AChineseMind-BodyExerciseImprovesSelf-ControlofChildrenwithAutism:
ARandomizedControlledTrialAgnesS.Chan1,2,3*,SophiaL.Sze1,2,NicolsonY.Siu1,ElizaM.Lau1,Mei-chunCheung41NeuropsychologyLaboratory,
Department of Psychology, TheChineseUniversityof HongKong, Shatin,
HongKongSAR, China, 2IntegrativeNeuropsychologicalRehabilitation
Center, The Chinese University of Hong Kong, Shatin, Hong Kong SAR,
China, 3Henan Songshan Research Institute for Chanwuyi, Henan,
China, 4InstituteofTextilesandClothing,
TheHongKongPolytechnicUniversity, Kowloon, HongKongSAR,
ChinaAbstractSelf-control
problemscommonlymanifestastemperoutburstsandrepetitive/rigid/impulsivebehaviors,
inchildrenwithautismspectrumdisorders(ASD),
whichoftencontributestolearningdifficultiesandcaregiverburden.Thepresentstudyaims
tocomparetheeffect of atraditional
ChineseChan-basedmind-bodyexercise, Nei YangGong, withthat of
theconventional
ProgressiveMuscleRelaxation(PMR)techniqueinenhancingtheself-control
ofchildrenwithASD. Forty-sixage-
andIQ-matchedASDchildrenwererandomlyassignedtoreceivegrouptraininginNei
YangGong(experimentalgroup) or PMR(control group) twiceper week for
four weeks. Theparticipants self-control was measuredby
threeneuropsychological testsandparental
ratingonstandardizedquestionnaires, andtheunderlyingneural
mechanismwasassessedbytheparticipants
brainEEGactivityduringaninhibitory-controltaskbeforeandafterintervention.Theresultsshow
that the experimental group demonstrated significantly greater
improvement in self-control than the control
group,whichconcurswiththeparentalreportsofreducedautisticsymptomsandincreasedcontroloftemperandbehaviors.
Inaddition, the experimental group showed enhanced EEG activity in
the anterior cingulate cortex, a region that mediates self-control,
whereasthePMRgroupdidnot. Thepresentfindingssupportthepotential
applicationof ChineseChan-basedmind-body exercises as a formof
neuropsychological rehabilitationfor patients withself-control
problems. ChineseClinical Trial Registry; RegistrationNo.:
ChiCTR-TRC-12002561; URL: www.chictr.org.Citation: ChanAS, SzeSL,
SiuNY, LauEM, CheungM-c(2013)
AChineseMind-BodyExerciseImprovesSelf-Control of
ChildrenwithAutism: ARandomizedControlledTrial. PLoSONE8(7):
e68184. doi:10.1371/journal.pone.0068184Editor:HosseinFatemi,
UniversityofMinnesota, UnitedStatesofAmericaReceivedNovember30,
2012; AcceptedMay23, 2013; PublishedJuly10, 2013Copyright:
2013Chanet al. This is anopen-access articledistributedunder
theterms of theCreativeCommons AttributionLicense,
whichpermitsunrestricteduse, distribution,
andreproductioninanymedium, providedtheoriginal
authorandsourcearecredited.Funding: This study was partly supported
by a donation from Mr. Sau Hung Li to The Chinese University of
Hong Kong and partly by the research fund from TheHong Kong
Polytechnic University (A-PK67 and 4-ZZD1). The funders had no role
in study design, data collection and analysis, decision to publish,
or
preparationofthemanuscript.CompetingInterests:Theauthorshavedeclaredthatnocompetinginterestsexist.*E-mail:
[email protected] dysfunction,
whichrefers to difficulties inworkingmemory, attention, planning,
responseinhibition, mental
flexibil-ity,and/orself-monitoring,isatypicalcognitivedeficitassociatedwith
autism spectrum disorders (ASD). Of these executivedysfunctions,
response disinhibitionand mental inflexibility arerelatively more
common in individuals with ASD [13]. It has alsobeensuggestedthat
executive dysfunctions accounts for
typicalautisticfeatures,suchasuncontrollablebehavioral
andemotionalreactions, repetitive behaviors, strong need for
sameness, restrictedinterests, and inappropriate social
communication and interaction.As there is not effective
pharmacological intervention forenhancing the executive control of
emotions and behaviors inindividuals with ASD, the majority of the
interventions areprimarilybehavioral [45].
Despitethereportedeffectiveness ofsome of the behavioral
interventions inreducing behavioral oremotional disturbances, the
intervention programs tend to be veryintensive and time consuming
[67]. For instance, althoughappliedbehavioral
analysiswasfoundtobeeffectiveinreducingvariousautistic symptoms,it
requires intensive trainingfor at least20hours perweekforat least
twoyears [7]. Furthermore, suchpositive outcomes are less prominent
for children
withlimitedmentalabilityormoresevereautisticsymptoms,whoarenotableto
follow the rules and requirementsof the training[8]. In view ofthe
limitations of the conventionalinterventions,some
researchershavebeenexploringvariousalternativemethods,suchasmassage[911],
acupuncture[1213], musictherapy[1416], anddiet/nutrition[1719].
Althoughsomepreliminarydatasupports thepositive effects of these
novel interventions, the treatment efficaciesremain largely
inconclusive [20]. Our researchteamhas beenstudying the effects of
a traditional Chinese Shaolin medicalconcept (called Chanyi) in
reducing some of the executivedysfunctions
inindividualswithASDforthepast years[2124].The present study
further examines one component of thisinterventionapproach, i.e.,
themind-bodyexercise,
asapossibleinterventiontoimprovetheself-control
ofchildrenwithASD.According to the National Center for
Complementary andAlternative Medicine (NCCAM) establishedby the
USgovern-ment, a mind-body interventionis defined as any
interventionwhichfocusesontheinteractionsamongthebrain, mind,
bodyandbehavior, withtheintent tousethemindtoaffect
physicalfunctioning and promote health. The fundamental assumption
ofthese interventions is that because the mindandthe body
areinter-connected, individuals have the internal ability to
changetheir ownthoughts andbehaviors toenhancetheir mental
andphysical health.
Mind-bodyinterventionshavelongbeenusedinChinatoimprovebothmental
andphysical health, andarenowPLOSONE | www.plosone.org 1 July2013 |
Volume8 | Issue 7|
e68184becomingincreasinglypopularinWesterncountries.Moreover,arangeofscientificstudieshaveexaminedthetherapeuticeffectsofmind-body
interventions on depression [2526], anxiety [27],insomnia [28],
chronic pain[29], andcardiovascular problems[30].Although the
existing studies have found encouraging empiricalevidence for the
treatment efficacy of mind-body interventions, themajority of the
studies have examined adult or elderly populations.As a result, the
effects and applicability of mind-body
interventionsonthepediatricpopulationarerelativelylessunderstood.
