By Nancy J. Selfridge, MD, and Gretchen LeFever Watson, PhD
Dr. Selfridge is Professor, Clinical Foundations Department, Ross University School of Medicine, Barbados, West Indies
Dr. Gretchen Watson is Associate Professor, Clinical Foundations Department, Ross University School of Medicine, Barbados, West Indies, and President, Safety & Leadership Solutions, Norfolk, VA
Dr. Selfridge and Dr. Watson report no financial relationships relevant to this field of study.
EXECUTIVE SUMMARY
• Attention deficit hyperactivity disorder (ADHD) exacts a significant toll on patients and their families, causing disruption of function and relationships at work and school. The economic burden of ADHD and costs related to decreased productivity are significant.
• The current standard of care consists of behavioral interventions and stimulant medication; however, symptoms often are recalcitrant to these therapies and medication treatment has significant potential for undesirable effects.
• Functional neuroimaging studies support the premise that functional connectivity abnormalities in ADHD brains may be targeted directly and improved by mindfulness and meditation interventions.
• A variety of mindfulness and meditation interventions appear to be effective for improving ADHD symptoms of inattention and hyperactivity/impulsivity for adult and pediatric patients.
Attention deficit hyperactivity disorder (ADHD) has an estimated prevalence in the United States of 9.4% in children and 4.4% in adults.1 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition requires that a child, adolescent, or adult with ADHD demonstrates a persistent pattern of inattention and/or hyperactivity/impulsivity that is significantly disruptive, interferes with normal functioning, and is inappropriate for the individual’s stage of development.2 The standard-of-care treatment for both pediatric and adult patients consists of behavioral and psychotherapeutic interventions first (including interventions for parents/family of children with ADHD), followed by medication treatment when behavioral interventions fail to adequately improve symptoms and function.3 An estimated 64% of children diagnosed with ADHD are prescribed medication for the condition, usually amphetamine-class stimulants or methylphenidate. Adult use of ADHD psychostimulant medication continues to rise.4 Both adults and children with ADHD diagnoses also may have coexisting conditions: depression, anxiety, learning disabilities, and conduct disorders are common. Untreated ADHD symptoms and coexisting conditions commonly interfere with school, learning, relationships, and work. Thus, the disorder exacts a large toll on individual patients, their families, and the healthcare system in general. The economic impact of child and adult ADHD in the United States has been estimated to range from $146 billion to $266 billion in “excess costs.” Those costs are associated with the healthcare, educational, and judicial systems and are related to losses at work via productivity and income.5
Pathophysiology and Basic Science Research
Approximately one in five patients diagnosed with ADHD in childhood continues to have symptoms into adulthood. Thus, the natural history of the disorder suggests that central nervous system maturation processes mitigate symptoms in most patients. Modern neuroimaging technologies provide some insight into the neuropathophysiology of ADHD. No single anatomical area appears responsible for the ADHD symptom complex. Instead, neuroimaging research consistently demonstrates impaired functional activity and connectivity between several cortical and subcortical brain regions and networks. There are individual differences in these functional neuroimaging findings among ADHD patients, with some patients demonstrating greater cortical dysfunction and some demonstrating greater subcortical dysfunction, helping to explain varying clinical presentations and coexisting conditions.6-8
See Table 1 for a comparison of brain areas and networks that appear to be commonly affected in ADHD and their known or hypothesized functions.6-9 Psychostimulants prescribed for ADHD increase central dopamine and norepinephrine, targeting executive and attentional functioning, and presumably altering activity in associated brain regions and networks. However, these medications have potential for significant adverse effects, for addiction if misused, and for diversion for nonmedical purposes. Recent Cochrane reviews of amphetamine and methylphenidate for ADHD concluded that the risk of adverse effects is significant and evidence for effectiveness is weak, primarily caused by methodologic flaws in existing studies and a lack of robust, randomized, double-blind, placebo-controlled studies.10,11 It can be argued that the ideal treatment for ADHD — one that has strong evidence of efficacy and low or no risk of harm — has yet to be discovered. Further, since brain maturation alone seems to resolve ADHD manifestations for most individuals, is there a way to harness the brain’s innate capacity for neuroplasticity with interventions and practices that kindle natural maturational processes?
