A Pilot Trial of Mindfulness Meditation Training for ADHD in Adulthood: Impact on Core Symptoms, Executive Functioning, and Emotion Dysregulation

A Blended Intervention Targeting Emotion Dysregulation in Adults With Attention-Deficit/Hyperactivity Disorder: Development and Feasibility Study

BACKGROUND

Many adults with attention-deficit/hyperactivity disorder (ADHD) experience difficulties related to emotion regulation. Such difficulties are known to substantially impact quality of life and overall functioning. Yet, there is a lack of treatment interventions specifically designed to address these challenges.

OBJECTIVE

This study aimed to describe the development and assess the feasibility, along with the initial clinical outcomes, of a novel blended intervention for adults with ADHD. The blended intervention combines both face-to-face and digital components and is specifically designed to address emotion dysregulation in ADHD.

METHODS

This intervention was an 8-week blended intervention combining weekly face-to-face group sessions with a supplementary digital companion app. The intervention is based on elements from dialectic behavioral therapy skills training and positive psychology. To evaluate its feasibility, we performed a 10-week feasibility study with an uncontrolled pre-post study design, including 16 adults with ADHD and co-occurring emotion dysregulation. The feasibility measures encompassed adherence, satisfaction, and perceived credibility of the intervention. Clinical outcomes were evaluated by self-reported symptoms of emotion dysregulation, inattention, hyperactivity-impulsivity, executive function, depression, anxiety, and a measure of quality of life. Paired sample 2-tailed t tests were used to analyze clinical outcomes with a Bonferroni-corrected significance level.

RESULTS

Both treatment credibility and treatment satisfaction were rated favorably by the majority of the participants. In particular, the participants emphasized meeting others with ADHD as beneficial. In terms of adherence, 3 participants withdrew before initiating the intervention, while another 4 participants did not complete the intervention. On average, the participants who enrolled in the intervention attended 6.2 of the 8 group sessions and completed 6.7 of the 8 skills training modules in the companion app. In terms of clinical outcomes, there was a reduction in symptoms of emotion dysregulation from before to after the intervention (d=2.0). Significant improvements were also observed in measures of inattention (d=1.1) and hyperactivity-impulsivity (d=0.9). However, no significant improvements were found in the domains of depression, anxiety, quality of life, and executive functioning.

CONCLUSIONS

The results are encouraging, both in terms of feasibility and the preliminary clinical results on emotion dysregulation. The blended format, combining digital and face-to-face elements, may also seem to offer some advantages: the group-based format was valued as it facilitated peer interaction, while a rather high completion of modules in the companion app highlights its potential to enhance skills training between the group sessions. Future randomized controlled trials are called for to further evaluate the clinical effectiveness of the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05644028; https://clinicaltrials.gov/study/NCT05644028.

A review of recent treatments for adults living with attention-deficit/hyperactivity disorder

Background

Attention-deficit/hyperactivity disorder (ADHD) is a neuro-developmental disorder prevalent among children and adults. Adults living with ADHD can experience significant distress affecting their daily functioning on emotional, physical, interpersonal, familial and financial levels. Intervention programmes may be a way to mitigate these challenges.

Aim

This review identified good evidence-based intervention studies for adults with ADHD and described the usefulness of these interventions.

Method

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, articles were searched from 2009 to 2019 across four medical- and psychological-focused electronic databases using EBSCOhost. All articles selected for the review's thematic meta-synthesis were appraised by attaining a threshold score of at least 61%, using the Smith-Franciscus-Swartbooi appraisal tool. Two autonomous reviewers engaged in the review process. The study adhered to all ethical principles pertaining to systematic review practice.

Results

Forty studies were identified for summation, including pharmacological, non-pharmacological and neuro-stimulation approaches. Most interventions used a multimodal approach. Results indicated the most effective stimulant and non-stimulant as methylphenidate and atomoxetine, respectively. Effective non-pharmacological approaches to treatment were identified as cognitive-behavioural treatment, mindfulness-based approaches, psycho-education and dialectical-focused therapies. Bright light treatment and neurofeedback were reported as the most efficacious neuro-stimulatory methods.

Conclusion

Pharmacological and non-pharmacological approaches, as well as neuro-stimulation or a blend of these approaches were acknowledged as the most effective recent modalities in the treatment of adult ADHD.

Contribution

This review reported on the most current approaches to treat adult ADHD. This will facilitate a better understanding and informed decisions with regard to dealing with adult ADHD.

Digital Cognitive Training for Children with Attention Deficit Hyperactivity Disorder

The present article used a pilot study to determine the effectiveness of digital cognitive mindfulness training developed based on dialectical behavioral therapy (DBT) in reducing attention deficit hyperactivity disorder (ADHD) symptoms in children. The sample consisted of 90 children (8-10 years old) diagnosed with ADHD. The participants were randomized into two groups: an experimental group (n = 45) and a control group (n = 45). Results were assessed at three time points: before, after the study, and one month after the end of the study. Regarding ADHD symptoms, the ANCOVA results showed that there were no statistically significant differences between the study groups for inattention and hyperactivity/impulsivity after testing. One month after completion of the program, there was a significant alleviation in symptoms of inattention, executive functioning, learning problems, aggression, and peer relationships. Hyperactivity was the only variable that showed a decrease both post-test and during follow-up. These results suggest that a DBT-based mindfulness program is a promising method of reducing ADHD symptoms in children.

Inflammation and emotion regulation: a narrative review of evidence and mechanisms in emotion dysregulation disorders

Emotion dysregulation (ED) describes a difficulty with the modulation of which emotions are felt, as well as when and how these emotions are experienced or expressed. It is a focal overarching symptom in many severe and prevalent neuropsychiatric diseases, including bipolar disorders (BD), attention deficit/hyperactivity disorder (ADHD), and borderline personality disorder (BPD). In all these disorders, ED can manifest through symptoms of depression, anxiety, or affective lability. Considering the many symptomatic similarities between BD, ADHD, and BPD, a transdiagnostic approach is a promising lens of investigation. Mounting evidence supports the role of peripheral inflammatory markers and stress in the multifactorial aetiology and physiopathology of BD, ADHD, and BPD. Of note, neural circuits that regulate emotions appear particularly vulnerable to inflammatory insults and peripheral inflammation, which can impact the neuroimmune milieu of the central nervous system. Thus far, few studies have examined the link between ED and inflammation in BD, ADHD, and BPD. To our knowledge, no specific work has provided a critical comparison of the results from these disorders. To fill this gap in the literature, we review the known associations and mechanisms linking ED and inflammation in general, and clinically, in BD, ADHD, and BD. Our narrative review begins with an examination of the routes linking ED and inflammation, followed by a discussion of disorder-specific results accounting for methodological limitations and relevant confounding factors. Finally, we critically discuss both correspondences and discrepancies in the results and comment on potential vulnerability markers and promising therapeutic interventions.

A Scoping Review of Factors Associated With Emotional Dysregulation in Adults With ADHD

OBJECTIVE

Emotion dysregulation is frequently seen in adults with ADHD and is associated with many adverse outcomes. We conducted a scoping review of factors associated with emotion dysregulation in adults with ADHD.