Afewstudieshaveexploredtheeffectsofrelaxationtrainingandmind-body
interventions on the psychological and cognitive functions
ofchildren, and the results have so far beenpositive [3138].
Itshouldbenotedthatmanyofthemind-bodytechniques,
suchasmeditationandTai Chi, requires eitherahighdegreeof
mentalcontrol or involves slowmovements that might not be
easilymasteredbychildrenwithparticular neurodevelopmental
disor-ders. Nevertheless, the emerging positive outcomes of
certainforms of mind-body training for normally developed children
haveprovided insights into their potential effects on children with
ASD.Thepresent studyinvestigatedtheefficacyof themind-bodyexercise,
Nei Yang Gong, which is one component of a newlydeveloped mind-body
intervention. The intervention, which
isbaseduponaChineseChantraditionnamedChanwuyi (i.e., Zen,martial
artsandhealing) fromtheSanhuangzhai monastery[39],isalso known as
the Dejian Mind-Body Intervention (DMBI),
asnamedaftertheGrandMasterof Chanwuyi Shi Dejian(aShaolinmonk).
Recentempirical
studiesonthisinterventionhaveshownthatithaspositiveeffectsinimprovingphysicalhealth,moodandcognitive
function in community-dwelling adults [40], childrenwith
autistic/Aspergers disorder [2224], and individuals
withbraindamage[41] anddepression[2526]. Whilethepreviousstudies
examinedthe effects of the holistic approachof Chanyi,which
includes psychoeducation, mind-body exercises and dietmodification,
the present study examinedthe effect of a singlecomponent of
themodel, themind-bodyexercises, as
apossibleinterventionforchildrenwithASD.Somewhat like Tai Chi, Nei
Yang Gong involves sets of
slowmovementsthatemphasizesmooth,gentle,andcalmmovements.The basic
principles andpractices of Nei Yang Gong have beenelaborated in two
published books [39,42] and on the website of
acharityfoundation(www.chanwuyi.org). Thepracticeof Nei YangGong
has two primary functions. First, it aims to foster self-awareness
and mental self-control to help restore a calmandrelaxedstate.
Second, ithelpstoreducestress, increaseflexibilityof thelimbs,
andimprovethecirculationof Qi andblood. Forexample,
theshoulderrelaxation movement helpstorelaxtheneck and the
shoulders while improving self-control and self-awareness. It
should be noted that Nei Yang Gong has beendeveloped on the basis
of the Chan medical model, whichemphasizesthemaintenanceof anatural
andrelaxedattitudetoachievesmoothcirculationofQi
andblood.Inthisway,Nei YangGong differs from some of the other
mind-body techniques, such asmindfulness and meditation, which
require a high degree ofconscious mental awareness andself-control.
Givenits requirednatural attitude, it is anticipated that Nei Yang
Gong will be easilymastered by and feasibly applied to children
with ASD. Ourhundreds of clinical cases of
childrenwithneurodevelopmentaldisorders reveal that even children
with moderate mentalretardationareabletolearnandbenefitfromNei
YangGong.Our previous randomized controlled study revealed the
possibleneural mechanismunderlyingthe therapeutic effect of Nei
YangGong[43].ItwasfoundthatregularpracticeofNeiYangGongwasable to
foster a simultaneously relaxed and attentive brain state,
asreflected in increased electroencephalographic (EEG)
alphaasymmetry and intra- and inter-hemispheric EEG theta
coherenceindices. In contrast, this altered brain activity was not
foundamongtheparticipants of thecomparisongroup,
whopracticedProgressiveMuscleRelaxation(PMR). As
relaxationandatten-tiveness are both significant factors for
improving performance, NeiYang Gong can be regarded as both a
cognitive
enhancementmethodandarelaxationexercise.Therefore,itisanticipatedthatthe
childrenwhopractice Nei Yang Gong (i.e., the experimentalgroup)
will show greater improvement in self-control(as measuredby
standardized neuropsychological tests) and greater reduction
inrelatedbehavioral andsocial problems(asmeasuredbyparentalreports
on daily behaviors and social communication) thanchildren who
practice PMR(i.e., the control group).
DerivedfromtheworkofJacobson[44],PMRisaconventionalandwell-establishedbehavioraltreatmenttechnique.Itwas
selectedforthecomparisongroupbecauseof therepeatedempirical support
forthe effectiveness of PMRin alleviating anxiety,
physiologicalarousal,andbehavioraldisturbances[4547].Furthermore,giventhe
concreteness and simplicity of PMR, it can be applied
tochildrenwithASDatayoungerageandwithalowerfunctioninglevel.
Scientificevidencesupports theapplicabilityandeffective-ness of
PMRinreducingaggression, increasingself-control
andinducingrelaxationinchildrenasyoungasage6[48,49]andinchildren
with learning disabilities [50,51]. Moreover, a few
studieshavereportedthat PMRaloneor as acomponent of
CognitiveBehavioral Therapyhas positiveeffects
inreducinganxietyanddisruptivebehaviorofindividualswithASD[5254].Thepresentstudyalsocomparedtheneuralactivitypatternsofthe
two groups as measured by EEGassessment during aninhibitory control
task (i.e., a Go/No-Go task) to explore
thepossibleunderlyingneurological
mechanismrelatingtoimprovedself-control.TheEEGtestwas
adoptedbecauseitisnon-invasive,practical,
andeasytoadministertochildrenwithASDwhohavedifficulty sitting
still. The source of the scalp-EEGactivity
waslocalizedusingthestandardizedlow-resolutionbrainelectromag-netic
tomography (sLORETA) analysis method [55] with theanterior
cingulate cortex (ACC) as the region of interest. The
ACCplaysasignificantroleininhibitorycontrol
[5658]andreducedactivitylevelsintheACChavebeenfoundinchildrenwithASDwhenperforming
aninhibitory task [5961]. Accordingly, it isanticipated that if the
children practicing Nei Yang Gong showimprovementinself-control,
thenthesourceactivitylevelsintheACCduringaninhibitorycontrol
taskwill beelevated, whereasthis neurophysiological change will not
be found in thosepracticingPMR.MaterialsandMethodsThe protocol for
this trial and supporting CONSORT checklistare available as
supporting information; see Checklist S1 andProtocol
S1.StudyDesignThe study was designedas a
randomizedcontrolledparalleltrial. The recruited children with ASD
were randomly and equallyassigned into the experimental group (who
received training on NeiYang Gong), or the control group (who
received training onProgressive Muscle Relaxation). Their ability
to exercise self-control was measured before and after the one
month
ofintervention.TheprogressoftheparticipantsthroughoutthetrialisdepictedinFigure1.Mind-BodyExerciseImprovesSelf-Control
ofAutismPLOSONE | www.plosone.org 2 July2013 | Volume8 | Issue 7|
e68184EthicsStatementThis study was conducted in accordance with
the HelsinkiDeclaration of the World Medical Association Assembly.