Table 1. Brain Networks, Function, and Dysfunction in ADHD |
|||
|
Network |
Anatomic Regions |
Known/Hypothesized Function |
Changes in ADHD |
|
Central Executive Network (CEN) |
Frontoparietal, dorsolateral PFC |
Organization and planning, value-based decision making |
Hypoactive, decreased functional connections to SN and DMN |
|
Ventral Attention Network (VAN) |
Temporoparietal junction, supramarginal gyrus, frontal operculum, anterior insula |
Directing attention to salient stimuli, excluding irrelevant stimuli and background noise |
Hypoactive |
|
Dorsal Attention Network (DAN) |
Interparietal sulcus, frontal eye field |
Selecting external stimuli that are compatible with personal goals and experience |
Overactive |
|
Default Mode Network (DMN) |
Anterior medial PFC, posterior cingulate cortex, dorsomedial PFC subsystem, medial temporal lobe subsystem |
Daydreaming, mind wandering, contemplating, reflecting on oneself; deactivates when engaging in a task |
Persistently overactive, inability to “switch off”, decreased functional connections to DMN/CEN |
|
Salience Network (SN) |
Anterior insula, dorsal anterior cingulate cortex, amygdala, ventral striatum, substantia nigra/ventral tegmentum |
Selecting stimuli deserving of attentional focus and coordinating neural responses to them; modulating switch between DMN and CEN |
Decreased functional connections to DMN/CEN |
|
Reward System |
Striatum, anterior cingulate cortex and orbitofrontal cortex, dorsolateral prefrontal cortex |
Reward anticipation and processing, balancing short-term rewards with risks and long-term goals |
Exaggerated neuro-functional activity in response to negative and positive emotional and reward stimuli |
|
ADHD: attention deficit hyperactivity disorder; PFC: prefrontal cortex |
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When behavioral interventions work to manage ADHD symptoms, it is likely that at least part of their efficacy is due to therapeutic effects on neural functioning. Starting with the seminal functional magnetic resonance imaging (MRI) research of Richard Davidson, PhD, at University of Wisconsin,12 mindfulness-based and other meditation practices have been shown to alter function in some of the same regions and neural networks affected by ADHD. These functional changes include increased metabolism, blood flow to prefrontal areas, increased mass in areas involved in attention switching and perception of bodily state, increased metabolic rate in frontal and parietal circuits associated with attention, increased activity in the prefrontal executive (dorsolateral prefrontal cortex) and anterior cingulate attentional circuits, and increased cohesiveness of brain electrical activity. The default mode network (DMN) and central executive network (CEN) appear to be important both in ADHD-related pathogenesis (see Table 1) and in brain changes associated with meditation practice. DMN activity typically is increased when one’s brain is in a “resting” state and has no specific task to perform. Activation of the DMN is typified by mind-wandering or daydreaming, and activity can be “switched off” rapidly when an individual needs to attend to a specific task or object. In ADHD, DMN activity tends to be increased at baseline and does not switch off and on rapidly and readily in response to external attentional demands. The CEN is involved in connections between the DMN and the CEN and facilitates the rapid switches from “resting” to attentively focused states as needed. Meditation studies in normal and ADHD subjects suggest that functional activity within the DMN and CEN decrease and increase respectively, and connections between the DMN and CEN increase both in active meditation (state) and as long-term consequences of meditation practice (trait), precisely the opposite of the activity changes associated with ADHD.13-18 EEG changes associated with ADHD include abnormal ratios of theta, beta, and alpha waveform activity, as well as decreased coherence of specific waveform frequencies across brain regions.19 Again, meditation practices in normal subjects appear to move brainwave activity and coherence in directions opposite to those observed in ADHD-diagnosed individuals. Thus, meditation interventions, which typically are low-cost and low-risk, may be entirely rational for addressing ADHD symptoms.
