Below this, I present some research on mindfulness interventions - a good study would compare CBT head-to-head with mindfulness for ADHD.
Cognitive Behavioral Therapy vs Relaxation With Educational Support for Medication-Treated Adults With ADHD and Persistent SymptomsThis is from the comments section of the paper (subscription required):A Randomized Controlled Trial
JAMA. 2010;304(8):875-880. doi:10.1001/jama.2010.1192
Context Attention-deficit/hyperactivity disorder (ADHD) in adulthood is a prevalent, distressing, and impairing condition that is not fully treated by pharmacotherapy alone and lacks evidence-based psychosocial treatments.Objective To test cognitive behavioral therapy for ADHD in adults treated with medication but who still have clinically significant symptoms.
Design, Setting, and Patients Randomized controlled trial assessing the efficacy of cognitive behavioral therapy for 86 symptomatic adults with ADHD who were already being treated with medication. The study was conducted at a US hospital between November 2004 and June 2008 (follow-up was conducted through July 2009). Of the 86 patients randomized, 79 completed treatment and 70 completed the follow-up assessments.
Interventions Patients were randomized to 12 individual sessions of either cognitive behavioral therapy or relaxation with educational support (which is an attention-matched comparison).
Main Outcome Measures The primary measures were ADHD symptoms rated by an assessor (ADHD rating scale and Clinical Global Impression scale) at baseline, posttreatment, and at 6- and 12-month follow-up. The assessor was blinded to treatment condition assignment. The secondary outcome measure was self-report of ADHD symptoms.
Results Cognitive behavioral therapy achieved lower posttreatment scores on both the Clinical Global Impression scale (magnitude –0.0531; 95% confidence interval [CI], –1.01 to –0.05; P = .03) and the ADHD rating scale (magnitude –4.631; 95% CI, –8.30 to –0.963; P = .02) compared with relaxation with educational support. Throughout treatment, self-reported symptoms were also significantly more improved for cognitive behavioral therapy (β = –0.41; 95% CI, –0.64 to –0.17; P <001),> more treatment responders in cognitive behavioral therapy for both the Clinical Global Impression scale (53% vs 23%; odds ratio [OR], 3.80; 95% CI, 1.50 to 9.59; P = .01) and the ADHD rating scale (67% vs 33%; OR, 4.29; 95% CI, 1.74 to 10.58; P = .002). Responders and partial responders in the cognitive behavioral therapy condition maintained their gains over 6 and 12 months.
Conclusion Among adults with persistent ADHD symptoms treated with medication, the use of cognitive behavioral therapy compared with relaxation with educational support resulted in improved ADHD symptoms, which were maintained at 12 months.
Trial Registration clinicaltrials.gov Identifier: NCT00118911
They essentially raise the point I want to make - other interventions might be more effective. CBT is easy to use and study, so it gets much more attention than other interventions.The treatment evaluated in this study targeted patients who were taking medications for ADHD but still had residual symptoms. Further study is required to examine whether this cognitive behavioral therapy intervention may be useful for individuals who may be unwilling or unable, for medical reasons, to take medication for ADHD. Additionally, because the only other tested treatment6 is a group intervention, further investigation is needed to examine whether different patients or settings may be more receptive or conducive to an individual vs a group approach.
This study suggests that cognitive behavioral therapy for ADHD in adults appears to be a useful and efficacious next-step strategy for adults who show continued symptoms despite treatment with medication. Generally, the treatment was well tolerated, with very low drop-out rates, and had positive and sustained effects on ADHD symptoms. Clinical application of these strategies to patients in need is encouraged.
In a meta-study (Knouse, Cooper-Vince, Sprich, & Safren, 2008) of various psychosocial interventions for residual symptoms of ADHD (after pharmaceutical intervention), mindfulness training did prove successful and worth further research (DBT was also quite successful, which combines CBT concepts with mindfulness practices):
Group mindfulness meditation trainingZylowska and colleagues recently tested a novel application of mindfulness-based meditation practice to address the symptoms of adults and adolescents with ADHD [23]. Reasoning that practice of the control of attention required during mindfulness exercises would improve attentional control, distractibility awareness and emotion regulation for these patients, the authors conducted an uncontrolled feasibility study of 24 adults and eight adolescents, examining the effects of an 8-week group-formatted training program. Their Mindfulness Awareness Practices (MAPs) for ADHD involved eight weekly 2.5-h sessions and daily at-home mindfulness practice. Sessions relied heavily on experiential practice of mindfulness skills and also included psychoeducation regarding ADHD, shorter assigned practice periods than in traditional MAPs, emphasis on mindfulness in daily living, visual teaching aids to illustrate concepts and use of self-affirming meditations to address self-esteem issues.
