mindfulness-based intervention for adhd...•4 mindfulness •3 yoga •adults: 6 rcts (n=339) •4...
TRANSCRIPT
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
Self-
regulation of
attention to
the present
Orientation
to
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
Why mindfulness for ADHD?
Siebelink, Greven (2019) ECAP
A
INATT
AC AE C E C E
HYP-IMPDispositional
mindfulness
√.65 √.61 √.35
.21
.37 .40
√.00 √.22 √.18
√. 21√.65
√. 13
• ADHD (traits) linked to lower dispositional mindfulness
• Genetic sharing
Why mindfulness for ADHD?
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)
Zhang, Díaz-Román & Cortese (2018) Evid Based Mental Health
Meta-analysis: meditation-based intervention for children and adults with ADHD
Adults: ADHD symptom reduction• Combined (g = -0.66)• Inattentiveness (g = -0.70)• Hyperactivity-impulsivity (g= -0.40), n.s.
Zhang, Díaz-Román & Cortese (2018) Evid Based Mental Health
Meta-analysis: meditation-based intervention for children and adults with ADHD
Zhang, Díaz-Román & Cortese (2018) Evid Based Mental Health
• 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.”
Meta-analysis: meditation-based intervention for children and adults with ADHD
Zhang, Díaz-Román & Cortese (2018) Evid Based Mental Health
• 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
c
• ADHD runs in families
• More parenting stress
Greven 2014 J Child Psychol Psychiatry | Theule 2013 J Empt Behav Disord
MYmind: involving parents
Child
• 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)
CAU
Endpoint (8 weeks)
Follow-ups (2 & 6 months)
Children + parents
ParentTeacher
Child
N=104
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
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
MindChamp qualitative: feasibility
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
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
MindChamp qualitative: feasibility
“My child then says: ‘Mum, breathe.’ And that we then can talk about it, that we need a short break to calm down.”
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
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
MindChamp qualitative: feasibility
“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!”
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
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
MindChamp qualitative: feasibility
“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.”
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
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
MindChamp qualitative: feasibility
“I think she is mentally too young. To understand what it was really about.”
MindChamp qualitative: effects
MindChamp qualitative: effects
“I keep getting better and better in seeing how he deals with things and what kind of help he needs.”
MindChamp qualitative: effects
• Warmer relationships
• Conversations
• Fewer fights
MindChamp qualitative: effects
“We realized that it is extremely important that we let her be herself and not always try to fit her in the perfect picture.”
MindChamp qualitative: effects
“My dad and I are both really impulsive and explode easily. That happens a lot less now after the mindfulness training.”
MindChamp qualitative: effects
• Attention
• Planning
• Keeping structure
MindChamp qualitative: effects
MindChamp qualitative: effects
MindChamp qualitative: effects
• 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?
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 | [email protected]
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
1% 2%
16%
58%
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)
Analysed (ITT and PP n=47)
Lost to follow-up
(n=7; 2 NCs)
Lost to follow-up
(n=1)
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
(n=1)
)
Analysed (ITT n=46; PP n=45)
Analysed (ITT and PP n=46)
6-month follow-up (n=92)
Endpoint (n=102)
Baseline (n=104)
Child/adolescent studies
Adult studies