Effectiveness Of A Mindfulness-Based Cognitive Therapy (MBCT) Program For ADHD

Mindfulness-based cognitive therapy (MBCT) is an approach to psychotherapy integrating cognitive behavioral therapy with mindfulness meditation practices. Rather than an standardized program, MBCT uses evidence-based psychological strategies to cultivate moment-to-moment nonjudgmental awareness.

Janssen, L., de Vries, A. M., Hepark, S., & Speckens, A. E. M. (2020). The feasibility, effectiveness, and process of change of mindfulness-based cognitive therapy for adults with ADHD: A mixed-method pilot study. Journal of Attention Disorders, 24(6), 928–942. https://doi.org/10.1177/1087054717727350

Key Points

• The study explored the feasibility, effectiveness, and process of change of an adapted Mindfulness-Based Cognitive Therapy (MBCT) program for adults with ADHD.
• The dropout rate during the MBCT program was 16%, indicating feasibility for most adults with ADHD.
• Significant improvements were found in ADHD symptoms, executive functioning, self-compassion, and mental health after MBCT.
• No changes in mindfulness skills were found, possibly due to the short, 8-week duration of the MBCT program.
• Environmental factors, aspects of the training itself, and participant characteristics emerged as barriers and facilitators to engaging in MBCT.
• The process of change involved stages like stopping, noticing, allowing, gaining insight, changing perspective, improving self-regulation, changing behavior, and experiencing effects.

Rationale

Previous research demonstrated the potential for mindfulness-based interventions (MBIs) to improve attention regulation and executive functioning (Chiesa et al., 2011; Malinowski, 2013; Tang et al., 2015), suggesting mindfulness may benefit adults with ADHD.

A few MBIs adapted for adult ADHD showed preliminary efficacy in reducing core symptoms and improving functioning (Cairncross & Miller, 2016; Hepark et al., 2015; Mitchell et al., 2015). However, further rigorous research was needed to establish feasibility and effectiveness.

Moreover, little was known about ADHD patients’ perspectives on barriers and facilitators to engaging in MBCT. Qualitative research could provide richer insight into their experiences to inform further protocol refinements.

This pilot study aimed to explore feasibility, potential effectiveness in alleviating symptoms, processes of change, and perceived barriers and facilitators of an adapted MBCT program for adult ADHD.

The long-term goal was to develop an evidence-based psychosocial treatment for ADHD, given issues around medication non-response and interest in non-pharmacological options.

Method

This mixed-methods pilot study combined self-report questionnaires on ADHD symptoms and functioning with qualitative semi-structured interviews on barriers, facilitators, and process of change.

• The 8-week MBCT program was adapted from the standard manual to include more movement exercises (e.g., walking meditation) and less homework based on previous research showing these modifications may benefit adults with ADHD.
• Participants attended weekly 2.5-hour MBCT sessions consisting of guided mindfulness meditations, inquiry discussions, psychoeducation, and group activities. They also attended a daylong silent retreat around week 6.
• Semi-structured interviews lasting 30-45 minutes were conducted 3 months into the MBCT program, with patients either in 4 focus groups of 3-6 people each or individually via phone/in-person to accommodate availability.

Interviews were coded for themes by two independent judges using qualitative analysis software. Questionnaire and interview data were analyzed to explore research questions on feasibility, effectiveness, barriers/facilitators, and process of change.

Sample

The sample was composed of 31 adult ADHD patients (mean age 37 years, 55% female) who were referred by psychiatry clinics or general practitioners to participate in the MBCT groups.

Fourteen patients had the inattentive subtype, 14 the combined subtype, 1 the hyperactive/impulsive subtype, and 2 were undifferentiated.

Statistical Analysis

Quantitative pre-post treatment changes were analyzed using paired-samples t-tests and Cohen’s d effect sizes.

Results

Sixteen percent dropped out during the MBCT program. Completers showed significant pre-post improvements in ADHD symptoms, with a 26% clinically significant response rate.

Total executive functioning also improved significantly, mainly in domains of self-monitoring, working memory, planning, task monitoring, and organization.

Further benefits were found in self-compassion and mental health, but not physical health. Mindfulness skills did not significantly change, except for a trend toward increased acting with awareness.

