated biomarker in measuring stress in children.
Oxytocin is a neuropeptide produced in the hypothalamus. The primary biological function of oxytocin is for uterine contractions during childbirth and is necessary to produce milk22, 23. In addition, oxytocin is regarded as a love hormone due to its effects on social cognition and prosocial behaviors24, 25, 26, 27. More recent research revealed the association between oxytocin and mental health problems. For instance, high oxytocin levels were reported to associate with low anxiety levels in children and adolescents28, 29. In agreement, urinary oxytocin levels were found to decrease during a social stress task in children and adolescents30. In clinical subjects with anxiety disorder, salivary oxytocin levels were negatively correlated with anxiety symptoms, suggesting a role of oxytocin in regulating anxiety31.
There are currently no studies that investigate the efficacy of Brain Gym exercises on psychological well-being in children with special learning needs by using the combination of psychometrics and physiological approach. This study aims to examine the changes in parent-rated anxiety level and salivary stress markers i.e. cortisol and oxytocin after Brain Gym exercises in kindergarteners with learning difficulties or neurodevelopmental disorders. Results from this study could provide scientific evidence on the effectiveness of Brain Gym in ameliorating emotional instability and its underlying physiology in kindergarteners with special needs.
In this study, the following hypotheses were made.
Hypothesis 1: The Brain Gym intervention would reduce the levels of salivary cortisol.
Hypothesis 2: The Brain Gym intervention would increase the levels of salivary oxytocin.
Hypothesis 3: The Brain Gym intervention would reduce the anxiety levels of the participants.