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Mindfulness-based interventions (MBIs) are becoming increasingly popular as treatments for physical and psychological problems. Recently, several studies have suggested that MBIs may also be effective in reducing symptoms of attention-deficit hyperactivity disorder (ADHD). Most studies have examined the effectiveness in children, but there are now a sufficient number of individual treatment trials to consider a systematic review in adults. Majority of existing systematic reviews and meta-analyses only consider ADHD symptoms as an outcome, and most of them do not fully report potential biases of included studies, thus limiting considerably their conclusions. This is an important facet because some studies could be found ineligible to be included in future analysis due to their low quality. In this systematic review, we followed the PRISMA/PICO criteria and we thoroughly assessed the risks of bias for each of the selected studies according to Cochrane guidelines. We searched the available literature concerning MBIs in adult participants with ADHD using PsycINFO, PubMed, Scopus, and ERIC databases. In total, 13 studies conducted with 753 adults (mean age of 35.1 years) were identified as eligible. Potential moderators such as participants’ age, ADHD subtypes, medication status, comorbidity, intervention length, mindfulness techniques, homework amount, and training of therapists were carefully described. Aside from measuring the symptoms of ADHD, outcome measures were categorized into executive/cognitive functioning, emotional disturbances, quality of life, mindfulness, and grade point average at school. According to presented descriptive results, all the studies (100%) showed improvement of ADHD symptoms. In addition, mindfulness meditation training improves some aspects of executive function and emotion dysregulation. Although these are promising findings to support treatment efficacy of MBIs for ADHD, various biases such as absence of randomization and lack of a control group may affect the actual clinical value and implications of the studies. Moreover, the relatively low quality of selection and performance criteria in several studies, as well as relatively high attrition bias across studies, call for caution before considering conducting further analysis.
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Review Article
Behavioral and Cognitive Impacts of Mindfulness-Based
Interventions on Adults with Attention-Deficit Hyperactivity
Disorder: A Systematic Review
Hélène Poissant ,
1
Adrianna Mendrek,
2
Nadine Talbot ,
3
Bassam Khoury,
4
and Jennifer Nolan
1
1
Universite du Quebec à Montréal, Education and Pedagogy Department, Montréal, Quebec, Canada H3C 3P8
2
Bishops University, Psychology Department, Sherbrooke, Quebec, Canada J1M 1Z7
3
Universite du Quebec à Trois-Rivières, Sciences Education Department, Trois-Rivières, Canada G9A 5H7
4
McGill University, Educational and Counselling Psychology, Montréal, Quebec, Canada H3A 1Y2
Correspondence should be addressed to Hélène Poissant; poissant.helene@uqam.ca
Received 10 August 2018; Revised 18 December 2018; Accepted 20 January 2019; Published 4 April 2019
Academic Editor: Jesus Pastor
Copyright © 2019 Hélène Poissant et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Mindfulness-based interventions (MBIs) are becoming increasingly popular as treatments for physical and psychological problems.
Recently, several studies have suggested that MBIs may also be eective in reducing symptoms of attention-decit hyperactivity
disorder (ADHD). Most studies have examined the eectiveness in children, but there are now a sucient number of individual
treatment trials to consider a systematic review in adults. Majority of existing systematic reviews and meta-analyses only
consider ADHD symptoms as an outcome, and most of them do not fully report potential biases of included studies, thus
limiting considerably their conclusions. This is an important facet because some studies could be found ineligible to be included
in future analysis due to their low quality. In this systematic review, we followed the PRISMA/PICO criteria and we thoroughly
assessed the risks of bias for each of the selected studies according to Cochrane guidelines. We searched the available literature
concerning MBIs in adult participants with ADHD using PsycINFO, PubMed, Scopus, and ERIC databases. In total, 13 studies
conducted with 753 adults (mean age of 35.1 years) were identied as eligible. Potential moderators such as participantsage,
ADHD subtypes, medication status, comorbidity, intervention length, mindfulness techniques, homework amount, and training
of therapists were carefully described. Aside from measuring the symptoms of ADHD, outcome measures were categorized into
executive/cognitive functioning, emotional disturbances, quality of life, mindfulness, and grade point average at school.
According to presented descriptive results, all the studies (100%) showed improvement of ADHD symptoms. In addition,
mindfulness meditation training improves some aspects of executive function and emotion dysregulation. Although these are
promising ndings to support treatment ecacy of MBIs for ADHD, various biases such as absence of randomization and lack
of a control group may aect the actual clinical value and implications of the studies. Moreover, the relatively low quality of
selection and performance criteria in several studies, as well as relatively high attrition bias across studies, call for caution before
considering conducting further analysis.
1. Introduction
Mindfulness-based interventions (MBIs) have gained in pop-
ularity over the past decade. Clinical trials provide evidence
of their eectiveness in the treatment of depression, anxiety,
addictions, and other mental health problems. Most MBIs
involve three somatically focused meditative techniques
(body scan, sitting meditation, and mindful yoga) that are
thought to help participants cultivate nonjudgmental, mind-
ful awareness of present-moment experience. Recently, sev-
eral studies have suggested that MBIs may also be eective
in reducing symptoms of attention-decit hyperactivity dis-
order (ADHD). Most studies have examined the eectiveness
in children. There are now a sucient number of individual
Hindawi
Behavioural Neurology
Volume 2019, Article ID 5682050, 16 pages
https://doi.org/10.1155/2019/5682050
treatment trials to consider a systematic review in adults.
To our knowledge, only Cairncross and Miller [1] have
conducted a meta-analysis (six studies in children and four
in adults) on ADHD to measure the impact of MBIs on
symptoms of ADHD. The authors only considered publi-
cation bias in their study. The present systematic review
goes further by exploring in detail seven types of biases
according to Cochrane guidelines. This is an important
aspect of the present review because it allows identifying
studies with poor quality.
This systematic review examines if MBIs are eective
treatments of attention-decit hyperactivity disorder (ADHD)
in adults. ADHD is characterized by marked behavioral
symptoms such as inattention and/or hyperactivity and act-
ing impulsively. The prevalence of the disorder is about
3-4% in adults, and it is higher in males than in females.
ADHD often exists simultaneously with other conditions,
such as anxiety, depression, and personality disorders. The
most common treatment of ADHD consists of administra-
tion of psychostimulant medications. However, the pharma-
cotherapy is not always eective and is associated with
various side eects. Thus, MBIs represent a much-welcomed
addition to available treatments or a stand-alone therapy.
Comprehension of the mechanisms mediating the eec-
tiveness of MBIs in ADHD at both the behavioral and neuro-
nal levels has greatly improved. Thus, three large neural
networks have been implicated both in ADHD and in mind-
fulness meditation: the default mode network, salience net-
work, and central executive network [27]. Because of
space constraints, we concentrate in the present review only
on the behavioral level, considering the eects of MBIs on
hyperactivity, emotion dysregulation, decits in attention
and executive function (EF), and other problems. Most of
these dysfunctional behaviors seem to improve following
MBIs. The improvement of these behaviors in turn contrib-
utes to the general well-being of adults with ADHD.
However, due to the heterogeneous presentation of
ADHD, it is important to document the interindividual
dierences of individuals with ADHD. These dierences
between individuals with ADHD may aect the success of
MBIs in reducing symptoms. For example, there is more
evidence to suggest that MBIs are eective in reducing
inattention, so perhaps the intervention is more helpful for
individuals with ADHD with a predominantly inattentive
type [1]. Adults being more often characterized as inatten-
tive (instead of hyperactive) may react in a dierent man-
ner to MBIs compared to children. Other variables could
also aect whether MBTs are eective in improving func-
tioning in individuals with ADHD. For example, it is
unclear how factors such as the length of intervention,
mindfulness techniques, amount of homework, homework
compliance, and training of the therapist aect the out-
come of therapy [1]. These are important elements that
should be taken into account. Moreover, besides symptoms
of inattention and hyperactivity, other indicators of ecacy
of MBTs had been reported, namely, EFs, emotional distur-
bance, quality of life, and academic performance. We con-
sider these additional elements useful in supporting the
portrayal of ADHD.
The present systematic review attempts to provide more
evidence for the use of MBIs in adults with ADHD by
means of investigation into several variables and character-
istics that may moderate the eectiveness of MBIs. It is
important for us to report these elements so that the relation-
ship between these characteristics and intervention eective-
ness can be better understood. Moreover, incorporation of an
exhaustive analysis of biases with an assessment of the quality
of studies is presented here as an essential element of the
systematic review.
2. Methods
2.1. Eligibility Criteria. In order to conduct the systematic
review, we used the criteria from PRISMA-P [8]. These cri-
teria allow following a stepwise methodology in conducting
and reporting the outcomes of the systematic review. A data
sheet based on the PRISMA-P protocol was designed and
comprised information extracted from each selected study
based on (1) research design (including RCT, N-RCT, the
presence of a waiting list, pre-posttest, follow-up, and base-
line), (2) characteristics of participants (including number,
age, gender, diagnosis with subtype, comorbidity, and medi-
cation), (3) characteristics of the intervention (including
type, description, length, identity of therapists, and their
experience), and (4) characteristics of outcomes (ADHD
symptoms, executive functioning, emotional disturbance,
mindfulness, and quality of life).
We limited inclusion to peer-reviewed empirical published
studies that examined eects of meditation or mindfulness-
based interventions (MBIs) on symptoms of ADHD. All stud-
ies were published in English. We excluded books, reviews,
meta-analyses, qualitative, psychometric, or single-case stud-
ies, and duplicates.