METHOD

PubMed and PsycInfo (EBSCO) were searched. Articles were included if they measured ADHD, emotional dysregulation or some aspect of emotional dysregulation, and at least one other construct. Studies examining physiological underpinnings as well as clinical trials examining the effect of ADHD medications on emotional dysregulation were excluded because recent reviews have already examined these topics.

RESULTS

Thirty-five studies were included in the review. Factors such as biological sex, comorbidities, attachment style, using certain emotional regulation strategies, and ADHD subtype tend to be related to emotion dysregulation.

CONCLUSION

Clinicians working with adults with ADHD can collect information on these factors to better understand risk for emotion dysregulation, and emotion regulation skills may be one area for intervention.

Dysmenorrhea and psychological wellbeing among females with attention deficit hyperactivity disorder

Although rarely examined together, ADHD, emotional regulation (ER), and dysmenorrhea may be associated, which could create additive burdens on psychological well-being (PWB). Clinicians working with ADHD populations may need to take these challenges into consideration to maximize treatment outcomes. This study investigated the relationships among ADHD, dysmenorrhea, ER, and PWB within a sample of 266 adult females with a self-reported ADHD diagnosis. ADHD symptom severity was positively correlated with dysmenorrhea severity, but ER skills were not a significant moderator of this relationship. ADHD symptom severity was negatively correlated with PWB; however, this relationship was not moderated by dysmenorrhea severity nor ER ability. Overall, a positive association between ADHD symptom severity and dysmenorrhea severity was found in our sample. Further research is needed to understand the nature of this association, as well as factors that may contribute to PWB among individuals with these comorbid conditions.

The Effect of Meditation-Based Mind-Body Interventions on Symptoms and Executive Function in People With ADHD: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

This study aims to perform a systematic review and meta-analysis of the effect of MBIs (Mindfulness, Tai Chi, Yoga, and Qigong) on symptoms and executive function (EF) in ADHD.

METHOD

PubMed, Web of Science, the Cochrane Library, PsycINFO, CINAHL, Embase, and CNKI databases were searched to collect randomized controlled trials (RCTs) on the effects of MBIs on symptoms and EF in ADHD. Data extraction and methodological quality evaluation were conducted by two researchers, and a meta-analysis was conducted by Stata SE.

RESULTS

The pooled meta-analyses of MBIs revealed a positive and small effect on inattention (g = -0.26), hyperactivity/impulsivity (g = -0.19), and EF (g = -0.35).

CONCLUSION

Results suggest that MBIs have a significant improvement relative to the control condition. Although some results show that symptoms are affected by age, interventions, and total time of moderators, while EF is not affected by age and measurement, it needs to be supported by more research evidence. (J. of Att. Dis. XXXX; XX(X) XX-XX).

Near and Far Transfer Effects of Computerized Progressive Attention Training (CPAT) Versus Mindfulness Based Stress Reduction (MBSR) Practice Among Adults With ADHD

OBJECTIVE

The present study evaluated the near (attention) and far (reading, ADHD symptoms, learning, and quality of life) transfer effects of a Computerized Progressive Attention Training (CPAT) versus Mindfulness Based Stress Reduction (MBSR) practice among adults with ADHD compared to a passive group.

METHOD

Fifty-four adults participated in a non-fully randomized controlled trial. Participants in the intervention groups completed eight 2-hr weekly training sessions. Outcomes were assessed before, immediately after, and 4 months post-intervention, using objective tools: attention tests, eye-tracker, and subjective questionnaires.

RESULTS

Both interventions showed near-transfer to various attention functions. The CPAT produced far-transfer effects to reading, ADHD symptoms, and learning while the MBSR improved the self-perceived quality of life. At follow-up, all improvements except for ADHD symptoms were preserved in the CPAT group. The MBSR group showed mixed preservations.

CONCLUSION

Both interventions have beneficial effects, however only the CPAT group exhibited improvements compared to the passive group.

Effects and feasibility of psychological interventions to reduce inattention symptoms in adults with ADHD: a systematic review

BACKGROUND

Adult ADHD is common, highly comorbid, and restricts daily functioning. However, only a minority of patients receive appropriate treatment.

AIMS

Primary objective: To identify psychological interventions that diminish inattention symptoms in adults with ADHD. Secondary objective: To evaluate feasibility aspects.

METHODS

A search in PubMed, Cochrane Library, PsycInfo, PSYNDEX, and Eric was conducted. Interventions were grouped in: ADHD coaching, neuro feedback, cognitive training, psychoeducation, and behavioral therapy. Inattention symptoms were evaluated using standardized mean differences. Study quality was rated with the Cochrane Risk of Bias tool. Feasibility was assessed by number and time of sessions, setting, and qualification of the provider.

RESULTS

A total of N = 2229 results were identified, 19 randomized controlled studies were included in the analysis. Behavioral therapy showed effects on inattention symptoms [SMD: 0.44-1.71] when compared to inactive controls. In terms of feasibility, longer interventions did not outperform shorter ones and individual sessions were not superior to group sessions. No effects were given for neuro feedback, cognitive training, and psychoeducation in comparison to controls.

CONCLUSION

For adults with ADHD behavioral therapy seems an effective intervention to reduce inattention symptoms. In terms of feasibility, brief interventions may be valuable for a primary care setting.

Evidence of emotion dysregulation as a core symptom of adult ADHD: A systematic review

Attention Deficit Hyperactivity Disorder (ADHD) is a developmental disorder, with an onset in childhood, that accompanies the person throughout their life, with prevalence between 3 and 5% in adults. Recent studies point towards a fourth core symptom of the disorder related to the emotional information processing that would explain the repercussions that ADHD has on the social, academic, and professional life of the people affected. This review aims to describe emotion dysregulation features as well as the brain activity associated in adults with ADHD. A search of the scientific literature was launched in specialized databases: PsycInfo, Medline, Eric, PsycArticle, Psicodoc and Scopus, following PRISMA guidelines. Twenty-two articles met the inclusion criteria: (a) an ADHD clinical diagnosis, (b) participants over 18 years old, (c) emotion regulation measurement, (d) empirical studies, and (c) in English. Due to the heterogeneity of the studies included, they were classified into three sections: measures and features of emotion regulation (ER) in people with ADHD, neurological and psychophysiological activity related to ER, and treatments. The studies found that meet the selection criteria are scarce and very heterogeneous both in aims and in sample features. Adults with ADHD show a more frequent use of non-adaptive emotion regulation strategies compared to people without ADHD symptoms. Moreover, emotion dysregulation was associated with symptom severity, executive functioning, psychiatric comorbidities, and even with criminal conviction. Different patterns of brain activity were observed when people with and without ADHD were compared. These results may suggest that psychopharmacological treatments as well as behavioral therapies could be useful tools for improving emotional difficulties in adult ADHD.