In the study, 75% of adults and 87% of adolescents completed the treatment and the post-treatment assessment for an overall adherence rate of 78% with no specific predictors of dropout identified. The average number of sessions attended was seven. Self-reported at-home practice was 90.3 min and 4.9 days per week for the adults and 42.6 min and 4.02 days for adolescents. Both age groups gave the treatment a very high satisfaction rating. Completers reported a significant decrease in inattentive and hyperactive–impulsive symptoms from pre- to post-treatment via self-report rating scale. A total of 30% of participants showed reductions in symptom scores of 30% or more, which the authors considered clinically significant. Interestingly, subjects also improved in their performance on attention conflict tasks (Attention Network Task, Conflict and Stroop Interference), which require participants to attend and respond to competing aspects of a stimulus. They also improved on measures of set-shifting (trails A and B). However, future investigations will be needed to rule out regression to the mean or practice effects on these tasks. Depression and anxiety symptom scores improved for adults with ADHD, but not for adolescents. The authors of this study conceptualize their treatment as ‘self-regulation training’ and describe how it could be incorporated into a multimodal intervention for adults with ADHD.
AbstractAttention Deficit Hyperactivity Disorder (ADHD) is a disorder characterized by attentional difficulties. Mindfulness is a receptive attention to present experience. Both ADHD and mindfulness are associated with attention and personality. This study tests whether individuals with ADHD have lower mindfulness scores than controls and, if true, whether personality contributes to these differences. 105 adults (half with ADHD) were assessed for mindfulness, using the Kentucky Inventory of Mindfulness Skills, and personality, using the Tridimensional Character Inventory. Individuals with ADHD report themselves as less mindful than non-ADHD controls and more novelty-seeking, less self-directed, and more self-transcendent. Mindfulness is negatively associated with ADHD and positively associated with self-directedness and self-transcendence. Analyses of subscales of mindfulness suggest that ADHD is associated most with the ‘Acting in Awareness’ dimension perhaps due to shared items reflecting attentional variability. The current findings support that a large portion of variability in trait mindfulness can be explained by ADHD status and personality traits of self-directedness and self-transcendence. It further suggests that interventions that increase mindfulness might improve symptoms of ADHD and increase self-directedness and/or self-transcendence.
There is quite of a bit of evidence in other studies that show mindfulness is effective in ADHD. Transcendental meditation has also proven effective:The findings support the hypothesis that individuals with ADHD have lower trait mindfulness than non-ADHD adults. Using regression analyses, approximately half of the variability in trait mindfulness can be accounted for by demographic differences, ADHD status, and personality dimensions of SD, ST, HA, NS, and C. The most significant variables in the model are ADHD, SD, and ST. The overlap of ADHD and mindfulness is largely ascribed to the mindfulness subscale, Acting in Awareness, suggesting that much of the association is due to attention. Because conflict attention has been shown to change in response to mindfulness training (Tang et al., 2007) and to be lower in ADHD on average (Loo et al., 2007), the finding of an association of ADHD and mindfulness, specifically due to items of attention, suggests that mindfulness training might be a viable means of boosting attention in ADHD.
Aside from attentional variability, ADHD and mindfulness are associated with personality. The current study replicates a previously reported association of NS with ADHD (Lynn et al., 2005) but we find no association of NS with mindfulness. Conversely, in the present study, we found no association of HA with ADHD but observed a negative association of HA with mindfulness. Both ADHD and mindfulness are associated with SD and ST in the present study. In contrast to our expectation, we found little support that Cooperativeness is associated with mindfulness in the present study.
Self-directedness is a construct that has great importance in psychological health and well-being. Several decades of research have clearly demonstrated a strong association of positive mental health and high scores on SD (Cloninger, 2004). All personality disorders and many Axis I diagnoses are associated with low scores on SD (Cloninger, 2004). These data suggest that any intervention that improves SD may have a marked influence on treatment success for most, if not all, psychiatric disorders. The current data support the hypothesis that mindfulness and SD are strongly associated but the present data cannot determine causality. Future studies investigating mindfulness training on SD may help shed light on the impact it can have on the self-to-self relationship.
Self-transcendence is a character trait associated with an experience of being part of something greater than oneself, a relationship of self to the universe at large. Individuals low on ST are described as self-oriented, materialistic, irritable, controlling, serious; individuals that score high on ST are described as being judicious, idealistic, transpersonal, faithful and spiritual. The ST construct reflects a non-religious yet spiritual dimension of personality. The positive role of elevated ST in coping with aging, illness or end stage of life is well documented (Cloninger, 2004, 2006). The positive correlation of ST with mindfulness may reflect the necessity to ‘step out of oneself’, to adopt a meta-cognitive stance in mindfulness, and the relationship of ST to such meta-cognition. The previous (Lynn et al., 2005) and current report of individuals with ADHD scoring higher on ST might suggest that they would be more ‘mindful’ in contrast to the current findings. In our analysis of subscales of the KIMS, we found that the association of ADHD was largely with the ‘acting in awareness’ and not the other scales. In fact, the Observing subscale of the KIMS (one most associated with ST) was the only subscale that individuals with ADHD scored equal to non-ADHD individuals. Further work is needed to better understand why ST is elevated in ADHD (we speculate that an over-reliance on right hemisphere processing is a mechanism) but the findings suggest that it might prove to be a useful feature for learning or maintaining a mindfulness practice. An elevated ST in ADHD might make adopting a meta-cognitive stance easier (despite the attentional difficulties) and that might foster greater success when compared to other forms of behavioral intervention. ST is another aspect of character that may increase as a consequence of mindfulness training and when complemented by elevated SD, is known to be associated with well-being. Further research on mindfulness training and these two constructs of character are needed.In summary, the current study suggests that individuals with ADHD are lower on trait mindfulness. Changes in trait mindfulness are evident in pre to post intervention studies of mindfulness training (Carmody, Baer, Lykins E, & Olendzki, 2009) suggesting that mindfulness training may be a useful complementary tool for improving ADHD. In a small feasibility study we found support for this hypothesis (Zylowska et al., 2008). Controlled trials are needed to test this hypothesis and incorporation of both attentional measures (behavior and cognitive) and personality assessments are needed. The trait measures of mindfulness are also associated with two personality dimensions, self-directedness and self-transcendence, suggesting that training may also affect these two constructs, both important for overall wellbeing. Future work is needed to elucidate causal relationships between ADHD, mindfulness and character development.