Clinical Studies on Mindfulness and Meditation Practices for ADHD
A 2010 Cochrane systematic review included four studies of meditation-type interventions for childhood ADHD, two of which were doctorate dissertations from 1984 and 1987. The authors included two peer-reviewed, published studies in their review and determined that the quality of evidence was “very low” according to the GRADE classification. In addition, there was insufficient evidence to draw conclusions about the effectiveness (or risk of side effects) of meditation as an intervention for ADHD.20
Zhang et al conducted a 2018 meta-analysis of randomized, controlled trials of mindfulness and meditation-based interventions for ADHD in children/adolescents (six studies between 2004 and 2017) and adults (six studies between 2015 and 2018). Effect sizes of the interventions were determined from pooled data for the primary outcome of ADHD core symptoms of inattention plus hyperactivity/impulsivity reported together and on inattention and hyperactivity/impulsivity when reported separately. When only inattention or impulsivity/hyperactivity were the reported outcomes, these were used as the primary outcome. The analyses demonstrated statistically significant effect sizes for the interventions for reducing ADHD symptoms compared to controls.21 (See Table 2.)
Table 2. Comparison of Effect Sizes for Heterogeneous Trials of Mindfulness/ Meditation Practices for ADHD in Children/Adolescents and Adults |
||
|
Children/Adolescents |
Study Author |
Hedge's g (effect size), 95% CI, |
|
Jensen (2004) |
-0.23; -1.11 to 0.64; |
|
|
Haffner (2006) |
-0.74; -1.64 to 0.16; |
|
|
Kim (2014) |
-1.02; -1.91 to -0.12; |
|
|
Sidhu (2015) |
-0.44; -1.05 to 0.38; |
|
|
Gershy (2017) |
-0.10; -0.62 to 0.42; |
|
|
Lo (2017) |
-0.54; -0.94 to -0.14; |
|
|
Pooled Data Analysis |
-0.44; -0.69 to -0.19; |
|
|
Adults |
Fleming (2015) |
-0.46; -1.13 to 0.22; |
|
Mitchell (2017) |
-1.95; -2.99 to -0.92; |
|
|
Petterson (2017) |
-0.78; -1.50 to -0.06; |
|
|
Hoxhaj (2018) |
0.24; -0.19 to 0.67; |
|
|
Janssen (2018) |
-0.26; -0.62 to 0.09; |
|
|
Gu (2018) |
-1.28; -1.86 to -0.70; |
|
|
Pooled Data Analysis |
-0.66; -1.21 to -0.11; |
|
|
CI: confidence interval |
||
In 2017, Evans et al conducted a systematic review of a wider range of studies of meditation-based interventions for children with ADHD. This review of 16 studies included various study designs (one RCT, case studies, single-arm studies, and various active, inactive, and waitlist controls) and interventions (meditation, yoga, mindfulness martial arts, and other mindfulness-based programs). They measured and compared effect sizes, which were found to be significant for improving ADHD core symptoms. However, the overall risk of bias in all studies was deemed serious to critical because of methodologic flaws, including uncontrolled single-arm studies, small sample sizes, use on non-validated measures, lack of blinding, selection bias, and failure to account for subject attrition and missing data.22
In 2019, Poissant et al published a review and meta-analysis that included four of the adult trials reviewed by Zhang et al. Again, mindfulness-based interventions appeared to be beneficial for reducing ADHD symptoms in adults with significant effect sizes for most studies.23 However, all but one study (Janssen et al; 201824) had significant risk of bias due to flawed study design.
