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Review article
peer-reviewed

Mindfulness-Based Cognitive Behavioral Therapy as an Adjunct Treatment of Attention Deficit Hyperactivity Disorder in Young Adults: A Literature Review



Abstract

Attention deficit hyperactivity disorder (ADHD) is a childhood-onset neurological disorder that often continues into adult age. Stimulants medication are the mainstay of treatment, however, in the recent years, there has been a lot of studies conducted to understand the effectiveness and feasibility of mindfulness-based cognitive behavioral therapy for treatment of attention deficit hyperactivity disorder in children and adults. In this article, we have reviewed 17 articles to look for the beneficial effects of such therapy in adults. Overall, we found that there is a clear beneficial effect of such therapies, especially when used in adjunct with stimulant medication and may increase overall compliance. For better understanding, we suggest that large, well-designed studies should be conducted with robust strategies, allowing more comparison studies with the better analytical outcome.

Introduction & Background

Attention deficit hyperactivity disorder (ADHD) is a disorder of neurodevelopment in children with high persistence into adulthood. ADHD manifests with high levels of inattention, impulsiveness, and hyperactivity. This condition affects social, academic and occupational functioning. Sign and symptoms of adult ADHD include difficulty prioritizing, organizing, and completing tasks, variable attention to detail, hyperactivity, and reduced impulse control. These deficits often lead to adverse psychosocial outcomes including academic failure, dropping out of school, unintended pregnancy, sexually transmitted infections (STI) exposure, and criminal behavior (e.g.: increased risk of traffic violations). Furthermore, such individuals have lower levels of educational and occupational achievement [1]. Hyperactivity tends to be a less salient feature in adults, but impulsivity and low frustration tolerance are often present to varying degrees [2]. In addition to this, ADHD patients often have one or more comorbid conditions including neurodevelopmental disorders (like dyslexia or autism) and psychiatric disorders (like anxiety or oppositional defiant disorder) [1]. This article will review treatment options for ADHD in adults and about practical and feasible mindfulness-based approaches in treating these symptoms.

Current estimated prevalence of adult ADHD is 4.4% [3]. There have been many limitations in the past for the diagnosis of ADHD. The diagnostic and statistical manual (DSM-4) criteria were constructed with children in mind and offered only limited guidance regarding diagnosis in adults. As a result of relaxing strict age restrictions in DSM-5, estimates of prevalence based on the earlier criteria such as the one cited above should be considered conservative at best. Sixty-five percent of individuals diagnosed with ADHD in childhood continue to experience impairing symptoms at the age of 25 years [1, 4]. A study conducted in Australia comprising of 2179 individuals diagnosed with ADHD and aged 47–54 years (mean age 50.7±1.5 years) showed that inattentive symptoms were more significant compared to hyperactive symptoms (when depressive and anxiety symptoms were controlled) [5]. The inattentive symptoms are most common cause of functional impairment in adult ADHD [6]. The DSM-5 also notes that hyperactive symptoms become comparatively less evident compared to inattentive symptoms and difficulties persist with restlessness, abstraction, poor planning, and impulsivity [7]. A cross-sectional evaluation using the DSM-5 ADHD criteria was carried out in 3574 individuals from the study of 1982 Pelotas Birth Cohort to check the prevalence of ADHD beyond young adulthood [8]. ADHD prevalence rates in this study were found to be 2.1% for DSM-5 ADHD criteria and 5.8% for ADHD, disregarding age-of-onset criterion [8].

Given these, the fifth edition of the Diagnostic and Statistical Manual was released in May 2013 and replaced the previous version, the text revision of the fourth edition (DSM-4). DSM-5 included significant changes in the diagnostic criteria for ADHD and increased the guidance for diagnosing ADHD in adults: (1) Symptoms can now occur at age of 12 years rather than by age six years; (2) Several symptoms now need to be present in more than one setting, than just causing some impairment in more than one setting; (3) New descriptions were added to show the symptoms that might look at older ages; and (4) for adults and adolescents age of 17 years or older, only five symptoms are needed instead of six for younger children [7].

The standard of care for adults has evolved primarily from studies in children and the medications used in adults are the same as those employed in children and adolescents with ADHD. For adolescents of 12–18 years of age, the primary care clinician should prescribe Food and Drug Administration (FDA) approved medications for ADHD, with the assent of the adolescent and may prescribe behavior therapy as a treatment for ADHD, although preferably both medication and behavior therapy should be used together [9]. FDA-approved medications for ADHD in adults include amphetamine mixed salts, atomoxetine, dexmethylphenidate, lisdexamfetamine and methylphenidate [10].