Grosswald, S. J., Stixrud, W. R., Travis, F., & Bateh, M. A. (2008, December). Use of the Transcendental Meditation technique to reduce symptoms of Attention Deficit Hyperactivity Disorder (ADHD) by reducing stress and anxiety: An exploratory study. Current Issues in Education [On-line], 10(2). Available: http://cie.ed.asu.edu/volume10/number2/Here are a few paragraphs from the discussion:
My point is that while CBT might work, my sense is that it does not get to real issue, which is attentional skills. Mindfulness and meditation seem to get at the root issue and provide skills transferable to other areas of life.Even though the majority of subjects in the study were taking medication for ADHD and comorbidities, they were still experiencing cognitive and psychosocial symptoms extensive enough to present problems in school and at home. An effective non-pharmacolcogical option that can improve these symptoms would provide a valuable treatment option, whether alone or as an adjunct to medical and behavioral interventions. Because the Transcendental Meditation technique does not require focus or concentration, it seems well suited for children struggling with ADHD. This study indicates that children with ADHD can successfully learn the Transcendental Meditation technique and practice it on a regular basis.
We hypothesized that the Transcendental Meditation technique would have a positive effect on stress, anxiety, and ADHD symptoms. Results support to this hypothesis, showing significant pretest-post test improvements. The student ratings of positive effects were corroborated by the teacher ratings with high levels of confidence. Our secondary hypothesis was that the Transcendental Meditation technique would improve executive function. Statistically significant improvements were noted on both the teacher rated BRIEF and on the performance tests.
Stress and anxiety can overwhelm and lessen the effectiveness of the individual. Anxiousness contributes to poor impulse control, inability to sustain attention, impaired working memory, and lack of cognitive flexibility. This raises the question as to whether, in some cases, it is the symptoms of stress and anxiety that are being diagnosed as ADHD. Whether these problems are a result of ADHD or are the cause of ADHD-like symptoms, this study suggests that reducing stress and anxiety by the Transcendental Meditation technique can potentially improve ADHD symptoms and executive functions.
These results are consistent with previous research on the Transcendental Meditation technique showing reduced anxiety, increased emotional regulation, and improved social behavior in non-ADHD students. Improved executive function noted in our study is also consistent with research on the TM technique showing increased frontal brain coherence, which is associated with more effective executive functioning, improved attention, greater emotional stability, and decreased anxiety.
Compared to other meditation techniques, the Transcendental Meditation technique may be particularly suited to children with ADHD. It is easy to learn and is learned in less than an hour. The technique does not involve controlling the mind; and it requires no other time investment than the 10-15 minute sessions twice a day. Yet changes in the brain are seen within a short time (Travis & Arenander, 2006). Different meditation techniques have different effects. A study of the effects of mindfulness meditation in adults and adolescents with ADHD (Zylowska, et al. 2007), showed improvements in attention and inhibition among the adolescents. However, that study did not show improvements in anxiety or depression. In contrast, these improvements were seen in our study of the Transcendental Meditation technique. In addition, the TM practice was associated with improved executive function.
The current findings suggest that TM may be a beneficial intervention for students with ADHD, and that it can be practiced comfortably within the typical school day. Studies on student learning have emphasized the importance of “downtime” for integrating new learning. Therefore, two periods a day of deep mental rest would be expected to improve learning and retention in all students.
2 comments:
Hi William,
One way to look at it would be to say that cognitive behavioral training would seem to encourage "vertical" development (as in the Wilber-Combs Lattice), whereas relaxation training would probably tend to encourage some kind of horizontal trained state.
If there were enough vertical development, the person might gain some self-awareness and self-control and the ability to make better choices, whereas relaxation or mindfulness training wouldn't necessarily develop that same sort of vertical self-awareness.
It would be interesting to see whether both CBT and mindfulness together would be better than CBT alone. As well as your question as to whether mindfulness might outperform relaxation techniques.
Very interesting articles it is.
Smith Alan
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