mindfulness-based intervention for adhd...•4 mindfulness •3 yoga •adults: 6 rcts (n=339) •4...

Mindfulness-based intervention for ADHD

c.greven@donders.ru.nl

Corina Greven

Overview

1. Historical background

2. Mindfulness for ADHD

3. Own research

4. Future

Historical background

• Past 2500 years: Buddhist practices

• 1970s: Mindfulness-based stress reduction (MBSR)

• 2000s: Mindfulness-based cognitive therapy (MBCT)

MBSR: Kabat-Zinn (1979) | MBCT: Segal, Williams, Teasdale (2002)| Bishop (2004) Clin Psychol| Crane (2017) Psychol Med

Jon Kabat-Zinn

Definition mindfulness

regulation of

attention to

the present

Orientation

experience

Bishop (2004) Clin Psychol

3-minute breathing space

Active creationDeliberate choices

Mindfulness and ADHD – how does that fit together?!

• Limitations of care-as-usual

• Targeting ADHD-related problems

• Neuropsychotherapy

Songua-Barke (2013) Am J Psychiatry | Bachmann | (2016) Front Psychiatry | Moffitt (2011) PNAS

Why mindfulness for ADHD?

Tang et al. (2015) Nat Rev Neuroscience

Siebelink, Greven (2019) ECAP

AC AE C E C E

HYP-IMPDispositional

mindfulness

√.65 √.61 √.35

.37 .40

√.00 √.22 √.18

√. 21√.65

√. 13

• ADHD (traits) linked to lower dispositional mindfulness

• Genetic sharing

Cairncross & Miller (2016) J Atten Dis

Limitations

• Few controlled and/or randomised studies

• Small samples• 9 studies• Effect size:

Children: d = -.47Adults: d = -.68

• 10 studies• Effect size:

Children: d = -.66 Adults: d = -.91

Inattentiveness

Hyperactivity-impulsivity

Meta-analysis: mindfulness for children and adults with ADHD

Zhang, Díaz-Román & Cortese (2018) Evid Based Mental Health

• Children: 7 RCTs (n=270)

• 4 mindfulness

• 3 yoga

• Adults: 6 RCTs (n=339)

• 4 mindfulness-based intervention

• 1 dialectical therapy + meditation

• 1 CBT + meditation

Meta-analysis: meditation-based intervention for children and adults with ADHD

Children: ADHD symptom reduction• Combined (g = -0.44)• Inattentiveness (g = -0.52)• Hyperactivity-impulsivity (g= -0.40)

Adults: ADHD symptom reduction• Combined (g = -0.66)• Inattentiveness (g = -0.70)• Hyperactivity-impulsivity (g= -0.40), n.s.

• Good news: mindfulness reduced ADHD symptoms!

• Stronger evidence for adults

• Stronger effects for inattentiveness

• But: “Despite statistical significance, methodological limitations mean there is insufficient evidence to support meditation-based therapies for ADHD.”

• Power

• Objective/ blinded outcomes

• Standardised intervention

• Few RCTs on mindfulness for ADHD

Limitations

• RCT

• Adequately powered

• Pre-registration

• Protocol: Siebelink, Bögels, Boerboom, de Waal, Buitelaar, Speckens, Greven (2018). BMC Psychiatry

MindChamp

Child: Mindfulness-based Cognitive

Therapy

Parent: Mindful parenting

+MYmind

• 8 weekly group sessions (1,5 hours)• 5-9 children and parents• Homework

Bögels (2008) | van de Weijer-Bergsma (2012) | Haydicky (2015) | Shecter (2013) | van der Oord (2012)

MYmind training

• ADHD runs in families

• More parenting stress

Greven 2014 J Child Psychol Psychiatry | Theule 2013 J Empt Behav Disord

MYmind: involving parents

• 8 - 16 years

• Primary diagnosis of ADHD

• Medication allowed

• Receiving care-as-usual (CAU), has remaining symptoms

Child/ parent

• Previous mindfulness training

• Psychosis, bipolar, active suicidality, untreated PTSD, substance use

• IQ < 80

• Dutch inadequate

Inclusion criteria Exclusion criteria

Mindfulness + CAU

Baseline

Endpoint (8 weeks)