Group-based emotion regulation skills training for adults with ADHD: A feasibility study in an outpatient psychiatric setting

The aim of this open non-controlled clinical trial was to investigate the feasibility and preliminary treatment effects of a new group-based skills training program for adult ADHD: Group Therapy for Improving Emotional Acceptance and Regulatory Skills in Adults with ADHD (GEARS). Out of the 226 allocated patients, 213 initiated the treatment and 170 (80%) were considered treatment completers (i.e., attending at least 9 out of 14 sessions). A total of 158 of the completers also completed pre- and post-treatment assessments, and 126 provided assessments at the 3-month follow-up. Treatment credibility received high ratings, as did treatment satisfaction. Preliminary treatment effects showed significant improvements in emotion regulation with large effect sizes. Significant effects were also found for all secondary outcome variables: ADHD symptom levels, depression, anxiety, and quality of life. All significant effects remained at the 3-month follow-up. In conclusion, GEARS should be considered a feasible treatment in an outpatient psychiatric setting. The results also indicate that GEARS could be an effective treatment for adults with ADHD who are also experiencing problems with emotion regulation. However, a randomized controlled trial is needed to further evaluate the effectiveness of this new treatment.

Mindfulness Interventions for Attention Deficit Hyperactivity Disorder: A Systematic Review and Meta-Analysis

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition impacting children and adults. Current treatments are limited and there is increasing interest in the use of mindfulness, which is growing in popularity. Previous systematic reviews have typically focused on specific ages, outcome measures or interventions. The current review aimed to take a more comprehensive approach. Title and abstract searches were performed in five databases for randomized and non-randomized controlled trials or pre-post studies with participants with an ADHD diagnosis or a score above a clinically relevant cut-off on a validated ADHD measure. Studies had to measure symptoms of ADHD, global or social functioning. Extraction of key information including participant status (i.e., diagnosis, scale scores, comorbidities, medication use), study design, and outcome measures was conducted. Effect sizes (Hedge’s g) were calculated and where a measure had been used in at least three studies with the same population, meta-analyses were considered. Twenty-nine studies were initially identified, with seven deemed poor quality and removed from further analysis leaving, 22 studies containing data from 1237 children and adults with ADHD along with data from 525 family members. The data indicate possible benefits of mindfulness on self-compassion, quality of life, wellbeing, depression, and anxiety. The findings also suggest that mindfulness may also improve ADHD symptoms, executive function, problematic behaviours, and emotional dysregulation, although results vary by age of patient and measures used. Parent stress and parenting style have received limited attention, highlighting the need for more studies in these areas. Whilst the data presented suggest that mindfulness may be beneficial, the evidence base is not as strong as the popularity of the approach. Many of the studies lacked blind assessment, adequate randomization, or suitable control conditions. As such high-quality controlled studies considering medication, other psychosocial interventions, use of active and in active controls and comorbidity as well as longer follow-up periods, are needed to confirm this.

Moderators of long-term treatment outcome when comparing two group interventions for adolescents with ADHD: who benefits more from DBT-based skills training?

BACKGROUND

Psychosocial interventions for adolescents with attention-deficit/hyperactivity disorder (ADHD), targeting emotional dysregulation and impulsive behaviors, have been requested, but the heterogeneity within this group makes it unlikely that there is one treatment that fits all. The aim of this study was to identify which adolescents with ADHD might have an effect from a structured skills training group (SSTG) based on dialectical behavioral therapy, by exploring pre-treatment characteristics as potential moderators of long-term treatment outcome.

METHODS

This study was based on follow-up data from a randomized controlled trial comparing the SSTG (n = 71) to a psychoeducational control intervention (n = 57) for adolescents with ADHD (15-18 years old). Clinical characteristics (sex, age, medication status, ADHD presentation, severity of ADHD symptom, psychiatric comorbidity, impairment of emotional dysregulation and functional impairment) were explored as potential moderators of pre-treatment to follow-up change in ADHD symptoms and functional impairment. Moderation analyses were performed using the PROCESS macro for SPSS.

RESULTS

Three moderators (severity of hyperactivity/impulsivity, conduct problems and impairment of emotional dysregulation) were identified in regard to the outcome self-rated change in ADHD symptoms. Participants with elevated pre-scores on these variables had a better effect of the SSTG than of the psychoeducational control intervention. No moderators were found in regard to the parental-rated outcomes.

CONCLUSIONS

The SSTG seems to be beneficial for adolescents with ADHD who perceive pronounced symptoms of hyperactivity/impulsivity, conduct problems and emotional dysregulation. Our findings need to be confirmed in future trials evaluating dialectical behavioral therapy-based skills training for adolescents with ADHD, where these moderators could be used as criteria for inclusion or stratification.

TRIAL REGISTRATION

https://doi.org/10.1186/ISRCTN17366720 , retrospectively registered.

Impact of mindfulness training on in-the-moment attentional control and emotion dysregulation in older adults: secondary analysis of a pilot, placebo-controlled randomized controlled trial

Mindfulness-based interventions show increasing promise for improving attention and emotion regulation- processes that critically support healthy aging. Given their complex, multi-faceted nature, identifying specific aspects of attention and emotion regulation that are modifiable with training in older adults, particularly compared with active control groups, is an ongoing challenge. We performed pre-registered, secondary analyses of a pilot randomized controlled trial comparing the effects of a four-week mindfulness-based attention training (MBAT) group and a lifestyle education (LifeEd) active control group on attention and emotion dysregulation in older adults. Differential training outcomes were assessed for: (a) in-the-moment effects of mind-wandering on sustained attention, measured by performance decrements preceding self-reported mind-wandering, and (b) self-reported emotion dysregulation. Baseline working memory (WM) performance was tested as a moderator of training effects. There were no significant between-group differences for change in in-the-moment effects of mind-wandering on attention or emotion dysregulation. However, baseline WM moderated training effects, such that older adults with higher WM showed greater reductions in emotion dysregulation following mindfulness training. This has potential implications for identifying aging cohorts that may benefit most from this type of training.

Dialectical behavioral therapy-based group treatment versus treatment as usual for adults with attention-deficit hyperactivity disorder: a multicenter randomized controlled trial

BACKGROUND

Studies on structured skills training groups have indicated beneficial, although still inconclusive, effects on core symptoms of ADHD in adults. This trial examined effects of Dialectical Behavioral Therapy-based group treatment (DBT-bGT) on the broader and clinically relevant executive functioning and emotional regulation in adults with ADHD.

METHODS

In a multicenter randomized controlled trial, adult patients with ADHD were randomly assigned to receive either weekly DBT-bGT or treatment as usual (TAU) during 14 weeks. Subsequently, participants receiving TAU were offered DBT-bGT. All were reassessed six months after ended DBT-bGT. Primary outcomes were the Behavior Rating Inventory of Executive Function (BRIEF-A) and the Difficulties in Emotion Regulation Scale (DERS). Secondary outcomes included self-reported ADHD-symptoms, depressive and anxiety symptoms, and quality of life. We used independent samples t- tests to compare the mean difference of change from pre- to post-treatment between the two treatment groups, and univariate linear models adjusting for differences between sites.

RESULTS

In total, 121 participants (68 females), mean age 37 years, from seven outpatient clinics were included, of whom 104 (86%) completed the 14-week trial. Entering the study, 63% used medication for ADHD. Compared to TAU (n = 54), patients initially completing DBT-bGT (n = 50) had a significantly larger mean reduction on the BRIEF-A (-12.8 versus -0.37, P = 0.005, effect size 0.64), and all secondary outcomes, except for symptoms of anxiety. All significant improvements persisted at 6 months follow-up. Change on DERS did not differ significantly between the groups after 14 weeks, but scores continued to decrease between end of group-treatment and follow-up.