2.2. Information Sources and Search. We consulted Psy-
cINFO, PubMed, Scopus, and ERIC databases from the rst
available date until June 2018 (+reference lists of previous
reviews). By the end of the search, the selected studies cover
a period from 2002 to 2018. The search terms ADHD
AND meditation OR mindfulnessand associative terms
(e.g., impulsivity, inattention, and hyperactivity) were con-
sidered for inclusion. Impact of MBIs was extended to
cognition, EF, and brain structure alterations. We included
randomized and nonrandomized control trials (RCT and
N-RCT, respectively), pre-posttest (within-group) studies,
clinical trials, prospective or follow-up studies, and single-
or double-blind studies. Studies were excluded if they (1)
were conducted with children, (2) did not include a mind-
fulness- or meditation-based treatment, (3) did not include
a group of ADHD or ADD or hyperactivity disorders, (4) did
not examine treatment eects, (5) did not report clinical
outcomes, and (6) described solely mindfulness or medita-
tion instructions. We included dierent forms of MBIs as
long as the intervention contained signicant elements of
mindfulness. We also excluded gray literature,reports,
and unpublished studies. By the end of the selection pro-
cess, we included thirteen studies conducted with adults,
2 Behavioural Neurology
young adults, and college students. The full electronic pro-
cess search strategy for our databases is described below.
2.3. Risk of Bias in Individual Studies. We looked for risk of
bias in each individual study. Thus, we designed and adapted
a classication to report potential bias for each individual
study using the Cochrane Collaboration [9] recommenda-
tions. Biases included (1) sequence generation(e.g., Is the
allocation sequence acceptably generated? YESif explicitly
mentioned that the patients were randomly allocated), (2)
allocation concealment(e.g., Is the allocation acceptably
concealed? YESif participants and researcher could not
foresee assignment because of an explicit mention of a
method to conceal allocation), (3) blinding of participants,
personnel, and outcome assessors(e.g., Is knowledge of
the allocated treatment plenty prevented during the study?
YESin case of blinding or if the authors judged improba-
bly that the outcome measurement was inuenced by no
blinding, and (4) selective outcome reporting(e.g., Are
partial outcome data adequately addressed? YESif explic-
itly mentioned that nonmissing outcome data or reasons for
missing outcome data had little impact on outcomes). The
authorsjudgments involved answering specic questions
for each query and providing a detailed entry addressing
the sources of bias. In all cases, an answer YESindicates
a low risk of bias, an answer NOindicates a high risk of
bias, and an answer unclearindicates an uncertain risk of
bias (p. 196, [9]).
Selection bias comprises random sequence generation
(1) and allocation concealment(2) (p. 196, [9]). According
to the criteria proposed by the Cochrane Collaboration [10],
a study was rated low risk on random sequence generation if
the method used to allocate sequence produces equivalent
groups. If random sequence generation was not described
in sucient detail but the study was described as random-
ized and the groups were equivalent, we rated the risk
unclear. The studies, which have not fullled either condi-
tion, were rated high risk. Regarding allocation concealment,
we rated a study low risk when its method to conceal the
allocation sequence could not be predicted in advance of
or during intervention. If allocation concealment was not
described with sucient accuracy to allow an appreciation
of whether it could be foreseen but participants would not
necessarily identify the group to which they belong (i.e.,
treatment or control), the risk was rated unclear. The
remaining studies, which have not fullled either condition,
were rated high risk.
Performance bias and detection bias (3) reect the blind-
ing of participants and personnel (e.g., facilitators or trainers)
and reect the blinding of assessors to the condition. We
considered studies low risk if they described the blinding
of outcome assessors and used only self-report subjective
measures and/or objective measure (e.g., neuropsychological
measures). Unclear risk corresponded to self-report mea-
sures but nonblinding of assessors. For the nature of inter-
ventions in this study (MBIs), it is not habitual, nor always
advantageous, to blind personnel or participants. Therefore,
we expected studies to have an elevated risk for performance
and/or detection bias.
Attrition bias (4) is based on the recommendation by
Higgins et al. [10] to rate studies with above 20% attrition
of participants as high risk. An attrition rate lower than
20% where the groups (i.e., treatment and control) are equiv-
alent yields a low risk. Thus, studies were rated high risk if the
attrition rate was greater than 20% and the authors did not
use any analyses to compensate for the missing data. Studies
were rated unclear risk if the authors did not explicitly pro-
vide attrition rates or the computation of the attrition was
not possible using the provided data.
Reporting bias refers to reporting the outcome data par-
tially or omitting to report scales (or subscales) that may lead
to a bias. We decided to rate the study low risk if all the scales
and subscales were reported. We rated the study unclear risk
when subscales were not fully reported or it was unclear
whether omitting to report the subscales led to a bias.
Other biases included a researchers allegiance and fund-
ing source. These biases addressed the authorsrole in the
study development or implementation, as well as acknowl-
edgement of any conict of interest. Studies were rated high
risk when authors were actively involved in delivering inter-
ventions, evaluating participants, or conducting any other
aspects of the study. Studies were rated low risk when authors
were not involved in conducting the study. Studies were rated
unclear when the authors did not report their involvement
and information from the paper did not suggest their
involvement. Regarding funding, studies were rated high risk
when sources of funding can cause a conict of interest, low
when the study was not funded or when the sources of fund-
ing were disclosed with a nonconict of interest statement,
and unclear when the sources of funding were not reported.
Discussions about the judgment ratings were provided in
an iterative way until consensus about the ratings was
reached between judges (H.P., B.K., and A.M.). Prior to these
discussions, the rating coauthors familiarized themselves
with a series of articles and a document containing specic
instructions and examples of rating the studies from the
Cochrane Collaborations tools.
2.4. Summary Measures and Additional Analyses. The results
of the present systematic review are rst presented in a narra-
tive manner. Tables 1 and 2 give an overview of a PICO
description of each individual study considering two separate
types of research design: within and between subjects (see
Tables 1 and 2, respectively). For the bias analysis, apprecia-
tion of the quality of each study was converted into numeric
variables with quality scores ranging from 0 (high risk) and 1
(unclear risk) to 2 (low risk) on each of the seven bias evalu-
ation measures (the maximum score of quality for each study
is 14).
3. Results
3.1. Study Selection. The nal literature search resulted in 720
studies: PsycINFO (n= 225), PubMed (n= 460), Scopus
(n=23), and ERIC (n=12). An Endnote le was rst cre-
ated, and abstracts of all articles were saved on an electronic
le for further examination. The search was conducted in two
consecutive sessions from October 2016 to January 2017 and
3Behavioural Neurology
later updated from April 2018 to July 2018 resulting in the
incorporation of two new articles (with the help of N.T.).
The rst step consisted of the elimination of 178 duplicates
(+1 erratum). The nal study selection was based on eligibil-
ity assessment from two independent reviewers (H.P. and
A.M.). Disagreements were resolved through discussions.
After reviewing the abstracts of the 542 remaining studies,
458 studies were classied as irrelevant (erratum, theoretical
paper, qualitative study, no ADHD group, program develop-
ment, case study, study protocol, no treatment, and no quan-
titative outcome). From the remaining 84 studies, 56 were
reviews or meta-analyses; therefore, they were eliminated
Table 1
(a) Characteristics of single-group studies: research design and participants
1st author
(date) Research design
Age
participant
(y/o)
N%
males
% ADHD
subtypes % medication status % comorbid disorders
Hesslinger
(2002) [14] Pre-post
19-44,
x=319,
s=90
15 62.2
C=75,
I=125,
H=125
37.5 (MPH),
12.5 (other)
37.5 (MDD/Sx),
25 (social phobia),
25 (insomnia)
Morgensterns
(2016) [42]
Baseline (T1),
posttreatment (T2),
3-month follow-up (T3)
1963,
x=374,
s=104
98 31.6 C=866,
I=134
74.7 (atomoxetine+central
stimulants), 88.2
(psychoactive drugs)
71.1 (at least one
comorbid DSM-IV
diagnosis)
Zylowska
(2008) [11] Pre (T1) to post (T2) x=485,
s= 10.9 24 38 C=50,
I=42,H=8 63 83 (mood), 33 (AD),
33 (ODD), 92 (any)
(1) Statistics: n.r. = nonreported; y/o = years old; x= mean; s= standard deviation. (2) ADHD subtypes: ADHD = attention-decit and hyperactivity disorders;
I = inattentive; H = hyperactive; C = combined. (3) Comorbid disorders: AD/Sx = anxiety disorder or symptoms; ODD = oppositional deant disorder;
MDD/Sx = major depressive disorder or symptoms. (4) MPH = methylphenidate.
(b) Characteristics of single-group studies: intervention
1st author (date) Intervention Intervention length Therapist Informants
Hesslinger
(2002) [14]
ST-based DBT+mindfulness
components
2 h/week,
13 weeks = 26 hPsychotherapists trained in DBT Self, objective
Morgensterns
(2016) [42]
DBT (elements of acceptance,
mindfulness, functional behavioral
analysis, psychoeducation)
2 h/week,
14 weeks = 28 h
Two clinical psychologists who are trained
in CBT+DBT experienced from previous
study phases (T.H.) or had clinical supervision
from the experienced group leader
Self
Zylowska
(2008) [11] MAP+psychoeducation
2.5 h/week,
8weeks = 20 h+daily
at-home practice
Experienced mindfulness instructor
(D.W.)+ADHD researchers (L.Z. & S.S.) Self, objective
Intervention: CBT = cognitive behavioral therapy; DBT = dialectical behavior therapy; MAP = mindful awareness program; ST = skills training.
(c) Characteristics of single-group studies: measures of outcome
1st author
(date) ADHD symptoms Cognitive/executive
function
Emotional
disturbance
Quality
of life
Academic
performance Mindfulness
Hesslinger
(2002) [14] ADHD-CL, SCL-16
Fluency, Stroop,
DSS, KLT,
d2-Test, WMS-R
BDI n.r. n.r. n.r.
Morgensterns
(2016) [42]
CADHDSC_SRF: ADHD
symptoms (functional
impairment,
aggression irritability)
n.r. BDI, BAI, PSS
AAQ-9,
AAQoL,
KSQ
n.r. MAAS
Zylowska
(2008) [11]
ADHD Rating Scale IV
(adults), DSM-IV
ANT, TMT,
DST, VOC BAI, BDI n.r. n.r. n.r.