Methylphenidate and amphetamine salts are the stimulant drugs of choice for ADHD treatment. The pharmacological effects of amphetamines occur because of increased presynaptic release of dopamine and other biogenic amines in the brain. Methylphenidate inhibits the reuptake of dopamine and norepinephrine. Lisdexamfetamine (prodrug of dextroamphetamine) has decreased abuse potential. Atomoxetine, a selective norepinephrine reuptake inhibitor is an alternative non-stimulant drug for ADHD but it is less efficacious than stimulants. Stimulants are safe, but weight loss, insomnia, headache, and anorexia are the most common adverse effects. They also carry a significant risk of abuse and dependence [11].

Although, pharmacological treatment has thus shown to be effective in reducing ADHD symptoms, about 10-30 % of adults with ADHD do not adequately respond to stimulants and others choose to discontinue stimulant treatment due to adverse effects like decreased appetite, dry mouth, tension, or jitteriness [12].

As such, there are a number of reasons for pursuing alternative or adjunctive treatments for ADHD in adults: some patients experience side effects of the stimulant medications use; others experience only a 30% reduction in symptoms; such stimulants are less effective in adults than in children and some patients are not willing to undergo pharmacological treatment. Because many patients undergoing pharmacotherapy still experience functional deficits related to decreased self-monitoring, inattention and mood disturbance. Interventions such as mindful awareness practices that directly address these problems could be used as adjuvant treatments [13].

Review

Mindfulness-based interventions are a type of cognitive training involving various strategies to improve attention, affective self-regulation, tranquility and better quality of life in a healthy population [14]. With the help of functional magnetic resonance imaging (fMRI) studies, we have managed to demonstrate the effectiveness of mindfulness training in enhancing the cognitive control and have defined a particular pattern of regional brain activation consistently associated with mindful states [15]. By increasing attention, researchers believe mindful meditation (MT) can improve the core symptoms of ADHD that include task completion, self-regulation and impulse control.

Neuroimaging studies have also determined the overlapping brain regions that are implicated in emotion dysregulation in ADHD and the changes associated with mindful meditation. The areas involved including the prefrontal cortex (including dorsal and ventromedial regions), hippocampus, and amygdala were associated with improvement in emotion regulation after mindfulness training. These areas are also involved in emotional functioning in individuals with ADHD diagnosis [16].

There is a rationale for the mindfulness-based approach to treatment for ADHD. Many studies have measured the impact of mindfulness training in experienced meditators and even a brief training with meditation yields improvements in attention [17]. For instance, one study assessed the impact of five days (20 minutes per day) of meditation against relaxation. The result of the study after treatment showed that the meditation group performed much better on group detection than the relaxation group during the attentional task. Similar findings have been reported following four days of meditation training (20 minutes per day) [18]. Brief mindfulness training has shown improvement in executive functioning, visuospatial processing, and working memory. Findings of this and others studies suggested that even four days of meditation training can enhance the ability to sustain attention [18-19]. Mindfulness-based cognitive therapy (MBCT) is a form of interventional therapy that combines cognitive behavioral therapy (CBT) with mindfulness based meditation. Mindfulness can be defined as paying attention in a particular way and staying focused and relaxed in the present moment. The best approach for MBCT is in a group format with eight weekly sessions each of 2.5 hours and then an off day (silent day). Such group-delivered therapies are often more cost-effective than individual treatment. Furthermore, MCBT has the additional benefit over stimulants of reducing anxiety, depression, and stress in addition to treating the core problem of inattention [20].

Review of ADHD and mindfulness treatment studies

Several recent studies in adult ADHD samples provide promising preliminary support for mindfulness meditation training. There is emerging evidence that mindfulness meditation employed as a neurobehavioral intervention can help ADHD patients to regulate brain functioning and thereby improve the conscious direction of attention and emotional control [21].

We reviewed around 16 studies in recent years on the effects of mindfulness-based cognitive therapies in adults, the majority of which show a clear beneficial effect on ADHD symptoms in adults [13, 22, 23,24,25, 23, 26,27,28, 29,30,31,32, 20, 33,34]. Of 12 studies conducted within the last five years on the effectiveness of mindfulness-based cognitive therapies for ADHD in adults, all showed small-to-significant symptom reductions. A recent study by Cole, et al. in Geneva enrolled 49 adult ADHD patients with inadequate prior response to medication in a one-year program of individual therapy and weekly sessions of group therapy with different modules: mindfulness, emotion regulation, emotional tolerance, interpersonal effectiveness and impulsivity/hyperactivity and attention. Overall, the psychotherapeutic treatment resulted in significant improvements in almost all dimensions. The most important changes were observed for depression severity [Beck Depression Inventory (BDI)-II] (b=-0.30; p <0.0001), ADHD severity [ autism spectrum rating scales (ASRS) total score] (b=-0.16; p< 0.0001), and mindfulness skills [Kentucky inventory of mindfulness skills (KIMS) AwA] (b=0.21; p <0.0001), with moderate to large effect sizes. ADHD patients clearly showed a better pattern of response compared to control groups [34].