Theresearchprotocol was approvedbythe HumanSubjects
EthicsSub-committee(HSESC) of
theHongKongPolytechnicUniver-sity(Ref. No.: HSEARS20120517001)
andtheChineseClinicalTrial Registry (Registration No.:
ChiCTR-TRC-12002561).Writtenconsentwasobtainedfromtheparentofeachparticipantpriortothecommencementofthestudy.ParticipantsForty-eight
children with ASD aged between 6 and 17voluntarily
participatedinthe study withtheir parents writtenconsent. Prior to
the recruitment, the a priori sample size wasestimated based on the
effect size (0.7) of our previous research onthis Chinese mind-body
interventionfor autism; witha =0.05,power
=0.8,andtheusualattritionrateinourpreviousstudiesofabout 25%, the
minimum required samples in each group was
24.Thechildrenwererecruitedfromthreeprimaryschoolsandonesecondaryschool
inHongKongusinganonlineadvertisementand application platform, and
the existing database at theNeuropsychologyLaboratoryof
theChineseUniversityof
HongKong.Exceptfortwoindividuals,allparticipantsreceivedformaldiagnosis
of Autistic Disorder or Pervasive DevelopmentalDisorders Not
Otherwise Specified (PDD-NOS) by a clinicalpsychologist through a
standard clinical interview with theirparents based on the
DSM-IV-TRcriteria [62]. The clinicalpsychologist also assessed the
severity of each childs autisticFigure 1. CONSORT flow diagram. The
diagram shows the progress ofthe participants through the
enrollment,allocation, follow-up, and
dataanalysisphasesofthetrial.doi:10.1371/journal.pone.0068184.g001Mind-BodyExerciseImprovesSelf-Control
ofAutismPLOSONE | www.plosone.org 3 July2013 | Volume8 | Issue 7|
e68184symptoms inrelationtosocial interaction,
communicationandrepetitive/stereotypical behaviors using the
AutismDiagnosticInterview-Revised(ADI-R) [63].
Theinterviewincludeddetailedquestionsaboutachildsearlydevelopmentandcurrentfunction-ing,
withhigherscoresindicatingmoresevereautisticsymptoms.Childrenwithother
neurodevelopmental, psychiatric or neuro-logical comorbidities, or
wereonprescribedpsychiatricmedica-tion,
wereexcludedfromthestudy.Theremaining46childrenwerematchedintopairsaccordingto
their age and level of intelligence. The individuals in
eachmatchedpairwerethenrandomlyassignedintotheexperimentalorthecontrolgroupwithequalprobabilityusingthedrawinglotsmethod.
Therandomassignment was performedbyaresearchassistant who was blind
to the experimental design. Before the
endoftheintervention,sixchildrenintotaldroppedoutofthestudy,leaving20childreneachinthecontrol
andexperimental groups.Table1presents thedemographicandclinical
characteristics ofthe two groups. The children in both groups were
matched on age,t(38) =1.01, p =0.32, gender, x2(1) =1.11, p =0.29,
and severity ofautistic symptoms as measured by the four ADI-R
subscales, with tranging from 20.80 to 0.97, and p ranging from
0.34 to 0.87. Thetwo groups also demonstrated comparable levels of
generalintelligence, t(38) =0.36, p =0.72, which was assessed by
theresearchassistant usingtheshort formof theChineseversionofthe
Wechsler Intelligence Scale for Children-Fourth Edition(HongKong)
(WISC-IV(HK)) [64] or theStanfordBinet Intel-ligence ScaleFourth
Edition (SB-FE) [65] for non-verbal childrenandthosewhoshowedafloor
effect intheWISC-IV(HK). Sixchildren(i.e., 30%of theparticipants)
ineachgrouphadlimitedintelligencewithanIQscorebelow70.ProceduresPriortothebaselineassessment,thechildrenandtheirparentswerebriefedontheassessmentprocedureandinformedconsentswere
obtained from the parents. The assessment was conducted atthe Hong
Kong Polytechnic University. The children wereindividually assessed
in a quiet room by trained research assistantson their intellectual
functioning, self-control, and scalp EEGactivities. During the
assessment, the childrens parents wereinterviewedbyaclinical
psychologistontheirdevelopmental andmedical histories using a
structured clinical interview. Theresearch assistants who conducted
the neuropsychological andEEGassessments
wereblindedtotherationaleof thestudyandthe group assignment. During
the EEG assessment, each child wasrequiredtoperforman
inhibitorycontroltask(i.e., theGo/No-gotask) while their EEGdata
were obtained using a TruScanmeasuring set with 19 electrodes
positioned across the scalpaccordingtotheInternational
1020System[66]. Detailsof theGo/No-go task are elaborated in the
Measures section. Theelectrode impedances were maintained at #10
kV. The EEGsignalswere referenced to linked earsand sampled at 256
samplespersecond, withahigh-frequencylimitbandpassof 30Hz, andthen
fast Fourier transformed. Artifact-free EEG data wereselected based
on visual examination for eye movements andmuscle artifacts and
then captured for subsequent sLORETAanalyses. The sLORETA method is
a properly standardizeddiscrete, three-dimensional (3D)
distributed, linear,
minimumnorminversesolutionforexactandzero-errorlocalizationofthesourceofscalpEEGactivity[55].Thebaselineassessment
was performedtwoweeks beforethestart of the intervention. After the
baseline assessment, the twogroups of
childrenwereprovidedwithtrainingonNei
YangGongandProgressiveMuscleRelaxation, respectively,
foronemonth.Twoweeksaftertheintervention, thesamesetof
assessmentsonself-control,
dailybehaviorsandEEGactivitywereadministeredtothechildrenandtheirparents.MeasuresNeuropsychological
assessments on self-control. Thechildrens ability to exercise
self-control was assessed by
thefollowingthreestandardizedneuropsychological
tests,namelytheTowerofLondonTest,
theChildrensColorTrailsTestandtheFivePointTest:1)
TheTowerofLondonTestDrexelVersion(TOLDX)[67]is designed to test the
well-controlled and flexible execution ofgoal-directedbehavior. It
consists of tenitems that
involvemovingthreecoloredbeadsonthreeverticalpegstomatchatarget
arrangement whileadheringtothetestingrules. Thetest
issuitableforusewithchildrenaged7yearsandaboveTable1.BaselineDemographicandClinical
CharacteristicsofParticipantsintheControl andExperimental
Groups.CharacteristicsControlGroup
ExperimentalGroupt/x2Pvalue(n=20) (n=20)Age, years 12.42(3.25)
11.28(3.90) 1.01 0.32Gender-Male(%) 85.00 95.00 1.11 0.29IQ
80.50(18.51) 78.35(18.85) 0.36 0.72Diagnosis 0.17
0.68AutisticDisorder(%) 100 85 3.24 0.07PDD-NOS(%) 0
15SeverityofDisorderADI-RSocial Interaction 24.60(4.64) 23.20(4.48)
0.97 0.34ADI-RCommunication 18.65(4.06) 19.20(4.25) 20.42
0.68ADI-RStereotypedBehavior 6.60(2.60) 6.45(2.94) 0.17
0.87ADI-RAbnormal ,36months 3.15(1.73) 3.60(1.82) 20.80 0.43Notes.