(1) ADHD symptoms: ADHD-CL = Attention-Decit Hyperactivity Disorder Checklist; CADHDSC_SRF = Current ADHD Symptom Scale-Self-Report Form;
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; SCL-16 = Symptom Check List. (2) Cognitive/executive function:
ANT = Attention Network Task; d2-Test = selective attention; DSS = Digit Symbol Subtest; DST = Digit Span Test (WAIS-R); KLT = Konzentrations-
Leistungs-Test; TMT = Trail Making Test; VOC=vocabulary subtest (WAIS-R); WMS-R = Wechsler Memory Scale-R (mental control, digit span, visual
memory span). (3) Emotional disturbance: BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; PSS = Perceived Stress Scale. (4) Quality of
life: AAQ-9 = Adult Quality of Life Questionnaire; AAQoL = Adult ADHD Quality of Life Questionnaire; KSQ = Karolinska Sleep Questionnaire. (5)
Mindfulness: MAAS = Mindful Attention Awareness Scale.
4 Behavioural Neurology
Table 2
(a) Characteristics of between-group studies (age and percentages only for ADHD groups with treatment (Tx)): research design and participants
1st author (date) Research design Age (y/o)
Nof ADHD,
HC, Tx, and
WL/no/other
Tx
% males % ADHD
subtypes
% medication
status % comorbid disorders
Bachmann (2018) [13] RCT, pre/post 18-65, x=40,
s=1058 40, 0, 21, 19 38 C=81,I=19
None (3 months
before and during
the study)
14 (AD), 57 (Sx), 4 (OC), none
(Schizo, BD, SD, AU, SUI/SI,
ND, Somato)
Bueno (2015) [44] N-RCT, pre/post 18-45, x=312,
s=7543, 17, 29, 31 54.5 n.r. 69.7 (MPH) n.r.
Cole (2016) [40]
ADHD-treated vs. ADHD-WL
at baseline, post, 3-month and
6-month follow-up, end of treatment
x=366,
s=1002 62, 0, 49, 13 54 C=735,
I=225,H=5
61.22 (MPH),
24.49 (other) 46.94 (MDD, BD, AD, SD, BPD)
Edel (2017) [32] N-RCT, WL, pre-post x=338,
s=10191, 0, 39, 52 59 C=692,
I=308
43.6 (MPH),
38.5 (other)
25.6 (BPD), 30.8 (other PD),
17.9 (social anxiety), 10.3
(MDD/Sx), 5.1 (dysthymia),
2.6 (SD)
Fleming (2015) [35] RCT, baseline, post, 3-month follow-up x=212,
s=167 33, 0, 17, 16 58.8
C=59,
I=882+59
(4 (Sx))
29.4 (MPH), 41.2
(other), 29.4 (none) AD, MDD/Sx (% n.r.)
Gu (2018) [48]
RCT, ADHD-treated vs.
ADHD-WL pre-post,
3-month follow-up
19-24, x=202,
s=103 54, 0, 28, 26 57.1 C=63,I=
93 3
28.6 (MPH), 42.8
(other), 28.6 (none) n.r.
Hepark (2019) [45] RCT, WL 18-65, x=365,
s=10 103, 0, 55, 48 38
CAARS-INV:
I=52,H=5 8
CAARS-SR:
I=43,H=5 1
46 (MPH), 15
(other), 40 (none) n.r.
Janssen (2019) [50]
RCT, ADHD-MBCT+TAU vs.
ADHD-TAU, baseline, post,
3-month and 6-month follow-up
18+, x=397,
s=111120, 0, 60, 60 47 C=50,I=38,
H=8 60 38 (MDD/Sx), 2 (BD), 13 (AD),
70 (Somato), 2 (ED), 2 (dysthymia)
Mitchell (2017) [25] WL & treatment group, pre-post
18-50,
x=4055,
s=683
20, 0, 11, 9 45.5 C=273,
I=72754.5 (stimulants) 54.5
Schoenberg (2014) [12] RCT, WL, pre-post 19-53, x=395,
s=9550, 0, 26, 24 37.5 n.r. 38 (MPH), 24
(other), 38 (none) n.r.
(1) Statistics and design: n.r. = nonreported; y/o = years old; x= mean; s= standard deviation; HC = healthy control; N-RCT = nonrandomized control trial; RCT = randomized control trial; Tx = treatment;
WL = waiting list. (2) ADHD subtypes: ADHD = Attention-Decit and Hyperactivity Disorders; I = inattentive; H = hyperactive; C = combined. (3) Comorbid disorders: AD/Sx = anxiety disorder or symptoms;
AU = autism; BD = bipolar disorder; BPD = borderline personality disorder; ED = eating disorder; MDD/Sx = major depressive disorder or symptoms; ND = neurological disorders; OC = obsessive compulsive
disorders. (4) PD = any personality disorder; Somato = somatoform disorder; SD = substance dependence; SUI\SI+suicidality: self-injurious behavior. MPH = methylphenidate.
5Behavioural Neurology
(b) Characteristics of between-group studies: intervention
1st author (date) Intervention Intervention length Therapist Informants
Bachmann (2018) [13] MAP or PE 2.5 h/week, 8 weeks = 20 h+daily
home practice n.r. Self, objective
Bueno (2015) [44] MAP or no intervention 2.5 h/week, 8 weeks = 20 h+daily
home practice Highly experienced practitioners Self, objective
Cole (2016) [40]
DBT (+elements of mindfulness)
or CBT modules
(impulsivity/hyperactivity, attention)
2 h individual psychotherapy+group/week,
12-month period = 96 h+homework
assignments
Nurses, psychologists, and psychiatrists,
trained in DBT+CBT Self
Edel (2017) [32] MBT (+mindfulness component of
DBT) or ST (DBT-oriented skills training) 2 h/week, 13 weeks = 26 hExperienced psychologist working with
ADHD+5 y experience in DBT/MBT Self, expert-rated scale
Fleming (2015) [35] DBT (+elements of mindfulness)
or skills handouts
1.5 h group/week, 8 weeks = 12 h+7
10 min individual coaching/week+90 min
group (1st week follow-up)
Group leader (A.P.F.), coleader (L.R.M.),
graduate students in clinical psychology
with DBT training & intervention,
psychologist with experience in ADHD
students
Self, objective
Gu (2018) [48] MBCT
1 h individual/week,
6weeks = 6 h+30 min
self-practice/day workbook psychoeducation
Group leader, psychiatrist specializing in
ADHD+8 y experience, MBCT trainers,
psychologist with experience in ADHD
students
Self, objective
Hepark (2019) [45] MBDT (+PE) 12-week meditation exercises built up
gradually+home practice 30 min/day
Psychiatrist specializing in ADHD (10 y),
mindfulness teacher (S.H.) & nurse
specialist, Association of
Mindfulness-Based Teachers, 150 h
education (MBSR)/MBCT
Self, investigator
Janssen (2019) [50] MBDT (+PE) 2.5 h group/week, 8 weeks = 20 h+6 h
silent day+home practice 30 min/day
Mindfulness teachers at dierent levels
of competence Self, objective
Mitchell (2017) [25] MAP 2.5 h/week, 8 weeks = 20 h+home practice Ph.D. clinical psychology Self, objective
Schoenberg (2014) [12] MBCT 3 h/week, 12 weeks = 36 h+30-45 min
self-practice/day
Psychiatrist specializing in ADHD
with 9 y training in MBCT Self, objective
Intervention: CBT = cognitive behavioral therapy; DBT = dialectical behavior therapy; MAP = mindful awareness program; MBT/MBCT = mindfulness-based training; PE = psychoeducation; ST = skills training.
(c) Characteristics of between-group studies: measure of outcome
1st author (date) ADHD symptoms Cognitive/executive function Emotional disturbance Quality of life Academic performance Mindfulness
Bachmann (2018) [13] CAARS-SR/OR n-back n.r. n.r. n.r. n.r.
Bueno (2015) [44] ASRS ANT, CPT-2 BDI, STAI-T, PANAS-X AAQoL n.r. n.r.
Cole (2016) [40] ASRS v1.1, BIS-11 n.r. BDI-II, BHS, STAXI WHOQoL-BREF, QFS n.r. KIMS
Edel (2017) [32] DSM-IV-(SR/OR) n.r. WRI GSES n.r. MAAS
Fleming (2015) [35] BAARS-IV, BADDS CPT-2 BAI, BDI-II AAQoL GPA FFMQ
Gu (2017) [48] CAARS-S:SV ANT BAI; BDI-II VAS GPA MAAS
6 Behavioural Neurology
Table 2: Continued.
1st author (date) ADHD symptoms Cognitive/executive function Emotional disturbance Quality of life Academic performance Mindfulness
Hepark (2019) [45] CAARS-INV, CAARS-SR BRIEF-ASR BDI-II-NL, STAI OQ 45.2 n.r. KIMS
Janssen (2019) [50] CAARS-INV:SV, CAARS-S: SV BRIEF-A n.r. OQ 45.2, MHC-SF n.r. FFMQ-SF, SCF-SF
Mitchell (2017) [25] Current ADHD Symptom Scale DEFS, BRIEF-A, ANT, CPT,
DST, TMT, WAIS-R DERS, DTS n.r. n.r. n.r.