Qualitative analysis revealed facilitators like partner support, clear teacher communication, shared experiences with fellow ADHD participants, reflection exercises, and movement practices.

Barriers included life stressors, switching medication, lack of training repetition, lengthy meditations, self-criticism, procrastination, and ADHD symptoms interfering with participation and home practice.

Most patients described a process of change moving through stages like stopping current activities to focus inward, noticing thoughts/emotions, allowing and accepting experiences, gaining self-insight, shifting self-perspective, improving self-regulation skills, consciously changing behaviors, and enhancing wellbeing and self-compassion.

Insight

This mixed-methods pilot provides preliminary evidence that MBCT may be a feasible and effective psychosocial treatment option for adults with ADHD. The modest dropout rate suggests most could tolerate the training despite ongoing symptoms interfering at times.

Quantitative gains in reducing core ADHD symptoms and improving executive functioning align with benefits seen in previous initial studies of mindfulness for ADHD.

The qualitative interviews deliver valuable insights into patient experiences. They highlight the importance of adaptations like added movement, clear teacher communication, and bonding with fellow participants also facing attention challenges.

At the same time, too extensive changes may reduce effectiveness since patients largely endorsed standard components like reflection, sitting meditation, and the daylong retreat. Dropout predictors like more baseline dysfunction could inform exclusion criteria.

Patient accounts of the change process demonstrate how mindfulness training may impart self-regulation skills needed to moderate ADHD impairments. By repeatedly bringing attention to present experiences, participants cultivated awareness and acceptance of thoughts and emotions rather than over-identifying or avoiding them.

This meta-cognitive shift opened room to pause before responding, enhancing reflection and impulse control. Some translated emerging attentional stability into improved working memory, planning, and task monitoring in daily life.

Many described replacing habitual behaviors with conscious choices more aligned with intentions. Over time, reduced reactivity and self-judgment led to improved well-being.

Strengths

This study has several key strengths:

• Use of a mixed-methods approach, uniquely combining quantitative and qualitative data, allowed for an enriched, multidimensional understanding of MBCT’s utility for adult ADHD. Self-report measures objectively tracked changes in symptoms and functioning pre-to-post treatment. Semi-structured interviews elicited detailed first-hand accounts of participants’ treatment experiences, including nuanced change processes, which supported quantitative findings and have rarely been captured in MBIs for ADHD.
• The qualitative methodology was rigorous, including holding an adequate number of focus groups and interviews until saturation was reached. Using two independent coders enhanced objectivity in identifying themes. Strategies like member checking and triangulation also improved the validity of the interpretations.
• The study population was well-characterized, with 71% meeting criteria for moderate to severe ADHD based on symptom scores. Patients were referred through psychiatric care settings, supporting the clinical relevance and need for psychosocial interventions among adults with impairing ADHD.
• The adapted MBCT protocol preserved core elements of the evidence-based program while incorporating select modifications to facilitate engagement and effectiveness based on prior ADHD research. This allowed assessment of the feasibility of standard components for ADHD while also customizing aspects requiring more attention and behavioral regulation.
• Eight outcome domains were assessed, enabling a broad picture of MBCT’s impact across ADHD symptoms as well as key related areas like executive dysfunction, self-compassion, mental health status, and global functioning often impaired in the disorder.

Limitations

However, certain limitations should be considered:

• The small sample size (N = 31) and use of a within-group pre-post design prevents conclusively determining the efficacy of MBCT for adult ADHD. There was no control group with randomization or controlling for the passage of time. The estimated effect sizes could be inflated without accounting for natural variation over a 2-3 month period. Replication in a large randomized controlled trial (RCT) is warranted.
• Generalizability may be limited regarding the demographic and clinical profiles of participants. The sample was predominantly female, which differs from the ADHD population. They also had high rates of psychiatric comorbidity, like depression and anxiety disorders. Non-completers differed substantially on factors like age, functioning, and mental/physical health. Adaptations may be required with more diverse or symptomatic subpopulations of adults with ADHD.
• Assessments rely exclusively on subjective self-report measures, which can introduce biases like social desirability, especially without corroborating clinician, observer, or performance-based data. More objective neurocognitive or behavioral tests could have complemented patient ratings.
• Follow-up assessments were not conducted, preventing analysis of the long-term sustainability of benefits once the intensive MBCT program ended. Trajectories over months to years will better reveal who maintains gains or relapses to baseline functioning or distress.