ADI-R =Autism Diagnostic Interview-Revised; IQ=Intelligence
quotient as assessed by the Chinese version of the Wechsler
Intelligence Scale for
Children-FourthEdition(HongKong)ortheStanford-BinetIntelligenceScale-FourthEdition;
PDD-NOS =PervasiveDevelopmental DisordersNotOtherwiseSpecified.
Standarddeviationsareinparenthesis.doi:10.1371/journal.pone.0068184.t001Mind-BodyExerciseImprovesSelf-Control
ofAutismPLOSONE | www.plosone.org 4 July2013 | Volume8 | Issue 7|
e68184[67], although it has been used in studies with children aged
asyoungas 4[68]. Therecipients self-control is measuredbythe total
number of rule violations, with fewer violationsindicating better
self-control. The degree of impulsivity isindicated by the
initiation time, which is measured in terms ofseconds,
withalongerdurationreflectinglessimpulsivity.2)
ThesecondtrialoftheChildrensColorTrailsTest(CCTT-T2)[69]wasadoptedtotestinhibitorycontrolandflexibilityin
shifting mental processes and motor responses. The CCTTis
designedfor childrenaged8to16years,
althoughsomenormativedataareavailablefor childrenaged5to7years[70].
Thetest involves sets of duplicatenumbers embeddedwithin pink and
yellowcircles, and requires the child toconnect
thenumbersinascendingorderfrom1to15whilealternatingbetweenthe
twocolorsasquicklyaspossible.Thecompletion time (in seconds) is
used as a measure of inhibitoryandflexiblecontrol,
withashorterdurationreflectingbettercontrol.3) TheFivePoint Test
(FPT) [71]isafigural fluencytest thatwasadoptedtotestflexiblemental
control, asitrequiresthespontaneous generation of novel designs
without repetition byconnecting five points withstraight lines
within5minutes.Thetest issuitableforchildrenaged6andabove[70].
Thetotal numberof uniquedesigns generatedis measured, withhigher
amounts indicating better self-control and
greaterflexibility.Parental evaluationonbehavioral measures. The
par-entswereinterviewedontheirchildsbehavioral changesindailylife
using standardized questionnaires. As problems with self-control
have been found to be associated with typical autisticsymptoms
(e.g., repetitive/disinhibitory behaviors,
communicationandsocializationproblems), theparents
wereaskedtoratetheirchilds autistic symptoms based on the Autism
TreatmentEvaluationChecklist [72]beforeandaftertheintervention.
TheATEC was selected because it is a simple one-page evaluation
thathas been empirically found to be a sensitive measure for
evaluatingtreatment effectiveness forindividuals withASD[7375].
More-over, some preliminary evidence suggeststhat it is able to
monitortheprogressof childrenwithASDwithhighinternal
consistency[76]. TheATECconsists of four subscales: (1)
speech/languagecommunication; (2) sociability; (3)
sensory/cognitive awareness;and (4) health/physical behavior. The
total scores of the
foursubscaleswereusedforthepre-postcomparisonofeachgroup.Theparents
werealsoaskedtoanswer another
questionnairecontainingitemsabouttheirchildsabilitytoexerciseself-control,including
the control of his/her temper tantrums and rigidthoughts/acts, and
their difficulty in verbal expression. Thisquestionnaire was used
in our previous study to evaluate the effectof the Chan-based diet
modification in improving the self-control ofchildrenwithASD[23].
Theparentsratingon thisquestionnairewas consistent with their
rating on the standardized ATEC. Giventhat the rationale of the
present study was to examine thetreatment effect on self-control,
it was anticipated that the childrenwould show improvement in
self-control, but not in verbalexpression.
Thequestionnaireaskedtheparents toevaluatethedegreeof
changeineachproblembehavioraftertheone-monthinterventiononascaleof25to+5,where25indicatesalargereductioninproblembehavior,therebyindicatingalargedegree
of improvement; +5 indicates a large increase inproblembehavior,
therebyindicatingalargedecline; and0indicates no change. The mean
rating obtained
fromeachgroupwasusedforthesubsequentbetween-groupcomparisons.Event-related
EEGassessment. The event-related
EEGsignalsforeachchildwerecollectedduringaninhibitorycontroltest,
namely, the Go/No-Go task. The Go/No-Go task is acomputerized test
that measures the respondents ability to
flexiblyrespondtochangingstimuli andinhibit unwantedresponses.
Atotal of 192 black balls and 48 red balls (black:red ratio =4:1)
wererandomly displayed, one at a time, for 500ms followed by1000ms
of blankintervals, inthecenter of acomputer screen.Thechildwas
requiredtopress akeyas quicklyas possibleinresponse to a black ball
(Go stimulus), but to inhibit their
responsewhenaredball(No-gostimulus)appeared.Thetotaltestingtimewas6minutes.
AstheNo-goconditionrequiredtheinhibitionofan unwanted response
(i.e., pressing the key), the EEGdatacollected during this
condition were selected for
subsequentsLORETAanalysisoftheinhibition-relatedneural
activity.TheEEGdataforeachchildwasfirsttransformedusingExcelbeforebeingimportedintoEEGLABsoftwareusingMatLab7.1tocapturethecorrect
eventsandepochs. Theepochlimitswereset as 50ms as thestart and900ms
as theend. Artifacts intheepoched data were then pruned by visual
inspection and therejection method on the EEGPlot. The selected
data wereexportedandthenspectrallyprocessedbyfast Fourier
transfor-mation (FFT) for computation of the power data in the
theta band(47.5Hz) throughtheuseof theNeuroGuidesoftware. As
theACChas been reported to be one of the generators of
thetaactivitiesinthehumanbrain[7779]andtoplayamajorroleininhibitorycontrol,
sLORETA[55] was thus adoptedtolocalizethe sources of the theta
activities in response to the No-gocondition. The sources of the
theta activities were expressed as thethree-dimensional cortical
current density according to theMontreal Neurological
Institute(MNI) braincoordinates.Intervention: Nei YangGongvs.