Details from the study by Janssen et al are discussed here because of their unique standing among the current literature as a well-powered, multicenter, single-blind, RCT of mindfulness-based cognitive therapy (MBCT) for adult ADHD that included follow-up assessments. The intervention group received MBCT (eight 2.5-hour weekly sessions including sitting meditation, body scan, and mindful movement; a six-hour silent retreat; psychoeducation, cognitive behavioral therapy [CBT] techniques and group discussions; and treatment as usual [TAU]). Control group subjects received TAU only, inclusive of medication and behavioral support. A clinician blinded to subject allocation administered the Conners’ Adult ADHD Rating Scale (CAARS) at baseline and post-treatment to assess the effect of the intervention on ADHD symptoms overall and subset symptoms of inattention and hyperactivity/impulsivity as a primary outcome. Secondary outcomes were obtained by self-report during the post-treatment follow-up intervals using CAARS and additional validated instruments to measure executive function, mindfulness skills, positive mental health, self-compassion, and general functioning. A significant reduction in clinician-rated ADHD symptoms was noted post-treatment in this study in MBCT and TAU subjects (mean difference, -3.44; 95% confidence interval, -5.75 to -1.11; P = 0.004; d = 0.41), and this effect was maintained at six months’ follow-up. MBCT and TAU patients also demonstrated more improvements in secondary outcomes compared to TAU controls, both post-treatment and at six months’ follow-up.
Aadil et al published a narrative review of 16 MBCT interventions for adult ADHD. 25 Although they stated that the 12 most recent studies (2012-2017) all demonstrated small to significant symptom reductions, there were no statistical analyses included in the review for evaluating and comparing effect sizes in these studies. Of note, three of the six RCTs in the meta-analysis by Zhang et al were included in the review by Aadil et al.
Other reviewers of existing published mindfulness/meditation interventions for ADHD for adults and children, with or without other adjunctive therapies, have arrived at similar conclusions.26-29
Conclusion and Recommendations
Few controlled trials of the effects of mindfulness and meditation interventions for ADHD in children and adult populations have been published since the Cochrane review in 2010. Of the published trials, the prevailing outcomes suggest that mindfulness practices and meditation are effective interventions for ADHD and result in symptom improvement, although all studies to date are hampered by methodological weaknesses resulting in significant risk of bias. Further, study interventions are quite heterogeneous (e.g., incorporating elements of mindfulness or meditation with cognitive behavioral therapy, yoga, martial arts, or parent and family therapy), making it difficult to discern the contribution of the mindfulness-based/meditation interventions to treatment effect. The neural correlates of the ADHD symptom complex and the neurobiology of a meditation practice suggest that the latter may be a functional “antidote” for the brain network dysfunctions associated with ADHD symptoms.
Well-constructed, methodologically robust controlled trials that demonstrate statistically and clinically significant effectiveness are needed before meditation practices can be considered standard care. Though the expense of mindfulness-based courses may be limiting for some individuals, MBCT is covered by most insurance plans that include mental health and group therapy benefits. Further, several popular free or low-cost mindfulness and meditation digital applications teach basic principles and help guide a beginner’s practice. Whilst awaiting evidence from additional clinical studies, mindfulness and meditation interventions for ADHD (especially MBCT) can be endorsed for ADHD patients and their families who are interested and motivated, based on treatment potential, low risk, and demonstrated salubrious effects on mental health and well-being.
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- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. American Psychiatric Association: Arlington, VA; 2013.
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- Poissant H, Mendrek A, Talbot N, et al. Behavioral and cognitive impacts of mindfulness-based interventions on adults with attention-deficit hyperactivity disorder: A systematic review. Behav Neurol 2019;2019:5682050.
- Janssen L, Kan CC, Carpentier PJ, et al. Mindfulness-based cognitive therapy v. treatment as usual in adults with ADHD: A multicentre, single-blinded, randomised controlled trial. Psychol Med 2018;49:55-65.
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The current standard of care consists of behavioral interventions and stimulant medication; however, symptoms often are recalcitrant to these therapies and medication treatment has significant potential for undesirable effects. Functional neuroimaging studies support the premise that functional connectivity abnormalities in attention deficit hyperactivity disorder brains may be targeted directly and improved by mindfulness and meditation interventions.
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