Follow-ups (2 & 6 months)

Endpoint (8 weeks)

Follow-ups (2 & 6 months)

Children + parents

ParentTeacher

N=55 N=49

• Primary outcome: Self-control

• Parent-ratings (ecologically-valid)

• Teacher-ratings (probably-blinded)

• Neurocognitive tasks (objective)

• Secondary outcomes

• ADHD symptoms

• Comorbid symptoms

• Quality of life

• Outcomes in parents

Outcome measures

MindChamp qualitative study

‘purposive sampling’

19 parents

3 mindfulness teachers

17 children

QualitativeRCT

mindfulness group

MindChamp qualitative: design

1. Feasibility: facilitators and barriers

2. Effects

MindChamp qualitative: aims

• Analyses: Grounded Theory

Feasibility Facilitators Barriers

Contextual factorsA. FamilyB. Time and locationC. Time investment

A. Parent and childare co-teachers

C. Spending qualitytime together

A. Interference withfamily structure

B. Time of trainingC. Busy schedules

Training characteristicsA. Content of

trainingB. Other participantsC. Mindfulness

teachers

A. Variety, shortbreathing space, parallel training

B. Sharingexperiences, recognistion

C. Attitude, expertise and understanding

A. Homework + reward system

B. Strong personalities, disturbingbehaviour

C. Not alwaysdirective enough

Participant characteristicsA. Personal

characteristicsB. View on

mindfulnessC. Child age

A. Feeling responsible, being social

B. Alternative formedication, ‘planting a seed’

A. ADHD symptoms, comorbidities

B. Aversion tomindfulnessexercises

C. Being too young

teachers

C. Being too young

MindChamp qualitative: feasibility

teachers

C. Being too young

teachers

C. Being too young

“My child then says: ‘Mum, breathe.’ And that we then can talk about it, that we need a short break to calm down.”

teachers

C. Being too young

teachers

C. Being too young

“What I found very positive, is the possibility to exchange experiences with others. It made me think ‘Ah.. So I’m not crazy, it isn’t always our fault!”

teachers

C. Being too young

teachers

C. Being too young

“What my daughter found the most difficult, is that they scored the children. That another child got full marks and she didn’t. That was painful.”

teachers

C. Being too young

teachers

C. Being too young

“I think she is mentally too young. To understand what it was really about.”

MindChamp qualitative: effects

“I keep getting better and better in seeing how he deals with things and what kind of help he needs.”

• Warmer relationships

• Conversations

• Fewer fights

“We realized that it is extremely important that we let her be herself and not always try to fit her in the perfect picture.”

“My dad and I are both really impulsive and explode easily. That happens a lot less now after the mindfulness training.”

• Attention

• Planning

• Keeping structure

• No adverse effects!

• All except one recommended training

• MYmind mindfulness training is feasible

• Effects are diverse

• Quantification of group-level effects?

MindChamp qualitative: conclusions

• New adequately-powered RCTs are under way!

Future directions mindfulness for ADHD: Quo vadis?

• Dedication conference to innovative topic

• Role mindfulness ADHD intervention

• Important: Mindfulness goes beyond ADHD symptom reduction: it is about how a person deals with ADHD!

• Useful addition to care-as-usual

Future directions mindfulness for ADHD: Quo vadis?

• Mechanisms?

• Long-term effectiveness?• Optimal frequency, intensity and duration?• Role of mindfulness teacher?

• Role of parents?• Blinded outcomes• Include medication-naïve participants/ examine interaction

medication; – mindfulness; stand-alone intervention or enhance effects of other interventions

• Best evidence for prevention of depression relapse

• Also consistent evidence for pain, smoking, addictions

Kuyken (2016) JAMA Psychiatry | Goldberg (2018) Clin Psychol Rev

Mindfulness for other psychiatric disorders

Kuyken et al. (2016) JAMA Psychiatry

• 9 RCTs (N=1258)

• Control: care-as-usual, anti-depressants, cognitive-psychological

• 60-week follow-up

Meta-analysis: mindfulness for recurrent depression

• 142 RCTs, N=12,005 participantsPost-treatment

• Most consistent evidence for depression, pain, smoking, addictionsGoldberg (2018) Clin Psychol Rev

Meta-analysis: RCTs mindfulness for psychiatric disorders

• Adverse side effects

• Mild: becoming aware of symptoms can make people feel worse → typically perceived as therapeutic in long-term

• Severe: sleeplessness, addition to meditation, boredom, pain, transient meditation-induced psychosis → case reports, long-term meditators

• Well-trained mindfulness trainers• Certain disorders require extra care and handling

• Beyond passive monitoring: ‘Safety toolbox’: https://www.brown.edu/research/labs/britton/resources/meditation-safety-toolbox

Can mindfulness do more harm than good?