Schoenberg (2014) [12] CAARS-S:SV CPT-X n.r. OQ 45.2 n.r. KIMS
(2) ADHD symptoms: ASRS (v1.1) = Adult ADHD Self-Report Scale; BAARS-IV = Barkley Adult ADHD Rating Scale-IV; BADDS = Brown ADD Rating Scales; BIS-11 = 11th version of the Barratt Impulsiveness
Scale; CAARS-S:SV = ConnersAdult ADHD Self-Rating Scale; CAARS-SV = ConnersAdult ADHD Rating Scales-Screening Version; CAARS-SR = self-report version of the ConnersAdult ADHD Rating Scale;
CAARS-INV = investigator rating version of the ConnersAdult ADHD Rating Scale; DSM-IV-(SR/OR) = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (self-rating/other-rating). (2)
Cognitive/executive function: ANT = Attention Network Task; BRIEF-A = Behavior Rating Inventory of Executive Functioning-Adult Version; BRIEF-ASR = Behavior Rating Inventory of Executive
Function-Adult Self-Report version; CPT-2 = the ConnersContinuous Performance Test-2nd edition; CPT-X = visual Continuous Performance Task; DEFS = Decits in Executive Functioning Scale;
DST = Digit Span Test (WAIS-R); TMT = Trail Making Test; WAIS-R = Wechsler Adult Intelligence Scale-Revised. (3) Emotional disturbance: BAI = Beck Anxiety Inventory; BDI-II/BDI-II-NL = Beck
Depression Inventory (2nd edition); BHS = Beck Hopelessness Scale; DERS = Diculties in Emotion Regulation Scale; PANAS-X = Aect Schedule-Expanded form; STAI = State-Trait Anxiety Inventory;
STAXI = State-Trait Anger Expression Inventory; WRI = WenderReimherr Interview. (4) Quality of life: AAQoL = Adult ADHD Quality of Life Questionnaire; GSES = Generalized Self-Ecacy Scale;
MHC-SF = Positive Mental Health Short Form; OQ 45.2 = Outcome Questionnaire; QFS = questionnaire of social functioning; VAS = Visual Analog Scale (personal health status); WHOQoL-BREF = World
Health Organization Quality of Life. (5) Mindfulness: MAAS = Mindful Attention Awareness Scale; FFMQ = Five Facet Mindfulness Questionnaire; KIMS = Kentucky Inventory of Mindfulness Skills;
SCF-SF = Self-Compassion Short Form. (6) Academic performance: GPA = Grade Point Average.
7Behavioural Neurology
(but we examined their reference lists). Among the 28
remaining empirical studies, 15 were conducted with chil-
dren, adolescents, and/or their parents; therefore, they were
excluded. Thirteen studies conducted with adults, young
adults, and college students corresponded to all the selection
criteria; therefore, they were included. A detailed illustration
of the study selection process is found in Figure 1. The sys-
tematic review of the thirteen studies selected is presented
qualitatively (narrative review).
3.2. Study Characteristics and Results of Individual Studies.
Each of the following study characteristics (e.g., study size,
PICOS, and follow-up period) and results of individual
study are presented in Tables 1 and 2. Outcomes in terms
of benets are presented in a narrative manner for each
study in the form of a simple summary data for each
intervention group. For briefness, we choose not to list the
eect size (ES) for every outcome (e.g., all tests and subtests
and T1-T2-T3-T4, totalizing 470 ESs for all articles). Rather,
a summary of eect sizes (ESs) is given for each study with a
main focus on symptom outcomes and posttest (T2) or
follow-up. Most ESs were retrieved directly from the articles.
However, for Zylowska et al. [11], Schoenberg et al. [12], and
Bachmann et al. [13], the ESs were not provided by the
authors. Therefore, for consistency, we calculated the ESs
using Comprehensive Meta-Analysis (CMA) software. Since
Bachmann et al. [13] did not nd evidence for a signicant
main eect of type of treatment (MAP vs. the psychoeduca-
tion comparison group), we did not calculate any ES for this
study (see below).
In an early pilot study, Hesslinger et al. [14] evaluated a
training based on dialectical behavior therapy (DBT) to suit
the special needs of adult patients with ADHD. The overall
treatment goal was that patients would control ADHD
rather than being controlled by ADHD.Prior to and follow-
ing group therapy, symptoms were assessed using self-rating
scales of ADHD-CL (from DSM-IV), a short version of the
SCL-16 to assess nervousness, memory decits, carelessness,
excitability, emotional outburst, self-reproach, diculties
to start, inferiority complex, sleep disturbances, concentra-
tion decits, feeling of tension, embarrassment, exertion,
restlessness, worthlessness, thinking something is wrong
with comprehension, and the BDI [15]) to assess depressive
symptoms (see the appendix for the complete names of tests).
In addition, neuropsychological testing was performed at
baseline and following treatment, including a verbal and
Literature search produced
720 papers:
PubMed: 460
PsycINFO : 225
Scopus : 23
ERIC : 12
178 papers are
duplicate
records and
removed
1 paper is
an erratum
542 papers are
recorded once
458 papers are
irrelevant
84 papers are
relevant
56 papers are
reviews or meta-
analyses
28 papers are
empirical
studies
15 papers are
with children
13 papers are
with adults and
young adults
and retained for
further meta-
analysis
Figure 1: Flow chart of the eligibility criteria.
8 Behavioural Neurology
letter uency test, the Stroop test indicating mental speed and
inhibitory EFs, the digit symbol subtest to evaluate divided
attention, a test of continuous attention, the d2-Test measur-
ing selective attention, and tests measuring mental control,
digit span, and visual memory span indicating short-term
memory, working memory (WM), and general attentional
capacities [16]. The DBT treatment resulted in mild to
moderate improvements on all the measured symptoms
and even greater improvements in neurocognitive function
(ESs ranging from 0.99 to 2.22).
Subsequently, Zylowska et al. [11] enrolled adults and
adolescents with ADHD in the mindful awareness pro-
gram (MAP) [17, 18] adapted to meet the challenges of
ADHD symptoms, including a psychoeducational compo-
nent. Self-report scales of ADHD, depression, and anxiety
symptoms and several cognitive tests were administered to
participants during pre- and postintervention sessions.
ADHD symptoms were assessed via the ADHD Rating Scale
IV [19] that measures the severity of symptoms. Self-reports
of anxiety and depression were assessed using the BAI [20]
and BDI. Attention was assessed using the ANT [21] measur-
ing three aspects of attention: alerting (maintaining a vigilant
state of preparedness), orienting (selecting a stimulus among
multiple inputs), and conict (prioritizing among competing
tasks). Authors also used the Stroop test and measure of
attentional conict with the ANT [22]; the Trail Making Test
[23], which assesses set-shifting and inhibition; the Digit
Span Test, which measures WM; and the vocabulary subtest
(WAIS-R) [24]. Improvements were found in depression and
anxiety as well as improvements in ADHD self-reported
symptoms (ESs ranging from 0.50 to 0.93) and measures
of attentional conict and set-shifting after the training
(ES = 0 93 and 0.43, respectively).
Later on, Mitchell et al. [25] tested the impact of MAP for
adults with ADHD on symptoms, EF, and emotion dysregu-
lation. Adults were stratied by ADHD medication status
and then randomized into a group-based mindfulness
treatment or waitlist group. The authors observed large
eect sizes in improvement of self-reported and clinician
ratings of ADHD symptoms (ESs ranging from 1.35 to
3.14) and EF (ESs ranging from 1.45 to 2.67) as well as
self-reported emotion regulation (ESs ranging from 1.27 to
1.63), for the treatment group relative to the waitlist group.
EF self-report scales included the DEFS [26] and the
BRIEF-A [27], which consists of nine scales: Inhibit, Shift,
Emotional Control, Self-Monitor, Initiate, WM, Plan/Orga-
nize, Task Monitor, and Organization of Materials. Emotion
dysregulation was assessed by the DERS [28] and the DTS
[29]. The DERS assesses how often emotionally dysregulated
behavior occurs. Additional EF tasks were also administered:
the ANT, the CPT [30] to measure response inhibition, the
Digit Span Test [31] to measure WM, and the Trail Making
Test to assess attentional set-shifting and inhibition.
Edel et al. [32] recruited adults with ADHD and nonran-
domly assigned them to mindfulness-based training (MBT,
including elements of DBT) or a skills training group (ST).
The WRI [33] and scales covering the inattention and hyper-
activity/impulsivity symptoms (DSM-IV, [34]) were used for
pre- and postassessment. The WRI is an expert-rated scale
comprising symptom domains such as attentional dicul-
ties, hyperactivity/restlessness, (hot) temper, aective lability,
emotional overreactivity, disorganization, and impulsivity.
General linear models with repeated measures revealed that
both programs resulted in a similar reduction of ADHD
symptoms. The eect sizes were in the small-to-medium
range (ESs ranging from 0.06 to 0.49). However, some degree
of decrease in ADHD symptoms (30%) was more prominent
for the MBT participants since 30.8% of them showed
improvement compared to 11.5% of the ST participants.
Fleming et al. [35] conducted an RCT evaluating DBT
training adapted for college students with ADHD random-
ized to receive either DBT or skills handouts. ADHD symp-
toms, EF, and related outcomes were assessed at baseline,
posttreatment, and 3-month follow-up. Authors used the
BAARS-IV (based on DSM-5 criteria) to assess ADHD
symptoms. Self-report of current symptoms was used as a
primary outcome measure. EF was assessed with the BADDS,
a self-report questionnaire [36] that yields scores on cate-
gories of EF: organization and prioritization, focused and
sustained attention, regulation of alertness and sustained
eort, aect modulation, and WM. Anxiety and depressive
symptoms were assessed with self-report measures of BAI
and BDI-II [36]. The CPT-2 [37] provides assessment of
sustained attention, inhibition, and response variability
[38, 39]. Overall, participants receiving DBT group skills
training showed greater treatment response rates (59-65%
vs. 19-25%) and higher clinical recovery rates (53-59% vs.
6-13%) on ADHD symptoms (ES = 0 84 at follow-up) and
EF (ES = 0 81 at follow-up).