ProgressiveMuscleRelaxationThechildrenintheexperimental andcontrol
groupsattendedtraining classes at the Chinese University of Hong
Kong twice perweek for four weeks, with each session lasting for an
hour. The
twotrainingclasseswereadministeredonthesamedaysofaweek.Thechildren
in theexperimental groupwere taughtto practiceNei YangGongbya
clinicalpsychologist,withover
10yearsclinicalexperienceintrainingchildrenwithautism.TheNeiYangGongsetcomprised
five types of movement: tranquil stand, shoulderrelaxation, nasal
bridge massage, Qi-circulating movement,
andpassiveDanTianbreathing. Themovements
werearrangedinafixedsequenceandincorporatedwithspecificpiecesof
musictofacilitate the childrens mastery of the technique and to
keep themengaged. While practicing Nei Yang Gong, the children were
guidedtomovecalmlyandrelaxingly,
andwereencouragedtopersistwiththemovements.Tofosterself-awarenessandself-control,thechildrenwerealsoencouragedtopracticesomeformsofNeiYangGongthatservedasself-guidedmassagesforrelaxingandcalmingoneself
whenever theyfeel distressedandfrustrated, e.g., rollingtheir hands
slowly up and down between the chest and theabdomen, resting their
hands on their abdomen while quietlyobservingtheirbreathing.
TheselectedNei
YangGongmovementsinvolvedsimplebodilyactions(e.g.,movinghands/fingersupanddown,
and bending the knees) and the children were only asked
toperformthemovements inarelaxedandnatural manner. Fiveyears of
clinical
observationsuggestedtotheresearchteamthatevenchildrenwithmoderategrademental
retardationwouldbeabletolearnandpracticeNei YangGong. Eachchildwas
closelymonitored by the clinical psychologist during each session
toensurethatallthechildrenwereabletomasterthetechnique.Asthe
intervention progressed, the children were observed to
becomeMind-BodyExerciseImprovesSelf-Control ofAutismPLOSONE |
www.plosone.org 5 July2013 | Volume8 | Issue 7| e68184less agitated
and to move at a slower pace when practicing Nei
YangGong.Eachroundof Nei
YangGongwithmusiclastedfor5minutes.Thechildrenwereencouragedtopracticethemovements
dailyone to three times. The childrens practicing times and
frequencieswererecordedinlogbooklets, whichindicatedthat 65%of
thechildren practiced Nei Yang Gong at least 6days per week
forbetween5 and 45 minutesa day(mean =19.38; SD=11.82).
Theremainingchildrenpracticed5to25minutesaday, 3to5daysper week
(mean =13.66; SD=6.12). Given that the physicalconditions vary
among children, they were instructed to stop doingtheexerciseuntil
theybegansweatingtoavoidexhaustion.Thus,thedurationofpracticewasnotfixed.Thechildreninthecontrol
groupweretaught theProgressiveMuscleRelaxation(PMR)
techniquebyanotherclinical psychol-ogist withoveradecadeof
experienceinadministeringPMRtopediatricpopulation.
TheChineseversionof PMRfor childrenwas adopted. This versionwas
locallydevelopedbytheClinicalPsychologyDivisionoftheHongKongPsychologicalAssociation,andhasbeenusedinpediatricclinicalhealthsince2004.Clinicalexperience
andempirical evidence [50,51] suggestedthat evenchildren with
mental retardation would be able to master
thePMRtechnique.Ineachtrainingsession,thetherapistguidedthechildreninsequentiallytensingandrelaxingsevenmusclegroups(nose,mouth,shoulders,arms,hands,chestandfeet)asinstructedbyasoundtrack.
Tofacilitatethelearningof
theASDchildren,duringthepractice,visualandverbalcueswereprovidedonhowtocontractandrelaxeachmusclegroup(e.g,thetensing-relaxingof
the armmuscle was representedby animage of a
monkeyswingingfromonetreetoanotherprintedonacuecardtogetherwiththevoiceof
amonkeypresentedonthesoundtrack).
Thetherapistmonitoredtheprogressof eachchildandobservedthatall
childrenwere able tomaster the technique. EachroundofPMR lasted
about 20 minutes. In addition to the PMR technique,other
behavioral-based training techniques on social
skills,emotionalawarenessandbehavioralmonitoringwereincorporat-edintothetrainingprogram.After
thefirst trainingsession, thechildrenweregivenacuecardthat
listedthesevensteps of thePMRtechniqueforhomepractice.
Ineachsubsequent trainingsession, anydifficulties
thechildrenencounteredduringtheirhomepracticewerereviewed.Half
thechildrenpracticedPMRonce(i.e. 20minutes)
adayatleast6daysaweek,whiletheotherhalfpracticedbetween1and5days
per week. The average practice duration of the control
andexperimental groupswassimilar, t =21.28, p =0.21.DataAnalysesThe
mean performance of each group on the
self-controlneuropsychological test measures and the mean parental
rating onthe ATEC at pre- and post-training were compared using
repeatedmeasuresANOVAsandthenfollowedbyposthocpairedsamplettests.Thechangeinmeanperformance/ratingineachgroupwasalsocomputedforbetween-groupcomparisonusingindependentsamplet
tests.Toexaminetheeffectsofthetwotypesoftrainingonneural activity,
the regions of interest (ROI) analysis of thesLORETAmethodwas
usedtolocalizethesourceof
thescalp-EEGactivityandtocomparewithinandbetweengroups
usingvoxel-by-voxel paired sample t tests and independent sample t
testsrespectively. The sLORETAcomparisons were
computedwithsubject-wisenormalizationandlogtransformationforeachgrouptocomparethepre-postchangesinthesourcesofthetaactivityinthe
ACC during the No-go condition. Because specifichypotheses were
tested, no adjustment to the alpha level wasapplied for the planned
comparison to avoid lowering the power ofthetests.ResultsNei
YangGongImprovestheSelf-Control TestPerformanceRepeatedmeasures
ANOVAs were performedseparately foreachneuropsychological test
measures tocomparetheeffects ofNei Yang Gong andPMRinenhancing the
self-control of ASDchildren. Atthebaseline, thelevelsof
self-control inbothgroupswere comparable, as reflected by the three
neuropsychological testmeasures, which showed t ranges from 21.49
to 1.5, and p rangesfrom 0.15 to 0.72. The results of the
repeatedmeasures ANOVAsshowed that there were significant and
marginally significant Time(Pre vs Post) by Group (Control vs
Experimental) interactioneffects on the two indices of the TOLDX,
i.e., the frequency of ruleviolation, F(1,34) =6.02, p =0.02, and
the initial time,F(1,34) =3.25, p =0.08. Fortheothertwomeasures,
therewasasignificant main effect of Time (CCTT-T2: F(1,33) =13.23,p
=0.001, FPT: F(1,35) =18.05,p =0.00).Subsequent post hoct tests