CONCLUSIONS

This DBT-bGT was superior to TAU in reducing executive dysfunction, core symptoms of ADHD and in improving quality of life in adults with ADHD. Improvements sustained six months after ended treatment. The feasibility and results of this study provide evidence for this group treatment as a suitable non-pharmacological treatment option for adults with ADHD in ordinary clinical settings.

TRIAL REGISTRATIONS

The study was pre-registered in the ISRCTN registry (identification number ISRCTN30469893, date February 19^th 2016) and at the ClinicalTrials.gov (ID: NCT02685254, date February 18^th 2016).

Capturing daily-life executive impairments in adults: Does the choice of neuropsychological tests matter?

OBJECTIVE

Standardized executive functioning (EF) measures do not reliably capture EF-related difficulties reported in daily life. We aim to determine if an ecologically relevant neuropsychological battery is more strongly associated with self-reported everyday EF impairments than classically used tests.

METHOD

Fifty-nine adults aged 18-49 self-rated their EF abilities using the Barkley Deficits in EF Scale (BDEFS) and were randomly assigned to complete either a test battery composed of EF measures with hypothesized ecological relevance (Six Elements, Zoo Map, Hayling Sentence Completion, Iowa Gambling, and Auditory Startle Tasks) or one composed of traditional EF tasks (Card Sorting, Trail Making, Color-Word Interference, and Verbal Fluency). Associations were examined using linear regression.

RESULTS

There were no strong associations between BDEFS subscales and performance on either test battery. Only the regression model predicting Emotional Regulation from ecological tasks was significant. Iowa Gambling Task performance and corrugator muscle contraction in the Auditory Startle Task individually contributed significantly to the model, with small and moderate effect sizes respectively.

CONCLUSION

Results align with evidence that self-reported EF difficulties are not adequately captured by formal neuropsychological measures, even for performance-based measures which directly tap everyday constructs. Findings are interpreted cautiously in the context of a small, high-functioning sample.

The neurophysiology of the intervention strategies of Awareness Training Program on emotion regulation

Emotion regulation is essential for healthy living. Previous studies have found that mental training such as compassion meditation could help with emotion regulation. However, the underlying neural mechanism and possible intervention strategies of group-based Mahayana Buddhist intervention involved in emotion regulation are still unclear. This event-related potential (ERP) study investigated how compassion and wisdom meditations, two key components of the Awareness Training Program (ATP), may regulate emotion during different mental processing stages, namely attention deployment, cognitive change, and response modification. Eighty-five middle-aged working adults with moderate stress were voluntarily recruited for this study, using a 128-channel electroencephalogram system. After 7 weeks of training, participants (ATP attendance, n = 42; waitlist control, n = 43) were instructed to view negative pictures while practicing compassion or wisdom meditation, with corresponding priming words. Another normal priming condition and a neutral picture condition were set as control conditions. ERP results in the ATP group showed that negative pictures induced greater prefrontal activity (N400 component) in both compassion and wisdom meditation conditions compared with the normal condition, while the control group showed little difference between the conditions. Significantly higher heart rate variability was found in the compassion but not wisdom meditation when compared with the neutral priming condition. Correspondent changes in behavioural data were also found. Converging evidence showed that compassion meditation training could modulate negative emotion processing in stages of attention deployment, cognitive change, and behavioural responses. The prefrontal lobe could play an important role in the process of emotion regulation by compassion meditation, possibly due to the emphasis of the ATP on contemplative practices.

Do we over-diagnose ADHD in North America? A critical review and clinical recommendations

There has been a marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the last 25 years in North America. Some see this trend as positive and believe that it reflects a better identification of ADHD and even think that the disorder is still under-diagnosed. Others, however, contend that ADHD is over-diagnosed. To help mental health clinicians to maintain an informed and nuanced perspective on this debate, this critical review aims to (1) summarize empirical results on factors that might contribute to increase the number of ADHD diagnoses and (2) propose clinical recommendations coherent with these findings to improve clinical practices for ADHD assessment and treatment. We conclude that artifactual factors such as current formulation of diagnostic criteria, clinical practices, and inordinate focus on performance, which is rampant in North America, likely contribute to inflated prevalence rates.

Efficacy of cognitive behavioural therapy in medicated adults with attention-deficit/hyperactivity disorder in multiple dimensions: a randomised controlled trial

The study aimed to evaluate the efficacy of group cognitive behavioural therapy (CBT) in medicated adults with attention-deficit/hyperactivity disorder (ADHD) with a multidimensional evaluation and follow-up to week 36. Ninety-eight adult ADHD were randomly allocated to the CBT combined with medication (CBT + M) group or the medication (M) only group. The primary endpoint was the ADHD-Rating Scale (ADHD-RS). Secondary endpoints included emotional symptoms, self-esteem, automatic thoughts, quality of life (QoL), and executive function (EF). The outcome measures were obtained at baseline (T1), after the 12-week CBT treatment (T2), and at two follow-up time points (week 24, T3, and week 36, T4). Compared to the M-only group, the patients in the CBT + M group showed an overall significantly greater reduction from baseline in ADHD core symptoms (ADHD-RS total score at T3, and inattention subscale at T2 and T3), depression and anxiety symptoms (T2-T4), state anxiety (T2 and T3) and trait anxiety (T2), automatic thoughts questionnaire at T3, and QoL (physical domain, psychological domain, and social domain, most significant at T3 and weakened at T4). These findings further confirmed the efficacy of CBT on multiple dimensions and verified improvements in automatic thinking in adult ADHD. The superiority of the combination treatment mainly manifested in reduced inattention, emotional symptoms, and maladaptive thoughts and improved QoL. Trial registration number ChiCTR1900021705 (March-05-2019).

Internalizing and externalizing comorbidity and symptom burden in a VA ADHD specialty evaluation clinic

The purpose of this study was to evaluate psychiatric diagnosis and symptom comorbidity in veterans diagnosed with attention-deficit/hyperactivity disorder (ADHD). Study design was retrospective chart review from an ADHD evaluation clinic at a Veterans Affairs hospital. Participants were 227 military veterans who completed a standardized ADHD assessment and produced valid Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) profiles. There were no differences in rates of internalizing or externalizing psychiatric conditions diagnosed in inattentive compared to combined ADHD presentations. However, compared to a subsample with no psychiatric diagnoses, individuals diagnosed with ADHD endorsed significantly more internalizing symptom burden, with combined ADHD veterans also endorsing significantly greater levels of negative emotions and neuroticism. Base rates of comorbid classes of psychiatric diagnoses were not increased in individuals with ADHD, though higher rates of trauma disorders were seen in the combined group compared to the inattentive group. Multivariate base rates of MMPI-2-RF Restructured Clinical scales across various subgroups are presented. There was evidence for differential phenotypes of psychiatric symptoms across ADHD presentations in clinically referred veterans, predominantly related to higher rates of internalizing symptoms.