In a similar approach, Cole et al. [40] addressed training
skills by means of cognitive behavioral therapy (CBT) or
DBT. They assessed the benets of the program to reduce
residual symptoms. Patients with ADHD who were poor
responders to medication were enrolled in a one-year pro-
gram where they received individual therapy, associated with
group therapy with dierent modules that included mindful-
ness (along with emotion regulation, interpersonal eective-
ness and distress tolerance, impulsivity/hyperactivity, and
attention). Each subject was assessed at baseline, at 3 and 6
months, and at the end of the treatment for ADHD severity
with the ASRS v1.1, for depression with BDI-II, for hopeless-
ness with the BHS, for anger experience, expression, and con-
trol with STAXI [41], and for impulsivity with BIS-11. The
ADHD patients were compared with ADHD patients on a
waiting list. Overall, the treatment was associated with signif-
icant improvements in almost all dimensions. The most sig-
nicant changes were observed with large to moderate
eect sizes for depression (ES = 084) followed by ADHD
severity (ES = 063) and hopelessness (ES = 0 52).
Morgensterns et al. [42] also used DBT for adults with
ADHD in an outpatient psychiatric context. The treatment
uses elements such as acceptance, mindfulness, functional
behavioral analysis, and psychoeducation to target problems
common in ADHD. Self-rating scales were administered at
baseline before the rst session (T1), posttreatment (T2),
and 3-month follow-up (T3). Self-rating of current ADHD
symptoms was measured by the Current ADHD Symptom
Scale-Self-Report Form [43] that contains three parts: (1)
9Behavioural Neurology
the symptoms for ADHD, (2) impairment in major life areas,
and (3) symptoms of irritability and aggressiveness. More-
over, participants completed self-rating questionnaires for
assessing symptoms of psychiatric comorbidity: the BDI
and the BAI. The main results indicated that approximately
80% of the participants attended at least two-thirds of the ses-
sions. ADHD symptoms (ES = 0 22) and functional impair-
ment (ES = 0 15) in everyday life were reduced. The results
were stable at 3-month follow-up. Variables such as age,
comorbidity, ADHD medication status, and IQ level did
not predict outcomes.
A study from Bueno et al. [44] addresses the impact of
MAP on aective problems and impaired attention. Adults
with ADHD and healthy controls underwent MAP sessions
while similar patients and controls did not undergo the inter-
vention. The authors evaluated MAP-induced changes in
mood and attention using several measures: (1) the ASRS
for symptom assessment, (2) the BDI for attitudes related
to depression, (3) the STAI to describe how people feel at
a particular moment, and (4) the PANAS-X to assess feel-
ings or moods. Combinations of these ratings yield to
higher-order aective levels(positive aect and negative
aect) and lower-order aective levels(fear, sadness, guilt,
etc.). Attention was evaluated using the ANT and the CPT-2,
before and after intervention. The authors found that MAP
enhanced sustained attention (ANT) and detectability on
the CPT-2 and improved the mood of patients and healthy
controls with overall medium eect sizes (g>05) to large
eect sizes (g>08). Because of mixed results regarding the
enhancement of attentional performance (not all attentional
measures were found signicant), the authors call for more
studies that address the ecacy of mindfulness meditation
for ADHD in terms of its impact on EF.
In a recent study, Bachmann et al. [13] evaluated the
impact of MAP on neurocognitive performance in adults
with ADHD. The authors performed a RCT to investigate
WM with an n-back task during fMRI before and after an
8-week mindfulness intervention. ADHD symptoms were
assessed using the self- and observer-rated Conners Adult
ADHD Rating Scales (CAARS). The researchers found a
signicant decrease in ADHD symptoms and signicant
improvement in task performance in both the MAP and
the psychoeducation comparison group post- versus prein-
tervention but did not nd evidence for a signicant main
eect of treatment or a signicant interaction eect on any
ADHD symptoms (self- and observer-rated) nor on task per-
formance (WM). Results also revealed signicant increased
brain activation after MAP in the bilateral inferior parietal
lobule, right posterior insula, and right precuneus. A decrease
in self-rated inattention/memory problemsafter MAP
compared to baseline was associated with stronger activation
in parts of the left putamen, globus pallidus, and thalamus.
Hepark et al. [45] also looked at the ecacy of an
adaptation of mindfulness-based cognitive therapy (MBCT)
on core ADHD symptoms and EF. Adults with ADHD were
randomly allocated to MBCT or waitlist. Outcome measures
included investigator-rated ADHD symptoms, self-reported
ADHD symptoms, EF, depressive and anxiety symptoms,
and patient functioning. Symptoms (total ADHD, inattention,
and hyperactivity/impulsivity scores) were assessed by a
clinician with the CAARS-INV [46] as well as with the
self-report of the CAARS-SR [46]. EF was assessed using
the BRIEF. The BDI-II was used to assess the presence of
depression symptoms. The Dutch version of the STAI [47]
was administered. The ndings indicate that MBCT resulted
in a signicant reduction of ADHD symptoms as assessed
by the investigator or self-reported (Cohensd=078 and
0.64, respectively). Signicant improvements in EF were
also found (Cohensd=093). However, no improvements
were observed for depressive and anxiety symptoms.
Schoenberg et al. [12] looked at the eects of MBCT on
neurophysiological correlates (event-related potentials (ERPs))
of performance monitoring in adults with ADHD. Half of
patients were randomly allocated to MBCT, and the other half
to a waitlist control. Inattention and hyperactivity-impulsivity
ADHD symptoms, psychological distress, and social function-
ing were assessed. Clinical scales (the CAARS-S:SV) were
administered pre- and post-MCBT (or waiting list (WL)). Par-
ticipants also completed a standard visual continuous perfor-
mance task (CPT-X). Examining results for CAARS-S:SV
indicated reduced inattention, hyperactivity/impulsivity,
and global ADHD index symptoms pre to post-MBCT (ESs
ranged between 0.49 and 0.93). As expected, the main eect
of treatment was evident for CPT-X repeated-measures
ANCOVAs comparing accuracy score data indicated that
the number of false alarms (FA) signicantly decreased pre
to post in the MBCT group alongside a signicant slowing
in reaction times.
Gu et al. [48] conducted a clinical trial to assess MBCT
ecacy in the treatment of ADHD in college students.
Undergraduates with ADHD between ages 19 and 24 were
randomized either to receive MBCT or to be put on a waitlist.
ADHD symptoms, neuropsychological performance, and
related outcomes were assessed pre- (T1) and posttreat-
ment (T2), as well as at the 3-month follow-up (T3). Clinical
assessment was conducted with the CAARS-S:SV to assess
the extent of ADHD symptoms. Anxiety and depressive
symptoms were measured with the BAI and the BDI-II. In
addition, academic performance was collected (participants
GPA) using an ocial transcript. The authors tested the par-
ticipantsneuropsychological performance (MAAS) and
attentional networks with the ANT [49]. At follow-up, results
revealed that participants receiving MBCT showed greater
treatment response rates (57%-71% vs. 23%-31%) and symp-
tom reduction (ES = 1 26). Participants also experienced less
anxiety and depression (ES = 0 75 and 0.53, respectively)
than those on the waitlist. Moreover, MBCT participants
showed greater improvement on most neuropsychological
performance and attentional scores (ES for MAAS = 1 30,
ES for ANT subscales ranging from 0.19 to 1.19).
In a recent study, [50] investigated the ecacy of MBCT
+treatment as usual (TAU) versus TAU only in reducing core
symptoms in adults with ADHD. Participants were ran-
domly assigned to MBCT+TAU, an 8-weekly group therapy
including meditation exercises, psychoeducation, and group
discussions, or TAU only, including pharmacotherapy and/
or psychoeducation. Outcomes were ADHD symptoms
rated by blinded clinicians (CAARS-INV) and self-reported
10 Behavioural Neurology
(CAARS-S), EF, mindfulness skills, self-compassion, positive
mental health, and general functioning (see details in
Table 2(c)). Outcomes were assessed at baseline, posttreat-
ment (T1), and 3- and 6-month follow-up (T2 and T3, respec-
tively). In MBCT+TAU patients, a signicant reduction of
clinician-rated ADHD symptoms (CAARS-INV) was found
at posttreatment (T1) (ES = 0 41) and was maintained at the
6-month follow-up. MBCT+TAU patients compared with
TAU patients also reported signicant improvements in
self-reported ADHD symptoms (ES = 0 37, 0.71, and 0.79 at
T1, T2, and T3, respectively), mindfulness skills, self-com-
passion, and positive mental health up to the 6-month
follow-up. Patients in MBCT+TAU reported improvement
in executive functioning (EF) but only at the 6-month
follow-up. A signicant group x time interaction showed that
EF further improved over time in MBCT+TAU compared
with TAU resulting in an eect size of d=049 at the
6-month follow-up. The authors concluded that MBCT
might be a valuable treatment option alongside TAU for
adult ADHD aimed at alleviating symptoms.
3.3. Synthesis of Studies. For convenience, we divided the
above studies (n=13) according to the two main research
designs: within-group (Tables 1(a)1(c)) and between-
group (Tables 2(a)2(c)). Three studies used a within-group
design (with two or more time points) while the remaining
studies used dierent between-group designs (N-RCT, RCT).
All studies, except one [44], did not include a healthy control
group. Follow-up evaluations varied from none to three or
six months.
3.3.1. Participants. The sum of participants with ADHD was
753 with a mean age of 35.1 years (18-65 y/o). About half of
participants were males (47.7%). The combined and inatten-
tive subtypes of ADHD were the most predominant. Most
participants were on medication, with psychostimulants like
methylphenidate (MPH) being the most frequently reported.
Comorbidity was present in all studies, with major depressive
disorders and mood disorders being frequently reported. A
summary of participantscharacteristics is presented in
Tables 1(a) and 2(a).
3.3.2. Intervention. Our denition of MBI intervention
included mindfulness and/or meditation as a principal or a
partial component of the intervention. That included various
adaptations of (1) dialectical behavior therapy (DBT), (2)
mindful awareness program (MAP), and (3) mindfulness-
based/cognitive training (MBT/MBCT). The duration of
treatment varied considerably across studies (from six to
96 hours, mode value of 20 hours). The presence or absence
of homework also accounted for variability between studies.
