As a student of psychology, and an aspiring mental health practitioner, one of my key areas of interest involves understanding new forms of interventions and uncovering their evidence base (my previous blog on play therapy can be found here). For my MSc dissertation, I’ve been investigating the efficacy of both pharmaceutical and non-pharmaceutical interventions for Attention Deficit Hyperactivity Disorder (ADHD) in childhood.
ADHD is a neurodevelopmental disorder marked by inattention, hyperactivity, and impulsivity, causing significant impairment in daily functioning, and is one of the most common mental health conditions affecting children. Over the past few months, identifying studies relevant to my project has sparked my curiosity to learn more about the novel, contemporary approaches to treating childhood ADHD. As I attempted to sift through 4,200 odd studies, I began to discover and better understand the application and efficacy of mindfulness-based interventions (MBI) among children with ADHD symptomatology.
Through this blog, I will attempt to understand the current research base on this topic, and where we can go from here.
Can Mindfulness be linked with ADHD?
The concept of mindfulness was something I came across during the peak of lockdowns in India, in 2020. Mindfulness refers to having the knowledge of what we’re feeling, and accepting that feeling as it occurs, in the present moment. Through this process, we give ourselves the chance to freely accept all thoughts and feelings, be it something that makes us happy, or something that’s uncomfortable.
Flash forward to June 2022, when I began to ask myself why we aren’t talking about integrating mindfulness-based interventions for ADHD, especially among children enough (trust my “psychology-mode” brain to find every little connection such as this!). I noticed myself picking at the most basic aspects of mindfulness, such as having the knowledge of what goes on within ourselves and reconnecting our mind and body to the current moment.
While this concept is assumed to be one practised and understood only by adults, there are a number of mindfulness exercises that have been adapted to be made more understandable by children.
One example is my favourite, called the Hot Chocolate Breathing exercise. It’s easy to follow, and you can take a moment right now, and do it yourself! Start by holding an imaginary, warm cup of hot chocolate in your hands. Take a deep breath in, and imagine the smell of the warm chocolate entering through your nose. To cool the hot chocolate, breathe out, with your mouth, for four counts.
Through the concept of imagery, this simple, but fulfilling, exercise awakens all the senses within the child, with the thought of something we all love: chocolate. This exercise, though so simple, was meaningful and stuck with me, and I myself have found that it calms me down during moments of anxiety.
Mindful breathing exercises such as this, have benefits over and above feeling relaxed. For example, they can reduce heart rate and blood pressure. Keeping ADHD in mind, studies have shown that rhythmic breathing also helps regulate the autonomic nervous system, which provides both, an increase in attention levels as well as relaxation.
ADHD is one such neurodevelopmental disorder that has multiple aspects, from hyperactivity to inattention and impulsivity. Mindfulness, at its core, can help to better manage these symptoms for children in environments such as at school, or when playing at home. Through mindfulness exercises, mental health practitioners can provide children with a mindfulness “toolkit” of sorts, equipping them with the skills necessary to focus on the present moment (further information can be found here).
What are the current MBIs, and do they have an evidence base?
Given that a core principle of mindfulness is being in the ‘here and now’, I sought to understand if, and how, MBIs can be especially fruitful to reduce inattention-related symptomology in the spectrum of ADHD.
While most studies I’ve come across in ADHD literature focus on medication-based intervention, the past few years have witnessed an increase in literature on MBI, especially as individuals in the field aim to integrate non-pharmaceutical interventions into the treatment of ADHD.
A popular 2008 study was a catalyst in understanding MBIs for adolescents and adults, but the question I asked myself was if, and how we can integrate similar approaches among school-aged children. Twenty-four adults and 8 adolescents participated in an 8-week-long mindfulness training programme, following a format consisting of opening meditations, discussions, and practice exercises. The programme was well received by both age groups and found improvements in self-reported ADHD symptoms.
What I find particularly interesting is the fact that there is no one approach to mindfulness. Researchers and practitioners have developed various programmes, either at an individual, or a family level.
Two techniques — Mindfulness-based stress reduction (MBSR) training, and Mindfulness-based Cognitive Therapy (MBCT) — have been discussed in emerging literature surrounding this topic. MBSR is an 8-step stress reduction programme that allows individuals to gain awareness about their behaviour in relation to stressful situations. MBCT combines mindfulness and cognitive behavioural therapy practices and consists of learning meditation techniques.
MBSR techniques were originally developed in the 1970s to effectively manage pain and stress, but recent studies have diversified this technique among children with ADHD and their parents. For example, a 2020 study found that an adapted MBSR intervention (delivered to parents and children) led to significant reductions in ADHD symptomology, especially those relating to hyperactivity.
Interestingly, MBSR techniques involve practices such as yoga and meditation, and while the image of a young child sitting in a meditative position might seem absurd, emerging literature has indeed attempted to portray just the opposite. Though these interventions might require adaptations such as smaller groups and the usage of child-friendly imagery, evidence (as portrayed in a 2018 systematic review) found that yoga, meditation, and MBIs had statistically significant effects on ADHD symptoms. In addition, these interventions also found effects on outcomes such as the parent-child relationship.
Among the types of current non-pharmaceutical interventions, parenting interventions have been of great importance in the context of childhood ADHD. More specifically, the past few years have seen ‘mindful parenting’ gaining popularity in this sphere. This concept consists of dimensions such as self-regulating the parenting relationship, listening with full attention, and accepting oneself and the child in a non-judgemental manner, by being present in everyday parent-child interactions.
Research, being innovative as it is, has adapted mindful parenting into specific interventions for childhood ADHD as well. A randomized controlled trial conducted in Iran found that 8 sessions of ‘mindful parenting’ showed a reduction of not only ADHD scores but also parental distress from baseline (before the sessions) to follow-up (8 weeks later), as compared to a control group receiving medication only.
MyMind is an MBI, though originally meant for children on the autism spectrum and their parents, which has been adapted for ADHD. This is an 8-week treatment, based on a group format for children, while their parents parallelly receive mindful parenting training for the same duration. Each session consists of meditation exercises, and homework, and parents are trained to practice meditation exercises with their child. The mindful child training aspect consists of activities centred around enhancing attention, and children are taught to apply techniques learnt in difficult situations.
A 2011 study evaluated MyMind’s efficacy and found that parent-rated ADHD behaviour significantly reduced, along with parental stress. A recent study evaluating the same program found similar results, with parents reporting reductions in inattention problems as well as parenting stress.
To conclude, the interventions and studies I’ve discussed are only the tip of the iceberg in this field, and their results have definitely signposted us in the right direction. While the current evidence base seems to indicate that pharmaceutical intervention might be the most effective, MBIs can be a valuable tool that children can add to their “coping kit”, equipping them with simple, but meaningful exercises that they can make use of in daily life, and social situations. Involving parents and making them play an active role can go a long way in improving the parent-child relationship.