Implications

The collective results clearly demonstrate the need for continued optimization and testing of MBCT as an innovative psychosocial option for adults struggling to manage ADHD challenges.

Qualitative endorsements of improved self-regulation and functioning reveal personalized cognitive-emotional and behavioral pathways by which mindfulness training may help mitigate impairments.

Quantitatively corroborating patient-reported alleviations in core symptoms and executive dysfunction signals preliminary clinical efficacy.

Integrating qualitative change models with established theories on cognitive deficits and emotion dysregulation in ADHD could fruitfully advance mechanistic models.

Replication in methodologically rigorous RCTs is imperative, as is determining cost-effectiveness relative to heavily relied-upon pharmacotherapy.

If outcomes withstand further scrutiny, MBCT could significantly expand non-medication choices for those not responding optimally to stimulants or wishing to augment with skill-building approaches.

Once protocols are refined for optimal feasibility and effectiveness, MBCT could be integrated into multidimensional care models in an individual or group format. The group modality provides opportunities to normalize struggles, reduce stigma, and build supportive networks.

Evaluating predictors and moderators of response would facilitate treatment matching and personalization. Digital delivery could enhance accessibility for adults unable to attend intensive in-person trainings.

For relevant populations, combined treatment could potentiate outcomes superior to either standalone option.

Overall, MBCT shows promise for empowering adults to proactively develop capacities for navigating lifelong ADHD symptom management.

References

Primary reference

Janssen, L., de Vries, A. M., Hepark, S., & Speckens, A. E. M. (2020). The feasibility, effectiveness, and process of change of mindfulness-based cognitive therapy for adults with ADHD: A mixed-method pilot study. Journal of Attention Disorders, 24(6), 928–942. https://doi.org/10.1177/1087054717727350

Other references

Cairncross M., Miller C. (2016). The effectiveness of mindfulness-based therapies for ADHD: A meta-analytic review. Journal of Attention Disorders, 1-17. https://doi.org/10.1177/1087054715625301

Chiesa A., Calati R., Serretti A. (2011). Does mindfulness training improve cognitive abilities? A systematic review of neuropsychological findings. Clinical Psychology Review, 31, 449-464. https://doi.org/10.1016/j.cpr.2010.11.003

Hepark S., Janssen L., de Vries A., Schoenberg P. L., Donders R., Kan C. C., Speckens A. E. (2015). The efficacy of adapted MBCT on core symptoms and executive functioning in adults with ADHD: A preliminary randomized controlled trial. Journal of Attention Disorders, 1-12. https://doi.org/10.1177/1087054715613587

Malinowski P. (2013). Neural mechanisms of attentional control in mindfulness meditation. Frontiers in Neuroscience, 7, Article 8. https://doi.org/10.3389/fnins.2013.00008

Mitchell J. T., Zylowska L., Kollins S. H. (2015). Mindfulness meditation training for attention-deficit/hyperactivity disorder in adulthood: Current empirical support, treatment overview, and future directions. Cognitive and Behavioral Practice, 22, 172-191. http://dx.doi.org/10.1016/j.cbpra.2014.10.002

Tang Y.-Y., Holzel B. K., Posner M. I. (2015). The neuroscience of mindfulness meditation. Nature Reviews Neuroscience, 16, 213-225. https://doi.org/10.1038/nrn3916

Keep Learning

Here are some suggested Socratic questions for students to critically analyze and discuss this research paper further:

1. How could this research be expanded to strengthen the evidence base for MBIs in adult ADHD treatment? What outcomes should be measured and how?
2. How might findings differ in more diverse patient samples? Would adaptations be warranted based on factors like gender, ethnicity, culture, or psychiatric history?
3. Could digital or remote delivery enhance accessibility and sustainability of MBCT for ADHD? What features might facilitate adherence and effectiveness? What could be lost without the group format?
4. How could we enrich understanding of the change process? What other phenomenological or mechanistic theories might complement the stage model proposed here?
5. If efficacy is established, what dissemination efforts would promote real-world uptake and access to MBCT for underserved groups with ADHD?