Therapists included clinical psychologists, psychology gradu-
ate students, mindfulness instructors, practitioners, group
leaders, ADHD researchers, nurses, and psychiatrists. A
summary of intervention characteristics is presented in
Tables 1(b) and 2(b).
3.3.3. Outcomes. Besides the measures of ADHD symptoms
(inattention and hyperactivity), outcome measures can be
categorized into executive/cognitive functioning, emotional
disturbance, quality of life, mindfulness, and grade point
average at school.
(1) ADHD Symptoms. Prior to and following treatment,
researchers used dierent self-rating scales to assess symp-
toms of ADHD. Among the most frequently used self-
report scales were the following:
(1) The ConnersAdult ADHD Rating Scale
(CAARS-SR/CAARS-S:SV) from Conners et al. [46,
51] ([12, 13, 45, 48, 50], n=5)
(2) The Adult ADHD Self-Report Scale (ASRS v1.1)
from Kessler et al. (2005) ([40, 44], n=2)
(3) The Attention-Decit Hyperactivity Disorder Check-
list (ADHD-CL) from DSM-IV (1994) ([14, 32],
n=2)
The complete list of scales is available in Tables 1(c)
and 2(c).
(2) Executive/Cognitive Functioning. As additional measures
of outcomes, the most frequently used tests for executive/-
cognitive functioning were as follows:
(a) Objective tasks
(1) Various versions of Attention Network Test
(ANT) [21, 22, 49] ([11, 25, 44, 48], n=4)
(2) Various versions of the ConnersContinuous
Performance Test (CPT/CPT-2/CPT-X) from
Conners [30, 37] ([12, 25, 35, 44], n=4)
(3) The TMT (n=2)
(4) The Stroop test indicating mental speed and
inhibitory EFs ([11, 14], n=2)
(5) The digit span, vocabulary, memory scale, and
digit symbol subtests from the Wechsler Adult
Intelligence Scale-Revised (WAIS-R) [24, 31]
([11, 14, 25], n=2)
(6) n-back ([13], n=1)
(b) Subjective questionnaire
(1) The Behavior Rating Inventory of Executive
Functioning-Adult Version (BRIEF-A) from
Roth et al. [27] ([25, 45, 50], n=3)
The complete list of outcome measures is available in
Tables 1(c) and 2(c).
(3) Emotion Disturbance. Self-reports of anxiety, depression,
and other emotional disturbances were often assessed using
the following:
(1) The Beck Depression Inventory (BDI/BDI-II/B-
DI-II-NL) from Beck et al. [15] ([11, 14, 35, 40, 42,
44, 45, 48], n=8)
11Behavioural Neurology
(2) The Beck Anxiety Inventory (BAI) from Beck et al.
[20] ([11, 35, 42, 48], n=4)
(3) The State-Trait Anxiety Inventory (STAI) from Van
der Ploeg [47] ([44, 45], n=2)
(4) The Outcome Questionnaire (OQ 45.2) from Lambert
et al. (1996) ([12, 45], n=2)
The complete list of outcome measures is available in
Tables 1(c) and 2(c).
(4) Mindfulness. Mindfulness was assessed using the follow-
ing self-report questionnaires:
(1) The Mindful Attention Awareness Scale (MAAS)
from Brown and Ryan (2003) ([32, 42, 48], n=3)
(2) The Kentucky Inventory of Mindfulness (KIMS)
from Baer et al. (2004) ([12, 40, 45], n=3)
At two occasions, authors used the Five Facet Mindful-
ness Questionnaire (FFMQ) from Baer et al. (2006) ([35,
50], n=2).
(5) Quality of Life and Others. Self-report questionnaires or
semistructured interviews (QFS) were used in most studies
to evaluate the level of functioning and quality of life:
(1) The ADHD Quality of Life Questionnaire (AAQoL)
from Brod et al. (2006) ([35, 42, 44], n=3)
Other less frequently used measures, such as OQ 45.2
(n=2), are listed in Tables 1(c) and 2(c).
3.4. Risk of Bias within and across Studies. After characteriz-
ing each study according to PICO, we then evaluated each
study (n=13) on the seven categories of bias established by
the Cochrane Collaboration. As alluded earlier, this analysis
of bias gives us a useful complement of information besides
the sole calculation of eect sizes. Slight dierences in inter-
pretation of bias were discussed and solved between the
judges (HP, BK, and AM). Assessment of risk of bias was
rated high (red), uncertain (yellow), or low (green) for each
individual study and category (see Figure 2), then compiled
into percentages of studies that fall into high, uncertain, or
low risk on each category of bias (see Figure 3).
3.5. Selection Bias. Only three studies were rated low risk on
that criterion [12, 13, 50]. Four studies (31%) were rated
unclear risk because of insucient data on sequence genera-
tion. The remaining six (46%) studies were rated high risk.
Regarding allocation concealment, the same three studies
were judged as low risk because the occultation of the alloca-
tion sequence could not be predicted. Only one study was
judged as unclear risk because participants would not neces-
sarily identify the group to which they belong (i.e., treatment
or control). The remaining nine (69%) studies did not fulll
either conditions and were considered high risk.
3.6. Performance and Detection Bias. Not surprisingly, the
vast majority of studies (92%) in this review were rated high
risk for performance bias (blinding of participants and of
personnel). Only [50] satised this criterion according to
our interrater judgment. Detection bias reects the blinding
of assessors to the treatment condition. Overall, eleven stud-
ies (85%) were judged as low risk of detection bias (blinding
of assessors), one study as high risk, and one as unclear risk as
it included self-report measures but nonblinded assessors.
3.7. Attrition Bias. According to the application of the 20%
cut-ocriteria, six studies (46%) in this review were consid-
ered low risk of attrition bias. Three studies (23%) were rated
high risk (attrition rate > 20%, high dierential attrition, and
0 0.25 0.5 0.75 1
Other biases (research allegiance, funding, confounds)
Selective outcome reporti ng (reporting bias)
Incomplete outcome data (attrition bias)
Blinding of outcome assessment (detection bias)
Blinding of partici pants and personnel (performance bias)
Allocation concealment (selection bias)
Random sequence generation (selection bias)
Low risk
Unclear risk
High risk
Figure 2: Methodological quality graph: a review of the authorsjudgements about each methodological quality item presented as percentages
across all included studies.
12 Behavioural Neurology
no imputation of missing data). The remaining three studies
had no sucient description of attrition (or impossibility to
compute the attrition rate) and thus were judged as having
unclear risk.
3.8. Reporting Bias. Most of the studies (11/13) were rated
low risk since the outcome data were reported on all used
scales and subscales. Two other studies were rated unclear
risk as subscales were not fully reported.
3.9. Other Biases and Limitations. Overall, eight studies
(62%) were rated low risk, while the ve remaining studies
were judged as unclear risk. More precisely, we could iden-
tify an authors role in the study development and/or imple-
mentation (e.g., delivery of the intervention) in only three
(23%) out of the 13 studies. In four of the studies (31%),
the authors identied a funding source. Other studies were
not funded or did not report the funding source. Other lim-
itations that were reported by the authors of each paper were
included as an additional source of information (in narrative
form) but were not rated (see supplementary materials
(available here)).
After conversion of the high, uncertain, and low risk
scores into numeric variables (0, 1, and 2), we found stud-
iesquality mean scores ranging between 0.71 and 2 (with
2 being the highest quality) for each study. According to
our interrater judgment of quality, Bachmann et al. [13]
and Janssen et al. [50] were the most robust and valid studies
with 1.57/2 and 2/2 overall quality scores, respectively.
In sum, the majority of studies (but [12, 13, 50]) were
considered high risk on selection biases (random sequence
generation, allocation concealment), and all but [50] had a
performance bias (blinding of participants and personnel).
See Figure 3 and supplementary materials.
4. Discussion
4.1. Summary of Evidence. In this systematic review, we
assessed cognitive and behavioral eects observed in 13
studies using MBIs to alleviate ADHD symptoms and to
improve executive function and emotion dysregulation
among adults with ADHD. All the studies (100%) showed
improvement of ADHD symptoms following an MBI.
Researchers have also found a signicant improvement on
cognitive task performance in post- versus preintervention
or with treatment as usual (TAU). For most patients, reduc-
tion of ADHD symptoms was maintained at posttreatment
(3- to 6-month follow-up). In studies addressing other out-
comes, patients reported signicant improvements in mind-
fulness skills, self-compassion, and positive mental health up
to the 6-month follow-up.
Random sequence generation
(selection bias)
Allocation concealment
(selection bias)
Blinding of participants and
personnel (performance bias)
Blinding of outcome assessment
(detection bias)
Incomplete outcome data
(attrition bias)
Selective outcome reporting
(reporting bias)
Other biases (research allegiance,
funding, confounds)
Mean /2
Bachmann et al. (2018) 2 2 021221.57
Bueno et al. (2015) 0 0 0 2 2 2 2 1.14
Cole et al. (2016) 0 0 0 2 2 1 2 1.00
Edel et al. (2017) 0 0 0 012 2 0.71
Fleming et al. (2015) 1 1 0 2 2 2 1 1.29
Gu et al. (2018) 1 0 0 2 2 2 2 1.29
Hepark et al. (2019) 1 0 0 212 2 1.14
Hesslinger et al. (2002) 0 0 0 2 1 2 1 0.86
Jansenn et al. (2019) 2 2 2 222 2 2.00
Mitchell et al. (2017) 1 0 0 1 2 2 1 1.00
Morgensterns et al. (2016) 0 0 0 202 1 0.71
Schoenberg et al. (2014) 2 2 0 2 0 1 2 1.29
Zylowska et al. (2008) 0 0 0 202 1 0.71
High risk
Unclear risk
Low risk
Figure 3: Methodological quality summary: a review of the authorsjudgments about each methodological quality item for each
included study.