Examining the associations between PTSD symptoms and aspects of emotion dysregulation through network analysis

Despite the clearly established link between posttraumatic stress disorder (PTSD) and emotion dysregulation, little is known about how individual symptoms of PTSD and aspects of emotion dysregulation interrelate. The network approach to mental health disorders provides a novel framework for conceptualizing the association between PTSD and emotion dysregulation as a system of interacting nodes. In this study, we estimated the structural relations among PTSD symptoms and aspects of emotion dysregulation within a large sample of women who participated in a multi-site study of sexual revictimization (N = 463). We estimated expected influence to reveal differential associations among PTSD symptoms and aspects of emotion dysregulation. Further, we estimated bridge expected influence to identify influential nodes connecting PTSD symptoms and aspects of emotion dysregulation. Results highlighted the key role of concentration difficulties in expected influence and bridge expected influence. Findings highlight several PTSD symptoms and aspects of emotion dysregulation that may be targets for future intervention.

Efficacy of Non-pharmacological Treatments on Emotional Symptoms of Children and Adults with Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis

BACKGROUND

The present meta-analysis aimed to evaluate the efficacy of various non-pharmacological interventions on comorbid emotional symptoms such as depression, anxiety, and emotional dysregulation (ED) in children and adults with ADHD.

METHOD

Forty-four randomized controlled trials (23 studies with ADHD children and 21 studies with ADHD adults) were included. Risk of bias, heterogeneity assessment, and subgroup analyses were conducted.

RESULTS

We found that therapies targeting the relationship between children and others (i.e., parent-training [on ED and depression] and social skills training [on ED]) were efficacious in the treatment of emotional symptoms in children with ADHD at post-intervention. As for adults with ADHD, cognitive behavioral therapy was found to be effective for the improvement of emotional symptoms at both post-intervention and follow-up.

CONCLUSION

Our findings demonstrate that the efficacy of non-pharmacological interventions varies substantially across children and adults with ADHD. These results provide important implications for the selection of non-pharmacological interventions for children with ADHD.

The impact of psychological theory on the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in adults: A scoping review

Psychological theory and interpretation of research are key elements influencing clinical treatment development and design in Attention Deficit Hyperactivity Disorder (ADHD). Research-based treatment recommendations primarily support Cognitive Behavioural Therapy (CBT), an extension of the cognitive behavioural theory, which promotes a deficit-focused characterisation of ADHD and prioritises symptom reduction and cognitive control of self-regulation as treatment outcomes. A wide variety of approaches have developed to improve ADHD outcomes in adults, and this review aimed to map the theoretical foundations of treatment design to understand their impact. A scoping review and analysis were performed on 221 documents to compare the theoretical influences in research, treatment approach, and theoretical citations. Results showed that despite variation in the application, current treatments characterise ADHD from a single paradigm of cognitive behavioural theory. A single theoretical perspective is limiting research for effective treatments for ADHD to address ongoing issues such as accommodating context variability and heterogeneity. Research into alternative theoretical characterisations of ADHD is recommended to provide treatment design opportunities to better understand and address symptoms.

Mindfulness and Attention Deficit Hyperactivity Disorder: A Neuropsychological Perspective

ABSTRACT

Understanding the underlying mechanisms of mindfulness has been a hot topic in recent years, not only in clinical fields but also in neuroscience. Most neuroimaging findings demonstrate that critical brain regions involved in mindfulness are responsible for cognitive functions and mental states. However, the brain is a complex system operating via multiple circuits and networks, rather than isolated brain regions solely responsible for specific functions. Mindfulness-based treatments for attention deficit hyperactivity disorder (ADHD) have emerged as promising adjunctive or alternative intervention approaches. We focus on four key brain circuits associated with mindfulness practices and effects on symptoms of ADHD and its cognitive dysfunction, including executive attention circuit, sustained attention circuit, impulsivity circuit, and hyperactivity circuit. We also expand our discussion to identify three key brain networks associated with mindfulness practices, including central executive network, default mode network, and salience network. We conclude by suggesting that more research efforts need to be devoted into identifying putative neuropsychological mechanisms of mindfulness on how it alleviates ADHD symptoms.

The efficacy of mindfulness-based interventions in attention-deficit/hyperactivity disorder beyond core symptoms: A systematic review, meta-analysis, and meta-regression

BACKGROUND

Mindfulness-Based Interventions (MBIs) have been increasingly proposed as treatment in patients with Attention-Deficit/Hyperactivity Disorder (ADHD), showing promising results on different proposed outcomes, in both children and adults.

OBJECTIVES

To systematically review and meta-analyse studies concerning the effects of MBIs on either ADHD and associated features, associated clinical conditions, neurocognitive impairments, mindfulness skills, global functioning and quality of life.

METHODS

Searches were conducted on five databases, including controlled and observational studies on both adults and children populations. The review process was compliant to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Meta-analyses and meta-regression models were conducted.

RESULTS

Thirty-one full-texts were included. In both adults and children, MBIs showed to be more effective than waiting lists in improving ADHD symptoms and some other outcomes. In adults, a medium pooled effect size was shown by meta-analysis for ADHD symptoms but in some cases a publication bias was detected. Subgroup analysis and meta-regression confirmed the gap detected by our systematic review between the medium/large effect size of inactive-controlled studies and the low/negligible one of active-controlled studies. In children, no active-controlled studies have been conducted. Mindfulness Awareness Practice (MAP) and Mindfulness Based Cognitive Therapy (MBCT) were the most used protocols in adult studies, whereas a combination of MBCT and Mindfulness Based Stress Reduction (MBSR) was more preferred for children and adolescent patients.

CONCLUSIONS

Even if further studies with a better methodology are needed, we can suggest the MBIs may be useful as complementation and not as replacement of other active interventions.

Do group-based mindfulness meditation programs enhance executive functioning? A systematic review and meta-analysis of the evidence

Research examining the effects of group-based mindfulness interventions on executive functioning have yielded inconsistent findings, with some reports of enhanced performance and other reports of null findings. Inconsistencies in the literature may be due to methodological differences across studies, including the type of control group employed and sample characteristics (e.g., clinical vs. non-clinical samples). The current systematic review and meta-analysis examined the effect of group-based mindfulness programs on executive functioning in persons 18+ years of age. Following the standards for systematic review, a total of 29 studies were included in the meta-analysis, of which 21 comparisons contributed to the analysis of inhibition; nine to working memory; nine to attention shifting; and four to the analysis of verbal fluency. After removing outliers, random effects models suggested a small but significant synthesized effect of group-mindfulness training on overall executive functioning (95% CI = 0.256, 0.725). Examination of executive subdomains after removing outliers suggested a small, statistically significant effect for inhibition (95% CI = 0.055, 0.387), working memory (95% CI = 0.010, 0.437), and verbal fluency (95% CI = 0.071, 1.931). No significant pooled effects were found for attention shifting. A priori subgroup analysis by randomization, type of control group, and sample cohort revealed inconsistent results. Overall, the current review suggests that the effect of group-based mindfulness training on executive functioning is not robust.