confirmedthat thefourneuropsy-chological test measures were
consistent, indicating that theautistic childreninthe experimental
group showed better self-control than those in the control group
after the one-monthintervention (see Table 2). Although both groups
showedimprovement inreducingthefrequencyof ruleviolationintheTOLDX,
themeanreductionof theexperimental group(28.53)after the
interventionwas about four times that of the controlgroup (22.82),
and the group difference was statistically
significantwithalargeeffectsize(0.84), t(34) =2.45,p
=0.019.Furthermore,theexperimental group, but not thecontrol group,
becamelessimpulsive inproblem-solving, as reflected by their
significantlyincreasedaverageinitialtimeinattemptingtheTOLDXquestions[experimental:
t(18) =23.65, p =0.002, effectsize =0.86; control:t(16) =20.58, p
=0.57, effect size =0.14]. The reduction inimpulsivityof
thetreatment groupwas greater thanthat of thecontrol group, with a
mediumeffect size (0.77), t(33) =22.27,p =0.03. In regard to the
CCTT-T2, the children in theexperimental
groupshowedasignificantreductionincompletiontime (meanreduction
=217.29) with a large effect size (0.83),t(17) =3.53,p
=0.003,whilethechildreninthecontrolgroupdidnotshowanysignificantimprovement(meanreduction
=26.97),t(16) =1.71, p =0.11, effect size =0.41. Although the
between-group difference in the mean reduction of completion time
did notreachstatistical significance, t(33) =1.61, p =0.12,
theeffect size(0.55) is at the mediumlevel. Similarly, children in
both thecontrol groupandtheexperimental
groupgeneratedsignificantlygreater numbers of unique designs in the
FPT after theintervention(meanincrement: control group
=4.11andexperi-mental group =5.11), t(17) =22.69, p =0.015 and
t(18) =3.50,p
=0.003,respectively.Yet,thechangeintheexperimentalgroupwasrelativelymorerobust(alargeeffectsizeof0.80)thanthatinthe
control group (a mediumeffect size of 0.63). In sum, thechildren
who received training in Nei Yang Gong showed morenoticeable
improvement inself-control thanthe childreninthecontrol
groupacrossall theneuropsychological tests.Nei
YangGongReducesSelf-Control RelatedDailyBehavioral ProblemsWhile
the childrenwholearnedNei Yang Gong
demonstratedbetterperformanceinthelaboratorytestsofself-control,wethenfurther
analyzedtheirabilitytoexerciseself-control ineverydaylife. The
parents were interviewed using the ATEC on
theMind-BodyExerciseImprovesSelf-Control ofAutismPLOSONE |
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e68184commonautisticsymptomsbeforeandaftertheintervention,andwere
given a questionnaire rating the treatment effect
incontrollingtemperandobsessivebehaviors,andverbalexpressiondifficultyafterintervention.The
results of the repeatedmeasures ANOVAs showedthatthere were
significant main effects of Time on the sociabilitysubscale,
F(1,37) =14.25, p =0.001, and the health/physical/behavior
subscale, F(1,37) =4.74, p =0.04, and a marginallysignificant main
effect of Time on the sensory/cognitive awarenesssubscale, F(1,37)
=3.20, p =0.08. Given the significant main effectsof the three
measures, the post hoc t statistics are provided to shedsomelight
onthepossiblepre-post
changesbetweenthegroups.Table3presentsthepre-postcomparisonsonthesubscalesoftheATEC.
The baseline level of the mean rating across all subscales
iscomparablebetweenthetwogroups, witht
rangingfrom0.68to1.48,andprangingfrom0.15to0.50.Afterintervention,parentsof
the experimental groupreportedsignificant improvement inthree
subscales: sociability, t(19) =3.06, p =0.006, effectsize =0.68;
sensory/cognitive awareness, t(18) =2.11, p =0.049,effect size
=0.49; and health/physical/behavior, t(18) =2.87,p =0.01, effect
size =0.66. However, thechildreninthecontrolgroupwereratedas
showingsignificant improvement mainlyinthesociabilitysubscale,t(18)
=2.53,p =0.02,effectsize =0.58.Asexpected, as the two intervention
programs aimed to improve self-control, neither groups showed any
change in the speech/language/communication subscale, as revealed
by the non-significant results of the F test, F(1,37) =0.01, p
=0.92. Theseresults suggest that the mind-body exercise had a
positive effect onthecognitionand healthofchildren
withASD,whichmaynot beachievedbyconventional behavioral
intervention.Theresults of theparents evaluationof thechanges
intheirchilds temper outbursts, obsessive behaviors and verbal
expressionproblem, arealsoconsistent
withtheabove-mentionedfindings.With the temper outburst scale, the
experimental group reported asignificantly greater reduction
(21.63) than the control group(20.07), withalargeeffect size(0.86),
t(28) =2.36, p
=0.026(seeFig.2).Withtheobsessionscale,theexperimentalgroupreportedameanreductionof
1.43andthecontrol
groupareductionof0.56,whiledifferencewasonlymarginallysignificant,t(28)
=1.90,p =0.068, it had a mediumeffect size (0.69). With the
verbalexpression problem subscale, the experimental (20.77)
andcontrol (20.79) groups both showed no obvious change,t(28)
=0.35, p =0.97, effectsize =0.02. Thus, theparents reportsare
consistent with the neuropsychological assessments thatindicate
that the mind-body exercise appeared to have
somepositiveeffectsinimprovingtheself-control oftheASDchildren.As
expected, the children did not showany improvement inlanguage
expression as it was not the target of the trainingexercises.
Again, the parental reports onthis specific treatmenteffect
coheredwiththe neuropsychological test results
andouranticipatedresults, suggestingthat theparents ratings
werenotbiased(e.g., reportingexaggeratedpositiveeffects).In
addition to the positive effects, no parent reported
anyadverseeffectofthetwointerventionsduringthestudy.AlthoughsomechildrenmayhaveexperiencedfatiguewhilepracticingNeiYangGong,
theywereadvisedtostopwhenevertheyfelt tiredordiscomfort,
andtoresumepracticeaftertakingarest.Nei
YangGongEnhancesBrainActivityintheAnteriorCingulateCortexFurtherpre-postcomparisonsof
theEEGactivityof thegroupsduringtheGo/No-gotask(acommontest of
inhibitorycontrol)were performed using the sLORETA method. The
No-gocondition, whichrequirestheinhibitionofabehavioral
response,was selected for analysis. The ACC was set as the region
of interestbecauseit has beenfoundtomediateinhibitorycontrol
[5658]and to be hypo-active in individuals with ASD[5961].