13Behavioural Neurology
However, we also found the quality of studies to be vari-
able with a tendency for more recent studies to have less
biases. Notably, [50] was given a perfect score according to
our application of the Cochrane Collaboration standards. A
vast majority of studies were judged as high risk on the per-
formance bias (blinding of participants and personnel), and
several had issues with the selection biases (random sequence
generation, allocation concealment). As mentioned earlier, it
is not habitual, nor always advantageous, to blind personnel
or participants in this type of intervention, so the elevated
risk for performance and/or detection bias may be inevitable.
Attrition bias was found to have high or unclear risk in more
than a half of the studies. The reason for dropout of partici-
pants was not always clearly specied in those studies, so it
is dicult to decide if it might be related to adverse eects
or to some discomfort with treatment or instead to some
incidental reasons.
Despite the above limitations, most studies (except
one) scored well on the detection bias, meaning that the
trainers were not involved in the assessment of the partici-
pants and therefore could not interfere with the outcomes.
Moreover, most studies (except for the two studies being
unclear) were found free of suggestion of selective reporting
(reporting bias).
In sum, most studies show that mindfulness training or
structured programs with mindfulness components appear
useful for patients who respond partially or not at all to drug
therapy. Indeed, group skills training may be ecacious,
acceptable, and feasible for treating ADHD among college
students and adult patients. Mindfulness meditation training
seems to improve ADHD behavioral symptoms (inattention,
hyperactivity, and impulsivity) and some facets of EF and
emotion dysregulation. Although these are promising nd-
ings to support treatment ecacy of MBIs for ADHD, vari-
ous biases such as the absence of randomization and lack of
a control group may aect the importance of outcomes.
Other factors such as those documented in the present study
(see Tables 1 and 2) may also impact on the outcomes. For
example, the amount of home exercise, type of monitoring
of participantsprogress, or absence from sessions may also
aect the outcomes.
5. Conclusions, Future Research,
and Limitations
The aim of this systematic review was to look for symp-
toms and additional indicators of improvement of ADHD
mediated through mindfulness interventions. Each study
measured many outcomes, namely, executive functions,
emotional disturbance, quality of life, and academic perfor-
mance. Some outcomes were considered to be important
(e.g., symptoms), while others were surrogate outcomes
(e.g., attention test). Despite its comprehensiveness, this
review was not without limitations, mostly because of hetero-
geneity of available studies. Although all studies included a
mindfulness-based intervention for ADHD, there was a sub-
stantial variability among them, e.g., dierence in sample size
and duration of intervention. Future studies and potential
meta-analysis should consider these factors.
Appendix
Full Names of Most Frequently Used Outcome
Measures (See Also Tables 1(c)2(c))
ADHD symptoms measures:
(1) ADHD-CL = Attention-Decit Hyperactivity Disor-
der Checklist
(2) ASRS (v1.1) = Adult ADHD Self-Report Scale
(3) BAARS-IV = Barkley Adult ADHD Rating ScaleIV
(4) BADDS = Brown ADD Rating Scales
(5) BIS-11 = 11th version of the Barratt Impulsiveness
Scale
(6) CAARS-INV = investigator rating version of the
ConnersAdult ADHD Rating Scale; CAARS-S: SV =
ConnersAdult ADHD Self-rating Scale; CAARS-
SV = ConnersAdult ADHD Rating ScalesScreening
Version; CAARS- SR = self-report version of the
ConnersAdult ADHD Rating Scale
(7) CADHDSC_SRF = Current ADHD Symptom Scale-
Self-Report Form
(8) DSM-IV (SR/OR) = Diagnostic and Statistical Man-
ual of Mental Disorders, 4th Edition (Self-rating/
Other-rating)
(9) DSM-IV = Diagnost ic and Statistical Manual of Men-
tal Disorders, 4th Edition; SCL-16 = Symptom Check
List
Cognitive/EF measures:
(1) ANT = Attention Network Task
(2) BRIEF-A = Behavior Rating Inventory of Executive
Functioning-Adult Version
(3) BRIEF-ASR = Behavior Rating Inventory of Execu-
tive Function-Adult Self-Report version
(4) CPT-2 = The ConnersContinuous Performance
Test-2nd edition
(5) CPT-X = visu al Continuous Performance Task
(6) d2-Test = selectiv e attention
(7) DEFS = Decits in Executive Functioning Scale
(8) DSS = Digit Symbol Subtest
(9) DST = Digit Span Test (WAIS-R)
(10) KLT = Konzen trations-Leistungs-Test
(11) TMT = Trail Making Test
(12) VOC = Vocabulary subtest (WAIS-R)
(13) WAIS-R = Wechsler Adult Intelligence Scale-Revised
(14) WMS-R = Wec hsler Memory Scale-R
14 Behavioural Neurology
Emotional disturbance measures:
(1) BAI = Beck Anxiety Inventory
(2) BDI = Beck Depression Inventory; BDI-II = Beck
Depression Inventory (2nd edition)
(3) BHS = Beck Hopelessness Scale
(4) DERS = Diculties in Emotion Regulation Scale
(5) PANAS-X = Aect Schedule-Expanded form
(6) PSS = Perceived Stress Scale
(7) STAI = State-Trait Anxiety Inventory
(8) STAXI = State-Trait Anger Expression Inventory
(9) WRI = WenderReimherr Interview
Conflicts of Interest
The authors declare that there is no conict of interest
regarding the publication of this paper.
AuthorsContributions
H.P. conducted the literature search, data analysis, and
data interpretation and wrote the manuscript. A.M. inter-
rated the selection of articles and of analysis of bias and cow-
rote the manuscript. N.T. conducted the literature search
(update), created the gures, and collected the data. B.K. con-
ducted the analysis of bias (interrating) and data interpreta-
tion reviewed the manuscript. J.N. conducted the literature
search (phase 1) and is responsible for the endnote creation.
Acknowledgments
The project was funded by the Fonds de recherche du
Québec-Société et culture (FRQSC).
Supplementary Materials
Full details of analysis of bias for each of individual studies
(n=13). (Supplementary Materials)
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16 Behavioural Neurology
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Introdução: O Transtorno do Déficit de Atenção e Hiperatividade (TDAH) consiste em um transtorno do neurodesenvolvimento classificado pelo DSM-5-TR (APA, 2023) como um padrão persistente de desatenção e/ou hiperatividade-impulsividade que interfere no funcionamento do indivíduo. O TDAH é um transtorno que costuma ser identificado na infância, podendo persistir até a vida adulta. Objetivo: o trabalho objetiva identificar as técnicas de intervenção em adultos com TDAH, baseadas na Terapia Cognitivo-Comportamental (TCC). Metodologia: foram buscadas publicações sobre o tema, nas bases de dados PePSIC (Portal de Periódicos Eletrônicos em Psicologia), ScienceDirect(Scientific Eletronic Library Online - Elsevier Science) e MEDLINE (Medical Literature Analysis and RetrievelSystem Online). Os operadores booleanos utilizados foram AND e OR. O período realizado da pesquisa, contemplou artigo de 2014 a 2023, sendo utilizados os critérios de inclusão: no título e resumo dos artigos encontrados terem os descritores selecionados; artigos de livre acesso; período descrito. Resultados: As intervenções mais encontradas através desta pesquisa estão ligadas as técnicas de psicoeducação, reestruturação cognitiva, técnicas de resolução de problemas e estratégias de enfrentamento. Considerações finais: Este estudo apresenta evidências que corroboram com a eficácia das estratégias psicoterapêuticas no manejo dos sintomas do TDAH em adultos. Especificamente, as intervenções baseadas na abordagem da TCC, em combinação com farmacoterapia, demonstraram ser as mais bem-sucedidas na obtenção de resultados positivos. Além disso, ressalta-se que a psicoterapia não farmacológica quando utilizada em conjunto com o tratamento medicamentoso, pode resultar em uma melhora ainda maior dos sintomas.
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Mindfulness meditation is a form of mental training rooted in ancient wisdom traditions and is focused on cultivating a non-judgmental stance toward present-moment awareness. Here, we synthesize cognitive-behavioral effects in long-term meditators (LTMs) resulting from diverse and prolonged meditation practices. Preliminary evidence suggests that LTMs exhibit increased cognitive-sensory integration and decoupling of affective processes, as demonstrated in enhanced interoceptive awareness, reduced negative affective pain perception, and more rational decision-making. Additionally, LTMs may experience more emotional neutrality, self-boundary dissolution, and less normative self-awareness. Neuroimaging findings include increased bottom-up activation, particularly within the salience network (interoception, pain, affect), and reduced connectivity between the executive (dorsolateral prefrontal cortex) and salience (dorsal anterior cingulate cortex) networks (reduced pain). Research also displayed reduced amygdala activation to fear (reduced negative affect), increased temporoparietal junction activation (pre-reflective experiential processes, empathy), and altered midline default-mode network activation, which is associated with emotional neutrality and pre-reflective experiential processes, such as non-ordinary states of consciousness. Methodological limitations, specifically heterogeneous predictor variables, restrict the interpretation of trait effects, temporal dynamics in cognitive processing, and the unique influences of meditative activities. These limitations indicate the need for a unified research framework and a systematic neurophenomenological investigation of advanced meditation—through the study of unfolding states, stages, and endpoints in meditative development. In summary, LTMs display a distinct neurophenomenological gestalt of mindfulness, wherein meditative expertise is reflected in altered general brain processing, potentially enhanced cognitive integration, increased cognitive flexibility and self-regulation, and heightened non-dual awareness—signifying a potentially important form of embodied cognition.