The Effect of Mindfulness-based Programs on Cognitive Function in Adults: A Systematic Review and Meta-analysis

Mindfulness-based programs (MBPs) are increasingly utilized to improve mental health. Interest in the putative effects of MBPs on cognitive function is also growing. This is the first meta-analysis of objective cognitive outcomes across multiple domains from randomized MBP studies of adults. Seven databases were systematically searched to January 2020. Fifty-six unique studies (n = 2,931) were included, of which 45 (n = 2,238) were synthesized using robust variance estimation meta-analysis. Meta-regression and subgroup analyses evaluated moderators. Pooling data across cognitive domains, the summary effect size for all studies favored MBPs over comparators and was small in magnitude (g = 0.15; [0.05, 0.24]). Across subgroup analyses of individual cognitive domains/subdomains, MBPs outperformed comparators for executive function (g = 0.15; [0.02, 0.27]) and working memory outcomes (g = 0.23; [0.11, 0.36]) only. Subgroup analyses identified significant effects for studies of non-clinical samples, as well as for adults aged over 60. Across all studies, MBPs outperformed inactive, but not active comparators. Limitations include the primarily unclear within-study risk of bias (only a minority of studies were considered low risk), and that statistical constraints rendered some p-values unreliable. Together, results partially corroborate the hypothesized link between mindfulness practices and cognitive performance. This review was registered with PROSPERO [CRD42018100904].

Using e-diaries to investigate ADHD - State-of-the-art and the promising feature of just-in-time-adaptive interventions

Attention-deficit/hyperactive disorder (ADHD) is characterized by symptoms which are dynamic in nature: states of hyperactivity, inattention and impulsivity as core symptoms, and emotion dysregulation as associated feature. Although tremendous work has been done to investigate between-subject differences (how patients with ADHD differ from healthy controls or patients with other disorders), little is known about the relationship between symptoms with triggers and contexts, that may allow us to better understand their causes and consequences. Understanding the temporal associations between symptoms and environmental triggers in an ecologically valid manner may be the basis to developing just-in-time adaptive interventions. Fortunately, recent years have seen advances in methodology, hardware and innovative statistical approaches to study dynamic processes in daily life. In this narrative review, we provide a description of the methodology (ambulatory assessment), summarize the existing literature in ADHD, and discuss future prospects for these methods, namely mobile sensing to assess contextual information, real-time analyses and just-in-time adaptive interventions.

Effectiveness of Online Mindfulness-Based Intervention (iMBI) on Inattention, Hyperactivity-Impulsivity, and Executive Functioning in College Emerging Adults with Attention-Deficit/Hyperactivity Disorder: A Study Protocol

Attention-deficit/hyperactivity disorder (ADHD), a common neurodevelopmental disorder, often persists into adulthood. In Malaysia, the prevalence rate of hyperactivity symptoms is highest among Chinese Malaysians. There are limited evidence-based treatment options targeting the core symptoms of ADHD, as well as executive functioning. In addition, conventional psychotherapeutic approaches for adults with ADHD have been found to be highly labor-intensive. The present study will evaluate the effectiveness of an online mindfulness-based intervention to reduce inattention and hyperactivity–impulsivity and improve executive functioning among Chinese Malaysian college emerging adults with ADHD. Informed by established literature, we will design an 8-week online mindfulness-based intervention (i.e., iMBI). We will conduct a two-arm randomized controlled trial comparing an iMBI plus treatment-as-usual group (n = 54) and an enhanced treatment-as-usual control group (n = 54). Outcome measures of inattention, hyperactivity–impulsivity, and executive functioning will be collected at baseline, immediately post-intervention, and 1-month post-intervention. The findings of the present study will not only demonstrate the implementation of iMBI as a new treatment modality but also inform practitioners on the effectiveness of iMBI in reducing the burden of adults living with ADHD.

Immediate effects of meditation in college students: A pilot study examining the role of baseline attention performance and trait mindfulness

OBJECTIVE

Determine feasibility of a procedure to identify relationships between preexisting traits and immediate mindfulness meditation (MM) responses in novice college students.

PARTICIPANTS

Twenty-four novice college students participated between September 2016 and April 2017.

METHODS

We measured trait mindfulness, attention and executive function performance, and immediate MM-related changes in self-reported state mindfulness and state anxiety following a 13-min MM.

RESULTS

The procedure appeared to be feasible and acceptable to college students. Preliminary findings included increases in state mindfulness and decreases in state anxiety, which appeared to vary by level of trait mindfulness. Better attention performance correlated with greater increases in state mindfulness of body.

CONCLUSION

This pilot study demonstrated feasibility of investigating the relationship between baseline traits and college students' immediate MM responses. Using these methods, future studies can provide a unique examination of MM effects stratified by validated facets of state mindfulness of body and mind.

Mindfulness Training for Adults with Attention-Deficit/Hyperactivity Disorder: Implementation of Mindful Awareness Practices in a French-Speaking Attention-Deficit/Hyperactivity Disorder Unit

Introduction: Mindfulness-based programs are a promising option for patients with attention-deficit/hyperactivity disorder (ADHD), who face attention, hyperactivity, and emotion dysregulation issues in their daily life. Objective: To examine the implementation and impact of specific mindfulness training for adults with ADHD in a French-speaking unit. Methods: Thirty-eight adults with ADHD were included in an 8-week Mindful Awareness Practices (MAPs) program. Patients were assessed for ADHD symptoms, anxiety, depression, and mindfulness skills, before (T1) and after (T2) the eight sessions, and then 2 months later (T3). Results: The patients adhered to the program as the majority of them completed it. A significant decrease in ADHD, depression, and anxiety symptoms was found between T1 and T2. Regarding mindfulness skills, a significant increase was observed between T1 and T2 in Observing, Describing and Nonreactivity to inner experience cores, but not Acting with awareness and Nonjudging of inner experience scores. There was no significant change between T2 and T3. Conclusion: The MAPs program was successfully implemented and showed promising effects on ADHD symptomatology and related symptoms.

A systematic review and meta-analysis of mindfulness- and acceptance-based interventions for affect intolerance/sensitivity

Affect intolerance/sensitivity, defined as one's sensitivity to, or inability to tolerate, affective states, is a transdiagnostic process implicated in the development and maintenance of numerous forms of psychopathology. Mindfulness and acceptance interventions are posited to improve affect intolerance/sensitivity; however, there has been no quantitative synthesis of this research to date. Seven electronic databases were searched up until November 2018. Hedges' g values, 95% confidence intervals, p-values, and Q-values were calculated for a series of random-effects models. Twenty-five studies (pooled N = 1778) met eligibility criteria and were included in the qualitative synthesis (n = 22 included in the meta-analysis). There was a small, significant effect of mindfulness and acceptance interventions on improving affect intolerance/sensitivity from pre-to post-intervention (Hedges' g = -0.37, 95% CI = -0.52 to -0.23, p < .001), with effects maintained up to 6-months (Hedges' g = -0.35, 95% CI = -0.61 to -0.09, p < .01). There was a significantly larger effect for studies with inactive compared to active controls. No significant effect size differences were found for intervention length (<8 vs. ≥ 8 sessions), intervention type (mindfulness vs. acceptance) or sample type (clinical vs. non-clinical). Mindfulness and acceptance interventions modestly improve affect intolerance/sensitivity.