Theeffects of Nei Yang Gong and PMRin enhancing
ACCactivityTable2.MeanPerformanceandDifferenceScoreacrosstheNeuropsychological
TestsonSelf-Control oftheControl andExperimental
GroupsatPre-andPost-One-MonthIntervention.ControlGroup
Effect95%C.I. pvalueExperimentalGroup Effect95%C.I.
pvalue(n=19)Size(n=20)SizePre Post Diff Pre Post
DiffTOLDX#RuleViolation 3.88 1.06 22.82 1.11++1.524.13 0.00** 14.37
5.84 28.53 0.92++4.0612.99 0.00**(3.30) (2.16) (2.49) (13.22)
(7.07) (9.27)Initial Time 15.48 16.10 0.62 0.14 22.891.65 0.57
10.73 14.92 4.19 0.86++26.6221.77 0.00**(12.29) (9.36) (4.41)
(5.36) (6.56) (4.87)CCTT-T2#CompletionTime 59.38 52.41 26.97 0.41
21.6815.63 0.11 76.61 59.32 217.29 0.83++6.9527.63 0.00**(24.76)
(21.71) (16.83) (41.22) (34.26) (20.79)FPTUniqueDesigns 15.33 19.44
4.11 0.63+27.3320.89 0.02* 14.05 19.16 5.11 0.80++28.1722.04
0.00**(12.43) (11.67) (6.48) (8.63) (10.31) (6.37)Note. C.I.
=Confidence Interval; Diff =average of difference score by
subtracting pre-training score from post-training score; TOLDX=The
Tower of London Test DrexelVersion; CCTT-T2 =Trial
2oftheChildrensColorTrailsTest; FPT =FivePointTest.
Standarddeviationsareinparenthesis.#Lowervalueindicatesbetterperformance;*p,0.05,**p,0.01;++largeeffectsize,+mediumeffectsize.doi:10.1371/journal.pone.0068184.t002Mind-BodyExerciseImprovesSelf-Control
ofAutismPLOSONE | www.plosone.org 7 July2013 | Volume8 | Issue 7|
e68184duringtheNo-goconditionwerecomparedusingthesLORETAvoxel-by-voxelpairedtstatistics.Atthebaseline,theresultsofthevoxel-by-voxel
independent t statistics showcomparable ACCactivity levels between
the two groups during the No-go condition,t =0.76,p
=0.45.Afterone-monthintervention,theexperimentalgroupshowedsignificantly
elevatedactivity inthe rostral
ACCregion(Brodmannareas24)duringtheNo-gocondition,t =0.30,p =0.02
(circled region in the right-side image in Fig.
3).Treatment-induced activity elevation in this ACC region has
beenpreviouslyfoundtoindicatethelevel of
hypoactivityinchildrenwithASD as comparedwith
normallydevelopedchildren [60].
Incontrast,thecontrolgroupdidnotshow
anysignificantchangeinactivityintheACC,t =20.25,p
=0.81(left-sideimageinFig.3).TheenhancedACCactivityintheexperimental
groupindicatesthat the ACCmay be the neural mechanismunderlying
thepositivetreatment effects of Nei Yang Gong ontheself-control
ofASDchildren.DiscussionSelf-control
problems,suchasemotionaloutburst,repetitiveorobsessivethoughts or
acts, andimpulsivity,
arecommonbehav-Table3.MeanParentalRatingontheAutismTreatmentEvaluationChecklist(ATEC)oftheControlandExperimentalGroupsatPre-andPost-One-MonthIntervention.ControlGroup
Effect95%C.I.p ExperimentalGroup Effect95%C.I.p(n=19)Size
value(n=20)Size valuePre Post Pre PostSpeech/Language/ 6.53 5.68
0.27 20.702.39 0.27 5.80 5.05 0.29 20.461.96 0.21Communication
(3.39) (2.43) (3.25) (2.65)Sociability 17.53 14.63 0.58+0.495.30
0.02* 15.55 13.50 0.68+0.653.45 0.01*(6.28) (6.68) (6.18)
(5.91)Sensory/Cognitive 12.32 11.58 0.20 21.062.53 0.40 10.63 9.21
0.49 0.012.83 0.05*Awareness (5.28) (5.37) (5.51)
(4.91)Health/Physical/ 19.16 17.11 0.26 21.725.83 0.27 15.00 12.26
0.66+0.734.74 0.01*Behavior (9.46) (11.89) (7.78) (6.29)Note. C.I.
=ConfidenceInterval; Standarddeviationsareinparenthesis.
Lowervalueindicateslesssevereproblems;*p,0.05,**p,0.01;+mediumeffectsize.doi:10.1371/journal.pone.0068184.t003Figure
2. Parental rating of the treatment effects after one-month
training. The treatment effects as rated by the parents in
controlling thechildrens temper outburst and obsessive behaviors,
and verbal expression problem in daily life after one-month
training. A positive value
indicatesimprovementinthecorrespondingproblem.
*p,0.05(independentsamplettest).doi:10.1371/journal.pone.0068184.g002Mind-BodyExerciseImprovesSelf-Control
ofAutismPLOSONE | www.plosone.org 8 July2013 | Volume8 | Issue 7|
e68184ioral manifestations in children with ASD. These problems
hinderlearningandsocial development,
andincreasecaregiverburden.ThepresentfindingssupportedthepositiveeffectsoftheChineseChan-basedmind-bodyexercise,
Nei YangGong, inenhancingself-control and reducing the typical
autistic symptoms and
dailyemotionalandbehavioralproblemsofchildrenwithASD.Aone-month Nei
Yang Gong training program, totaling 8 one-hoursessions,
wasabletoelicit robust treatment effects that werenotobservable for
the other group receiving a conventional
behavioraltrainingtechnique.
Oneencouragingfindingofthepresentstudyis that this exercise can be
mastered by children with limitedlanguage ability and intellectual
functioning. Because of
thesimplicityandeffectivenessofthisChinesemind-bodyexercise, itcan
be considered as an alternative or complementary
interventionforimprovingexecutivecontrol
inchildrenwithASD.Thepotential benefitsof
themind-bodyexerciseinpromotingincreasedself-control foundinthe
present study are consistentwithprevious empirical studies
onmind-bodyinterventions. Forinstance, Bahrami et al. [31] reported
a 42%reduction instereotypic behavior in ASDchildren after 14 weeks
of Katatechniques (aformof mind-bodyexercise)
trainingcomparedtotheno-exercisecontrol group,
whichwassustainedatone-monthfollow-up.
Anotherstudy[37]alsoreportedsignificantlyreducedbehavioral
problemsamong24childrenwithASDafter8-weeksmovement-based therapy
(with yoga as one of the treatmentcomponents). A recent review
article in Science [80] concluded thattraditional martial arts
(aformof mind-bodyexercise) improvedexecutive control to a greater
extent than standard physicaleducation [36] or modern martial arts
[81] for children/adolescents withexecutivefunctiondeficits.