Another study conducted in 2015 reported that mindfulness-based cognitive therapy (MBCT) resulted in a significant reduction of ADHD symptoms and the symptom improvement was calculated both by investigators and by self-reported questionnaires [32]. The data clearly shows that mindfulness awareness practices improve attentional performance, affective symptoms, and quality of life in adult ADHD patients and should be considered as a useful complementary treatment in for adults with ADHD.

Conclusions

Adult ADHD can have a huge personal and economic impact. There is strong evidence that medications can be effective in adults, decreasing the symptoms and their sequelae. However, there remains a great need for evidence-based psychosocial interventions to serve as adjunct or alternative treatment for individuals intolerant or not desiring pharmacotherapy. Mindfulness-based cognitive therapy is an effective intervention and can be administered in an economically-feasible group format. Some of the limitations of studies to date include small sample size, single center enrollment, lack of follow-up and lack of control groups. There is a clear need for further research in this area.


References

  1. V A Harpin: The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. BMJ Arch Dis Child. 2004, 90:2–7. 10.1136/adc.2004.059006
  2. Silver, Larry B.: Attention-deficit/hyperactivity disorder in adult life.. Child and adolescent psychiatric clinics of North America. 2000, 9:511-523. http://psycnet.apa.org/psycinfo/2000-00431-004.
  3. Ronald C Kessler, Lenard Adler, M.D. Russell Barkley et.al : The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. Am J Psychiatry. 2006, 163:716-723. 10.1176/ajp.2006.163.4.716
  4. Faraone SV, Biederman J, Mick: The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006. 2005. 36:159–165. 10.1017/S003329170500471X
  5. Das D, Cherbuin N, Butterworth P, et al.: A population-based study of attention-deficit/hyperactivity disorder symptoms and associated impairment in middle-aged adults. PLoS ONE. 2012, 7:10.1371/journal.pone.0031500
  6. Knouse LE, Traeger L, O'Cleirigh C, et al.: Adult attention deficit hyperactivity disorder symptoms and five-factor model traits in a clinical sample: a structural equation modeling approach.. J Nerv Ment Dis. 2013, 201:833-840. 10.1097/NMD.0b013e3182a5bf33
  7. Attention-Deficit / Hyperactivity Disorder (ADHD), Symptoms and Diagnosis. (October 5, 2016). https://www.cdc.gov/ncbddd/adhd/diagnosis.html.
  8. Vitola ES, Bau CH D., Salum GA, et al.: Exploring DSM-5 ADHD criteria beyond young adulthood: phenomenology, psychometric properties and prevalence in a large three-decade birth cohort.. Psychol Med . 2017, 47:744-754. 10.1017/S0033291716002853
  9. Attention-Deficit / Hyperactivity Disorder (ADHD). (October 5, 2016). https://www.cdc.gov/ncbddd/adhd/guidelines.html.
  10. Adult ADHD: Pharmacologic treatment in the DSM-5 era. (2016 October). http://www.mdedge.com/currentpsychiatry/article/114028/adhd/adult-adhd-pharmacologic-treatment-dsm-5-era.
  11. Reddy DS: Current pharmacotherapy of attention-deficit hyperactivity disorder.. Drugs Today (Barc). 2013, 49:647-65.
  12. Janssen L, Kan CC, Carpentier PJ, et al.: Mindfulness based cognitive therapy versus treatment as usual in adults with attention deficit hyperactivity disorder (ADHD). BMC Psychiatry. 2015, 15:216. 10.1186/s12888-015-0591-x
  13. Bueno VF, Kozasa EH, da Silva MA, et al.: Mindfulness meditation improves mood, quality of life, and attention in adults with attention deficit hyperactivity disorder. Neuroimage. 2015, 100:254–262. 10.1155/2015/962857
  14. Chiesa A, Calati R, Serretti A: Does mindfulness training improve cognitive abilities? A systematic review of neuropsychological findings. Clin Psychol Rev. 2011, 4:449–464. 10.1016/j.cpr.2010.11.003
  15. Bueno FV, Kozasa EH, Aparecida da Silva M, et al.: Mindfulness training modulates value signals in ventromedial prefrontal cortex through input from insular cortex. Biomed Res Int. 2015 , 2015 :1-14. 10.1016/j.neuroimage.2014.06.035
  16. Hölzel BK, Lazar SW, Gard T, et al.: How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Sci. 2011, 10.1177/1745691611419671
  17. Keng S-L, Smoski MJ, Robins CJ: Effects of mindfulness on psychological health: A review of empirical studies. Clin Psychol Rev. 2011, 31:1041–56. 10.1016/j.cpr.2011.04.006