Tai Chi training for attention deficit hyperactivity disorder: A feasibility trial in college students

OBJECTIVE

Many young adults are affected by attention deficit hyperactivity disorder (ADHD) and often desire non-pharmacological treatment options. Mind-body techniques might serve as complementary therapies to first-line stimulant medications, but studies are limited. Tai Chi is an increasingly popular practice that integrates movement with cognitive skills relevant to ADHD. We performed a feasibility trial of Tai Chi training in undergraduates to inform the design of a fully powered randomized controlled trial (RCT).

METHOD

Undergraduates with ADHD were recruited, screened, enrolled, and assessed at baseline. They were assigned to three parallel seven-week intervention arms, Tai Chi, Active Control (cardio-aerobic fitness), and Inactive Control (no contact), with follow-up assessments. Feasibility of a larger clinical trial was evaluated, especially with respect to enrollment and retention. Additionally, potential clinical outcome measures were examined for practicality and reliability.

RESULTS

21 participants were assessed at baseline and 19 at follow-up (90 % retention). The primary clinical outcome measure, self-reported inattention symptoms (Conners' CAARS-S:L DSM-IV Inattentive Symptoms subscale), exhibited good test-retest reliability in controls (r = 0.87, n = 10) and correlated with reduced mindfulness (FFMQ acting with awareness subscale) at baseline (r = -0.74, n = 20). Class attendance and self-reported daily practice time were variable. Randomization to group classes was hindered by the college students' restricted schedules.

CONCLUSION

The high retention rate and good data quality suggest that an RCT of Tai Chi for ADHD is feasible. Further measures are identified to improve enrollment rates, adherence, and randomization procedures. Future work might extend to other young adult populations and high school students.

Depression and ADHD-Related Risk for Substance Use in Adolescence and Early Adulthood: Concurrent and Prospective Associations in the MTA

Childhood attention-deficit/hyperactivity disorder (ADHD) is prospectively linked to substance use and disorder. Depression emerging in adolescence is an understudied risk factor that may explain some of this risk. In the present study, we considered mediating and moderating roles of adolescent depression in explaining this association by using longitudinal data from the prospective 16-year follow-up of the Multimodal Treatment Study of ADHD (MTA). Participants were 547 children diagnosed with DSM-IV ADHD Combined Type, and 258 age- and sex-matched comparison children. In adolescence, depressive symptoms did not exacerbate effects of childhood ADHD on any substance use. For both groups, time-varying and average depressive symptoms were associated with more frequent use of all substances. Prospectively, we found no evidence of depression mediation to adult substance use. However, adolescent depression moderated the association between childhood ADHD and adult marijuana use. Although adults without ADHD histories used marijuana more frequently if they had elevated depressive symptoms in adolescence, marijuana use by adults with ADHD histories was independent of their adolescent depression. In adulthood, depression diagnoses and ADHD persistence continued to operate as independent, additive correlates of substance use risk. Our findings suggest a circumscribed role for depression in substance use risk that adds to, but does not alter or explain, ADHD-related risk.

Cognitive behavioural therapy in groups for medicated adults with attention deficit hyperactivity disorder: protocol for a randomised controlled trial

INTRODUCTION

Cognitive behavioural therapy (CBT) is an evidence-based treatment for adults with attention deficit hyperactivity disorder (ADHD). However, it is still inconsistent whether a combination of CBT would have additive effects in medicated ADHD in adulthood. And if CBT would have additional effects, what kind and which dimension would CBT play a part? This study estimates the efficacy of CBT in stable medicated adult ADHD, using long-term outcomes and multidimensional evaluations.

METHODS AND ANALYSIS

It is a two-armed, randomised controlled trial on the superiority of the efficacy of 12 weeks of CBT on medicated adult ADHD. We compare the short-term and long-term outcomes between CBT combined with medication (CBT+M) group and the medication-only (M) group, including ADHD core symptoms, emotional symptoms, executive function, self-esteem, life quality and brain function using functional near-infrared spectroscopy data. Participants are outpatients of the Peking University Sixth Hospital and those recruited online, diagnosed as adult ADHD and with stable medication treatment. We estimate ADHD core symptoms and combined symptoms at baseline (T1) and week 12 (T2), week 24 (T3), week 36 (T4) and week 48 (T5).

ETHICS AND DISSEMINATION

This trial has been approved by the Ethics and Clinical Research Committees of Peking University Sixth Hospital and will be performed under the Declaration of Helsinki with the Medical Research Involving Human Subjects Act (WMO). The results will be disseminated in a peer-reviewed journal and a conference presentation.

TRIAL REGISTRATION NUMBER

ChiCTR (ChiCTR1900021705).

Deconstructing the effects of concentration meditation practice on interference control: The roles of controlled attention and inflammatory activity

Prior work has linked meditation practice to improvements in interference control. However, the mechanisms underlying these improvements are relatively unknown. In the context of meditation training, improvements in interference control could result eitherfrom increases in controlled attention to goal-relevant stimuli, or from reductions in automatic capture by goal-irrelevant stimuli. Moreover, few studies have linked training-related changes in attention to physiological processes, such as inflammatory activity, that are thought to influence cognitive function. This study addresses these gaps by examining associations between cognitive performance and cytokines in the context of an intensive meditation retreat. Participants were randomly assigned to complete 3 months of meditation training first, or to serve as waitlist controls. The waitlist-control participants then later completed a separate 3-month training intervention. We assessed participants' interference control with a flanker task and used computational modeling to derive component processes of controlled and automatic attention. We also collected blood samples at the beginning, middle, and end of training to quantify changes in cytokine activity. Participants who completed training evidenced better controlled attention than waitlist controls during the first retreat intervention, and controls showed significant improvements in controlled attention when they completed their own, second retreat. Importantly, inflammatory activity was inversely associated with controlled attention during both interventions. Our results suggest that practice of concentration meditation influences interference control by enhancing controlled attention to goal-relevant task elements, and that inflammatory activity relates to individual differences in controlled attention.

Deficient Emotional Self-Regulation in Children with Attention Deficit Hyperactivity Disorder: Mindfulness as a Useful Treatment Modality

OBJECTIVE

The aim of this study was to investigate the efficacy of a structured mindfulness group intervention program targeting deficient emotional self-regulation (DESR) in a sample of children with attention deficit hyperactivity disorder (ADHD).

METHOD

Seventy-two children aged 7 to 12 years with ADHD were randomized into 2 groups (mindfulness and control). The dysregulation profile was measured using the Child Behavior Checklist (CBCL) Attention/Anxiety-Depression/Aggression scales.

RESULTS

Children with ADHD who received mindfulness-based group therapy showed lower levels of DESR after treatment, with a reduction in CBCL dysregulation profile (F (1,63) = 4.81; p = 0.032). All ADHD symptoms showed a moderately significant positive correlation with DESR (p < 0.01). Children with combined-type showed higher levels of DESR than children with inattentive-type (p = 0.018); however, no statistically significant changes were observed in the combined-type after mindfulness treatment.

CONCLUSION

This study suggests that mindfulness in the form of structured group therapy might be clinically relevant in treating children with ADHD and thus make an impact on the overall clinical outcome, regardless of the ADHD subtype.