Theeffectiveness ofthe traditional martial arts may be relatedto
their concurrentemphasis on physical training, self-control,
discipline, andcharacterdevelopment(e.g., respect, responsibility,
andpersever-ance), which tend to focus more on the executive
function.Similarly, as the Chinese mind-body exercise adopted in
thepresentstudywas developedbaseduponthe principlesof
ChineseChanandBuddhism,
thechildrenwereguidedtopracticewithapeacefulmindandtorelieveangeranddistress.Thismayexplainthedistinctiveeffectsoftheexerciseinenhancingself-control.Theunderlyingmechanismthatmayexplainthechangeintheparticipantsself-controlanddailybehaviorswasindicatedbythechangeinEEGactivityas
analyzedbythesLORETAmethod.Thefindingsshowthat
thechildrenwhopracticedNei YangGongfor one month had significantly
increased electrophysiologicalactivityintherostral ACCregion,
whereas thosewhopracticedPMRdidnotshowsuchelevation.
Studieshavebeenrepeatedlyreportedthat
childrenwithASDshowhypoactivityintheACCduring response-monitoring
and inhibitory tasks (e.g., the Go/No-go task) as compared to
normally developed children [5961]. Theenhanced ACC activity while
performing an inhibitory
taskobservedamongthechildrenwhocompletedone-monthNeiYangGong
practice suggests that the behavioral improvement of
childrenwithASD may beassociatedwith increasedACC activity.In
fact,the effect of Chan-based mind-body exercise on the brain
wasexploredinourpreviousrandomizedcontrolledstudy[43].
Thisstudyfoundthat individuals
whopracticedmind-bodyexerciseswereabletofosterarelaxedandattentivebrainstateasreflectedbytheiralteredEEGindices,
whereasthosepracticingPMRdidnotshowanyalterationinbrainactivity.
Arelaxedandattentivebrain state is crucial for achieving peak
performance andexercisinggoodself-control. Nevertheless,
howmind-bodyexer-cises change and increase the activity in the
neural system
warrantsfurtherinvestigation.ThetherapeuticeffectsofNeiYangGongonbrainfunctionsandactivityobservedinthepresent
studyareinlinewithour otherclinical observations andempirical
findings inrecent years.
Forinstance,twocasestudies,oneonachildwithautismandmentalretardation
and another on an adolescent with AspergersFigure 3.
Neuro-electrophysiological activity changes after one-month
training. Graphical representation of the sLORETA paired
t-statisticsresults comparing the pre- and post-one-month theta
source activity of the control and experimental groups during the
No-go condition of the Go/No-go task. The regions colored in red
indicate significantly elevated ACC activity (in the circle) after
one-month Nei Yang Gong training (experimentalgroup)atp,0.05,
whichwasnotobservedafterpracticingtheProgressiveMuscleRelaxation(control
group).doi:10.1371/journal.pone.0068184.g003Mind-BodyExerciseImprovesSelf-Control
ofAutismPLOSONE | www.plosone.org 9 July2013 | Volume8 | Issue 7|
e68184disorder, reported significantly improved inhibitory control
ofemotionalandbehavioraldisturbancesafterDMBI,withNeiYangGong as
one of the treatment components [22,24]. A recentrandomized
controlled study of the Chan-based
mind-bodyinterventionthroughdietarymodificationonchildrenwithASDalso
showed significant enhancement in inhibitory control
andelevationinACCactivityafterone-monthtreatment[23].
Otherpositiveoutcomesonemotional control,
cognitivefunctions(e.g.,attention), andfrontal
brainactivitywerealsoobservedinthreerandomized controlled trials on
patients withmajor depressivedisordersand community-dwellingadults
afterDMBI[2526,40].Thus, the results of thepresent studyshedfurther
light onthepotential application of Chinese Chan-based mind-body
exercise
asacomplementaryinterventionfortherehabilitationofindividualswithASDandotheremotional
andcognitiveproblems.Theresults of the present studyindicate that
the
one-monthChinesemind-bodyexercisehadpositiveeffectsinimprovingtheself-control
andalleviatingtheautisticsymptomsofchildrenwithASD. However, the
long-termeffects of the exercise and thesustainability of the
treatment effects remainunknownandareworth further investigation.
This study also explored the treatmenteffect of asinglecomponent
(mind-bodyexercise) of theDMBI.Our previous study reported a
similar positive outcome
foranothercomponent(dietmodification)oftheDMBIinimprovingtheself-control
of childrenwithASD[23]. Thus,
futurestudiescouldinvestigatewhethertheuseof bothtreatment
componentscould have additive treatment outcomes when applied
toindividuals with ASD. Because self-control problems are com-monly
observed in patients with other brain disorders
(e.g.,attention-deficit/hyperactivity disorder, traumatic brain
injury,and dementia), it may also be worth extending the
investigation ofthe effects of mind-body exercise to these clinical
populations. Lastbutnotleast,
giventheincreasingresearchinterestinmind-bodyinterventions (e.g.,
yoga) for improving health in Westerncountries, future studies
could also investigate the applicabilityand effectiveness of this
Chinese Chan-based mind-body exercise
inCaucasianpopulations.ConclusionsInsummary, this studyprovides
evidencethat
onemonthoftrainingintheChineseChan-basedmind-bodyexercise, Nei
YangGong, had a positive effect in enhancing the self-control of
childrenwith autismspectrumdisorders. This cognitive
enhancementcoincidedwithsignificantlyelevatedbrainactivityintheanteriorcingulate
cortex of the Nei Yang Gong group participants. Incontrast, this
improved brain functioning and elevated brainactivitywas not
observedinthe childrenpracticingprogressivemuscle relaxation. This
encouraging finding confirms the potentialclinical applicability of
this Chinese mind-body exercise inenhancing the self-control of
individuals with various
braindisorders.SupportingInformationChecklistS1
CONSORTchecklist.(DOC)ProtocolS1 Trial
protocol.(DOC)AcknowledgmentsTheauthorswouldespeciallyliketothankVenerableMasterDejianoftheSongshanmonasteryforhiseffortandgenerosityindevelopingtheChineseChan-based
mind-body intervention. They are also thankful to the
teachersatChiLinSecondarySchool, SanWuiCommercialSociety School,
SKHYat SauPrimary School, andSamShui Natives
AssociationLauPunCheungSchool,andtotheparentswhoassistedintherecruitmentoftheparticipants.Furtherappreciationisextendedtotheparentsandchildrenwhoparticipatedinthis
study. Finally, theauthors
wouldliketothankDebbieYan,LanHe,RexWong,YvonneHan,KarolineChiu,andAvaKwokfortheireffortsindatacollectionand/ordatamanagement.AuthorContributionsConceived
and designed the experiments: ACSS EL. Performed theexperiments: SS
NS. Analyzed the data: ACSS NS EL.
Contributedreagents/materials/analysis tools: ACMC. Wrotethepaper:
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