  18. Mitchell JT, Zylowska L, Kollins SH: Mindfulness meditation training for attention-deficit/hyperactivity disorder in adulthood: current empirical support, treatment overview, and future directions. Cogn Behav Pract. 2015, 22:172–191. doi:10.1016/j.cbpra.2014.10.002
  19. Menezes CB, de Paula Cout MC, Buratto LG, et al.: The improvement of emotion and attention regulation after a 6-week training of focused meditation: a randomized controlled trial. Evid Based Complement Alternat Med. 2013, 2013:11. 10.1155/2013/984678
  20. Janssen L, Kan CC, Carpentier PJ, et al.: Mindfulness based cognitive therapy versus treatment as usual in adults with attention deficit hyperactivity disorder (ADHD). BMC Psychiatry. 2015, 15:216. 10.1186/s12888-015-0591-x
  21. Bachmann K, Lam AP, Philipsen: Mindfulness-based cognitive therapy and the adult ADHD brain: a neuro psychotherapeutic perspective. Front Psychiatry. 2016, 27:117. 10.3389/fpsyt.2016.00117
  22. Sandra Schmiedeler: Mindfulness-based intervention in attention-deficit-/hyperactivity disorder (ADHD). Hogrefe. 2015, 43:123-131. 10.1024/1422-4917/a000341
  23. Hepark S, Kan CC, Speckens A: Feasibility and effectiveness of mindfulness training in adults with ADHD: a pilot study. Tijdschr Psychiatr. 2014, 56:471-6.
  24. Mitchell JT, McIntyre EM, English JS, et al.: A pilot trial of mindfulness meditation training for ADHD in adulthood: impact on core symptoms, executive functioning, and emotion dysregulation. J Atten Disord. 2013, 10.1177/1087054713513328
  25. Edel MA, Holter T, Wassink K, et al.: A comparison of mindfulness-based group training and skills group training in adults with ADHD: an open study. J Atten Disord. 2014, 21:10.1177/1087054714551635
  26. Neece CL: Mindfulness-based stress reduction for parents of young children with developmental delays: implications for parental mental health and child behavior problems. J Appl Res Intellect Disabil. 2014, 27:174–186. 10.1111/jar.12064
  27. Schoenberg LA, Hepark S, Kan CC, et al.: Effects of mindfulness-based cognitive therapy on neurophysiological correlates of performance monitoring in adult attention-deficit/hyperactivity disorder. Clin Neurophysiol. 2014, 125:1407–1416. 10.1016/j.clinph.2013.11.031
  28. Anderson SB, Guthery AM: Mindfulness-based psychoeducation for parents of children with attention-deficit/hyperactivity disorder: an applied clinical project. J Child Adolesc Psychiatr Nurs. 2015, 28:43–49. 10.1111/jcap.12103
  29. Bueno VF, Kozasa EH, Aparecida da Silva M, et al.: Mindfulness meditation improves mood, quality of life, and attention in adults with attention deficit hyperactivity disorder. Biomed Res Int. 2015, 2015:1-14. 10.1155/2015/962857
  30. Cassone AR: Mindfulness training as an adjunct to evidence-based treatment for ADHD within families. J Atten Disord. 2015, 19:10.1177/1087054713488438
  31. Fleming AP, McMahon RJ, Moran LR, et al.: Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students. J Atten Disord. 2015, 19:10.1177/1087054714535951
  32. Hepark S, Janssen L, de Vries A, et al.: The efficacy of adapted MBCT on core symptoms and executive functioning in adults with ADHD: a preliminary randomized controlled trial. J Atten Disord. 2015, 10.1177/1087054715613587
  33. Modesto-Lowe V, Farahmand P, Chaplin M, et al.: Does mindfulness meditation improve attention in attention deficit hyperactivity disorder?. World J Psychiatry. 2015, 5:397-403. 10.5498/wjp.v5.i4.397
  34. Cole P, Weibel S, Nicastro R, et al.: CBT/DBT skills training for adults with attention deficit hyperactivity disorder (ADHD). Psychiatr Danub. 2016 , 28:103–107.
Review article
peer-reviewed

Mindfulness-Based Cognitive Behavioral Therapy as an Adjunct Treatment of Attention Deficit Hyperactivity Disorder in Young Adults: A Literature Review


Author Information

Muhammad Aadil Corresponding Author

Department of Medicine, FMH College of Medicine and Dentistry, NEWARK, USA

Rosario M. Cosme

Child Psychiatry, Rush University Medical Center, Chicago, USA

Jonathan Chernaik

Child Psychiatry, Rush University Medical Center


Ethics Statement and Conflict of Interest Disclosures

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


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