Sex and Emotion Regulation Difficulties Contribute to Depression in Young Adults With Attention-Deficit/Hyperactivity Disorder

Many young adults with attention-deficit/hyperactivity disorder (ADHD) are at risk for depression. Yet, questions remain about factors associated with the development of depression in young adults with ADHD. This study examined the effects of sex and emotion regulation difficulties on depression in a sample of young adults with (n = 172) and without (n = 730) ADHD. Two aspects of emotion regulation difficulties were examined-impairments in emotional insight (i.e., lack of emotional awareness, nonacceptance of emotion, and lack of emotional clarity) and impairments in behavioral response to emotion (i.e., impulse control difficulties, difficulties engaging in goal-directed behavior, and limited access to emotion regulation strategies). Significant correlations between ADHD and all indices of emotion regulation difficulty emerged. Sex moderated the association between ADHD and lack of emotional awareness, difficulties engaging in goal-directed behavior, and limited access to emotion regulation strategies. Specifically, ADHD was significantly associated with limited emotion regulation awareness for women but not men, while ADHD was associated with greater difficulties engaging in goal-directed behavior and limited access to emotion regulation strategies for women compared to men. These three areas of emotion regulation dysfunction simultaneously mediated the association between ADHD and depression. The findings indicate the importance of considering emotion regulation and sex in understanding depression in young adults with ADHD.

Effects of mindfulness training on daily stress response in college students: Ecological momentary assessment of a randomized controlled trial

Objective

Mindfulness training has been shown to reduce rates of depression, anxiety and perceived stress, but its impact on stress and emotion regulation in real-world settings in the college-aged population is unknown. This study examines the effect of an 8-session long mindfulness training on first-year college students' daily experiences of stress and emotion regulation.

Methods

Fifty-two first-year students were randomized to the mindfulness training or the waitlist-control group during the fall academic semester. Before, during and after the trial, students completed 10-days of ecological momentary assessments (EMA), reporting on family and school or work stress, negative emotion, rumination, and interference by unwanted thoughts and emotions up to four times a day. Multilevel regression analysis compared levels of momentary stress and emotion regulation difficulties, as well as the strength of the moment-level association between stress and emotion regulation, by intervention condition, before, during and after the trial.

Results

Controls showed an exacerbation of family stress related negative emotion, rumination and interference, across the fall semester. However, intervention youth showed stable levels of emotion regulation responses to family stress across the semester. Emotion regulation responses to school or work stress did not differ by intervention condition.

Conclusions

Mindfulness training helps to prevent the depletion of emotion regulation capacity in this sample of relatively healthy first-year college students. EMAs allow the assessment of emotion regulation in the context of naturally occurring stress, and enhances the specificity and external validity of evaluations of psychological interventions.

Non-pharmacological interventions for adult ADHD: a systematic review

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common developmental disorder, often persisting into adulthood. Whilst medication is first-line treatment for ADHD, there is a need for evidence-based non-pharmacological treatment options for adults with ADHD who are either still experiencing significant symptoms or for those who have made the informed choice not to start medication.

METHODS

We systematically searched PsycINFO, MEDLINE (Ovid), EMBASE, CINAHL and CENTRAL for randomised controlled trials of non-pharmacological treatments for ADHD in adults. After screening of titles and abstracts, full text articles were reviewed, data extracted and bias assessed using a study proforma.

RESULTS

There were 32 eligible studies with the largest number of studies assessing cognitive behavioural therapy (CBT). CBT consisted of either group, internet or individual therapy.

CONCLUSIONS

The majority found an improvement in ADHD symptoms with CBT treatment. Additionally, mindfulness and cognitive remediation have evidence as effective interventions for the core symptoms of ADHD and there is evidence for the use of group dialectical behavioural therapy and hypnotherapy. However, evidence for these is weaker due to small numbers of participants and limitations due to the lack of suitable control conditions, and a high risk of bias.

The Effectiveness of Mindfulness-Based Therapies for ADHD: A Meta-Analytic Review

Objective: Mindfulness-based therapies (MBTs) have been shown to be efficacious in treating internally focused psychological disorders (e.g., depression); however, it is still unclear whether MBTs provide improved functioning and symptom relief for individuals with externalizing disorders, including ADHD. To clarify the literature on the effectiveness of MBTs in treating ADHD and to guide future research, an effect-size analysis was conducted. Method: A systematic review of studies published in PsycINFO, PubMed, and Google Scholar was completed from the earliest available date until December 2014. Results: A total of 10 studies were included in the analysis of inattention and the overall effect size was d = -.66. A total of nine studies were included in the analysis of hyperactivity/impulsivity and the overall effect was calculated at d = -.53. Conclusion: Results of this study highlight the possible benefits of MBTs in reducing symptoms of ADHD.

Efficacy of Nonpharmacological Treatments on Comorbid Internalizing Symptoms of Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Background: Attention-deficit/hyperactivity disorder (ADHD) is highly comorbid in adulthood. This meta-analysis was aimed at ascertaining the efficacy of different psychotherapies in improving comorbid internalizing symptoms in adults with ADHD. Method: Twenty randomized controlled trials and 12 uncontrolled pretest-posttest studies were included and combined using the inverse variance method. Risk of bias and heterogeneity assessment and moderator analyses were performed. Results: Cognitive-behavioral therapy (CBT) improved quality of life (QoL), emotional dysregulation (ED), depression, and anxiety symptoms, particularly at follow-up, which was predicted by core symptoms reduction. A significant between-group effect was obtained only on QoL, ED, and self-esteem for dialectical behavior therapy (DBT), mindfulness-based therapies (MBTs), and neurofeedback, respectively. Conclusion: Results support CBT efficacy for treating comorbid internalizing symptoms. More research is needed to determine the effectiveness of DBT, MBT, and neurofeedback. The small number of studies evaluating some therapies and the high risk of bias observed might limit these results.

Mindfulness and Attention: Current State-of-Affairs and Future Considerations

This review examines longitudinal studies of changes in components of attention following mindfulness training. A total of 57 retreat studies, non-randomized trials, and randomized controlled trials were identified. Employing the classical taxonomy proposed by Posner and Petersen (1990), outcome measures were broadly categorized based on whether they involved maintenance of an aroused state (alerting), selective prioritization of attention to target items (orienting), or assessed conflict monitoring (executive attention). Although many non-randomized and retreat studies provide promising evidence of gains in both alerting and conflict monitoring following mindfulness training, evidence from randomized controlled trials, especially those involving active control comparison groups, is more mixed. This review calls attention to the urgent need in our field of contemplative sciences to adopt the methodological rigor necessary for establishing mindfulness meditation as an effective cognitive rehabilitation tool. Although studies including wait-listed control comparisons were fruitful in providing initial feasibility data and pre-post effect sizes, there is a pressing need to employ standards that have been heavily advocated for in the broader cognitive and physical training literatures. Critically, inclusion of active comparison groups and explicit attention to the reduction of demand characteristics are needed to disentangle the effects of placebo from treatment. Further, detailed protocols for mindfulness and control groups and examination of theoretically guided outcome variables with established metrics for reliability and validity are key ingredients in the systematic study of mindfulness meditation. Adoption of such methodological rigor will allow for causal claims supporting mindfulness training as an efficacious treatment modality for cognitive rehabilitation and enhancement.