Article
We explored body‐scan postures suitable for people with attention‐deficit/hyperactivity disorder (ADHD) tendency by developing and validating the Mindfulness Encouraging/Discouraging Reactions Scales (MERS/MDRS), using university students. In Study 1, we conducted a survey to collect typical positive and negative reactions during mindfulness exercises from 21 participants and created the preliminary items. In Study 2, 192 participants completed existing state/trait mindfulness scales and the preliminary MERS and MDRS after mindful breathing. Based on an item response model, we developed and validated MERS and MDRS. In Study 3, 19 participants were categorized into one of four groups: (a) combined, (b) hyperactive/impulsive, (c) inattentive, and (d) without ADHD tendencies. They performed body‐scan meditations with each of the counterbalanced postures (upright, slumped, leaning‐back sitting, and supine), and completed the questionnaires. The analysis showed that those with hyperactivity/impulsivity tendency found the body‐scan meditation a challenge with the slumped posture and easier to perform in the supine posture; the upright posture provided high and low MERS to the hyperactivity/impulsivity tendency group and combined group, respectively; and sleepiness correlated with MERS in the supine posture ( r = .49) and the upright posture ( r = .51). We identified helpful body scan postures for people with ADHD tendency, using MERS and MDRS, but it was noted that these scales were created solely based on intuitive impressions for beginners, and it is not recommended that the items included in them be aimed for or avoided.
Chapter
Understanding the neurophysiology of Yoga and mindfulness, its action, and its impact on addiction and palliative care is the overarching focus of the chapter. Yoga and mindfulness are ancient behavioral practices that conjoin different body organ systems with the mind to have positive health outcomes. The literature has substantive evidence about Yoga and mindfulness as integrative approaches to health and well-being, influencing cognitive, affective, psychiatric problems/stress, immune-endocrine-neurology axis. Thus, this chapter also aims to identify the scope and application of the psycho-neuro-immuno-endocrinological approach in highlighting the neurophysiology of Yoga and mindfulness and its effects on general well-being, mental health, palliative care, and addiction rehabilitation. Possible mechanisms behind the effectiveness of Yoga and mindfulness are mentioned such as neurophysiological processes, neuro visceral integration modal, polyvagal theory, effect on cellular level and epigenetics, and mindfulness as a communication between intention, attention, and attitude. A module of Yoga which can be practiced by all to keep good health and that is also endorsed by government of India is provided for reference.
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Background There is a high need for evidence-based psychosocial treatments for adult attention-deficit hyperactivity disorder (ADHD) to offer alongside treatment as usual (TAU). Mindfulness-based cognitive therapy (MBCT) is a promising psychosocial treatment. This trial investigated the efficacy of MBCT + TAU v. TAU in reducing core symptoms in adults with ADHD. Methods A multicentre, single-blind, randomised controlled trial (ClinicalTrials.gov: NCT02463396). Participants were randomly assigned to MBCT + TAU ( n = 60), an 8-weekly group therapy including meditation exercises, psychoeducation and group discussions, or TAU only ( n = 60), which reflected usual treatment in the Netherlands and included pharmacotherapy and/or psychoeducation. Primary outcome was ADHD symptoms rated by blinded clinicians. Secondary outcomes included self-reported ADHD symptoms, executive functioning, mindfulness skills, self-compassion, positive mental health and general functioning. Outcomes were assessed at baseline, post-treatment, 3- and 6-month follow-up. Post-treatment effects at group and individual level, and follow-up effects were examined. Results In MBCT + TAU patients, a significant reduction of clinician-rated ADHD symptoms was found at post-treatment [ M difference = −3.44 (−5.75, −1.11), p = 0.004, d = 0.41]. This effect was maintained until 6-month follow-up. More MBCT + TAU (27%) than TAU participants (4%) showed a ⩽30% reduction of ADHD symptoms ( p = 0.001). MBCT + TAU patients compared with TAU patients also reported significant improvements in ADHD symptoms, mindfulness skills, self-compassion and positive mental health at post-treatment, which were maintained until 6-month follow-up. Although patients in MBCT + TAU compared with TAU reported no improvement in executive functioning at post-treatment, they did report improvement at 6-month follow-up. Conclusions MBCT might be a valuable treatment option alongside TAU for adult ADHD aimed at alleviating symptoms.
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Patients with Attention-Deficit/Hyperactivity Disorder (ADHD) and obsessive/compulsive disorder (OCD) share problems with sustained attention, and are proposed to share deficits in switching between default mode and task positive networks. The aim of this study was to investigate shared and disorder-specific brain activation abnormalities during sustained attention in the two disorders. Twenty boys with ADHD, 20 boys with OCD and 20 age-matched healthy controls aged between 12 and 18years completed a functional magnetic resonance imaging (fMRI) version of a parametrically modulated sustained attention task with a progressively increasing sustained attention load. Performance and brain activation were compared between groups. Only ADHD patients were impaired in performance. Group by sustained attention load interaction effects showed that OCD patients had disorder-specific middle anterior cingulate underactivation relative to controls and ADHD patients, while ADHD patients showed disorder-specific underactivation in left dorsolateral prefrontal cortex/dorsal inferior frontal gyrus (IFG). ADHD and OCD patients shared left insula/ventral IFG underactivation and increased activation in posterior default mode network relative to controls, but had disorder-specific overactivation in anterior default mode regions, in dorsal anterior cingulate for ADHD and in anterior ventromedial prefrontal cortex for OCD. In sum, ADHD and OCD patients showed mostly disorder-specific patterns of brain abnormalities in both task positive salience/ventral attention networks with lateral frontal deficits in ADHD and middle ACC deficits in OCD, as well as in their deactivation patterns in medial frontal DMN regions. The findings suggest that attention performance in the two disorders is underpinned by disorder-specific activation patterns.
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Objective: Between 2% and 8% of college students meet criteria for ADHD, with increased incidence in recent decades. There are very few clinical trials conducted on the meaningful intervention of ADHD in college. Mindfulness-based cognitive therapy (MBCT) effectively treats college students with ADHD and could be more feasibly applied in college mental health clinics. Method: Fifty-four undergraduates with ADHD between ages 19 and 24 were randomized to receive either MBCT or wait-list (WL) during a 6-week intervention phase. ADHD symptoms, neuropsychological performance, and related outcomes were assessed at pre-treatment, post-treatment, and 3-month follow-up. Results: Participants receiving MBCT group showed greater treatment response rates (57%-71% vs. 23%-31%) and experience less anxiety and depression, and greater levels of mindfulness; MBCT participants show greater improvement on neuropsychological performance. Conclusion: MBCT may be a useful intervention for college students with ADHD, improving participants’ ADHD symptoms, mindfulness, and sustained attention.
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Background: Attention deficit hyperactivity disorder (ADHD) is associated with marked impairments in familial, social, and professional functioning. Although stimulant treatments can be effective in adult ADHD, some patients will respond poorly or not at all to medication. Previous studies demonstrated that cognitive behavioural therapy- (CBT) and dialectical behavior therapy- (DBT) oriented interventions are effective in reducing the burden of the disease, which is mainly marked by depression, interpersonal difficulties, low self-esteem, and low quality of life. In order to determine the effectiveness of this intervention, we assessed the benefits of a CBT/DBT programme to reduce residual symptoms and help patients improve their quality of life. Subjects and methods: 49 ADHD-patients, poor responders to medication, were enrolled in a one-year programme where they received individual therapy, associated with weekly sessions of group therapy with different modules: Mindfulness, Emotion Regulation, Interpersonal Effectiveness and Distress Tolerance, Impulsivity/Hyperactivity and Attention. Each subject was assessed at baseline, at months 3 and 6, and at the end of the treatment for ADHD severity (ASRS v1.1), depression severity (BDI-II), hopelessness (BHS), mindfulness skills (KIMS), anger expression and control (STAXI), impulsivity (BIS-11), quality of life (WHOQOL-BREF), and social functioning (QFS). The 49 ADHD patients were compared with 13 ADHD subjects on a waiting list. Linear mixed models were used to measure response to treatment. Results: Overall, the psychotherapeutic treatment was associated with significant improvements in almost all dimensions. The most significant changes were observed for BDI-II (b=-0.30; p<0.0001), ASRS total score (b=-0.16; p<0.0001), and KIMS AwA (b=0.21; p<0.0001), with moderate to large effect sizes. Compared with the waiting list controls, ADHD patients showed a better, albeit non-significant, pattern of response. Conclusions: Individual and structured psycho-educational DBT/CBT groups support existing data suggesting that a structured psychotherapeutic approach is useful for patients who respond partially or not at all to drug therapy.
Article
Given recent attention to emotion regulation as a potentially unifying function of diverse symptom presentations, there is a need for comprehensive measures that adequately assess difficulties in emotion regulation among adults. This paper (a) proposes an integrative conceptualization of emotion regulation as involving not just the modulation of emotional arousal, but also the awareness, understanding, and acceptance of emotions, and the ability to act in desired ways regardless of emotional state; and (b) begins to explore the factor structure and psychometric properties of a new measure, the Difficulties in Emotion Regulation Scale (DERS). Two samples of undergraduate students completed questionnaire packets. Preliminary findings suggest that the DERS has high internal consistency, good test–retest reliability, and adequate construct and predictive validity.
Article
Adult attention-deficit/hyperactivity disorder (ADHD) is a serious mental disorder associated with impaired neurocognitive performance related to working memory function. Recent clinical trials have suggested that mindfulness is a promising intervention in adults with ADHD. We performed a randomised controlled clinical trial to investigate working memory (WM) with an n-back task in adults with ADHD during fMRI before and after an 8-week mindfulness intervention (MAP) compared with psychoeducation (PE). ADHD symptoms were assessed using the self- and observer-rated Conners Adult ADHD Rating Scales (CAARS). The complete pre-post data of 21 MAP and 19 PE participants were analysed. We found no group difference in ADHD symptoms or task performance at the pre-measurement, but there was a significant decrease in ADHD symptoms and significant improvement in task performance in both groups at the post-measurement. Furthermore, we found a significant increase in task-related activation in the right parietal lobe, with no difference between groups. Exploratory two-sample paired t-tests revealed significant increased brain activation after MAP in the bilateral inferior parietal lobule, right posterior insula and right precuneus. A decrease in self-rated 'Inattention/Memory Problems' after MAP compared to baseline was associated with stronger activation in parts of the left putamen, globus pallidus and thalamus.