Summary

• Mindfulness refers to the self-regulation of attention to the present moment, with an attitude of non-judgment, friendliness and curiosity

• Meta-analyses: Mindfulness effective in reducing ADHD symptoms.

• Larger effect sizes for a) adults, b) for inattentiveness

• Yet: higher quality studies are needed

• My qualitative results showed that mindfulness may be a useful addition to existing interventions by targeting effect-domains beyond ADHD symptoms (e.g., acceptance, family-child relationships, generalisation).

www.mindchamp.nl | c.greven@donders.ru.nl

MindChamp team• Dr Corina Greven• Prof Dr Jan Buitelaar • Prof Dr Anne Speckens• Prof Dr Susan Bögels• Nienke Siebelink (PhD student)• Shireen van Rosmalen-Kaijadoe, Fylis van Horrsen,

Josanne Holtland (MindChamp qualitative)• Janneke Dammers, Noor de Waal (research

assistants)• Ilse Dijkman (current stagiaire) • MindChamp interns• C. Aarnink, M. Fokkema, A. v. Steekelenburg

(mindfulness trainers• Henrieke Loman, Esther Leuning, Carin Demmers,

Loes Vinkenvleugel, Annemieke Brinkman, Mireille Huvenaars-Bakker (co-trainers)

Funding• Horizon 2020 (MiND)• Fonds Psychische Gezondheid• Karakter

Grazie per l'attenzione!

Satisfaction parents with mindfulness training

23%heel ontevreden

ontevreden

neutraal

tevreden

heel tevreden

1. Feasibility of MBCT

▪ Barriers to participation and at-home practicing

▪ Facilitators to participation and at-home practicing

1. Effects of MBCT

▪ On children with ADHD

▪ On parents (of children with ADHD)

▪ Relational effects

▪ Medication

▪ Adverse effects

1. Re-joining/recommending the MBCT; why?

Participants (n=47)

¨ Primary outcome missing (n=4)

Analysed (ITT and PP n=43)

Participants (n=53) ¨ Primary outcome missing (n=6; 1 NC)

Analysed (ITT n=47; PP n=45)

B. Not included after contact (n=401)1

¨ Not meeting inclusion criteria (n=98)

¨ Meeting exclusion criteria (n=17)

¨ Declined to participate (n=303)

¨ Other reasons4 (n=29)

2-month follow-up (n=100)

Assessed for eligibility (n=1565):

A. Patient file screened only (n=1060)

B. Contact with Family (n=505)

Enrollment

A. Not included after screening (n=1060)1

¨ Not meeting inclusion criteria (n=437)

¨ Meeting exclusion criteria (n=250)

¨ Not possible to contact2 (n=415)

¨ Other reasons3 (n=106)

8-week family-MBI:

¨ Completers (n=50)

¨ Non-completers (NC)5 (n=5)

Participants (n=54)

¨ Primary outcome missing (n=1, NC)

Analysed8 (ITT n=53; PP n=50)

Participants (n=48)

¨ Primary outcome missing (n=1)

Lost to follow-up

(n=7; 2 NCs)

Lost to follow-up

Randomly allocated to CAU + Mindfulness (n=55)

Randomly allocated to CAU only (n=49)

Drop-out6 (n=1, NC)

Excluded7 (n=1)

Lost to follow-up

(n=1, NC)

Lost to follow-up

Analysed (ITT n=46; PP n=45)

6-month follow-up (n=92)

Endpoint (n=102)

Baseline (n=104)

Child/adolescent studies

Adult studies

mindfulness-based intervention for adhd...•4 mindfulness •3 yoga •adults: 6 rcts (n=339) •4...

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