The effectiveness of a mindfulness- based
intervention compared to medication in reducing
ADHD- related symptoms and the working
mechanisms of the mindful parenting intervention.
Annemieke Kloosterman, BSc, and E.I. de Bruin,
Mw. dr.
University of Amsterdam
Research master child development and education
Graduate school of child development and education
Research master thesis
Name: Annemieke Kloosterman
Student number: 11080922
Abstract
Background. Attention- Deficit/Hyperactivity Disorder (ADHD) is a common problem in the
population. ADHD has a significant impact on the life of these children. Therefore, it is important that
effective treatments are developed. Currently, medication is considered an effective treatment for
ADHD, it has however some negative consequences. A promising new treatment is the mindfulness-
based intervention (MBI). It is hypothesized that self- compassion and mindful- awareness of the
parents are working mechanisms of this treatment. Aim. A comparison between medication and a
MBI. Second, analyse the presumed working mechanisms of the mindful parenting intervention.
Method. The participants were randomly assigned to each intervention. A pre-test preceded an
eight-week intervention (either medication or mindfulness), which was followed by a post-test. After eight
weeks a follow- up test was administered. Several variables were included in the analysis: ADHD-
related symptoms, mindful awareness, self-compassion and perceived amount of stress. For the
comparison a longitudinal multilevel analysis was performed. Furthermore, a simple mediation
analysis was performed for both mediators. Results and conclusion. The medication intervention was
an effective treatment according to all assessors between pre-test and follow-up. The time of impact
was between pre-test and post- test. The mindfulness intervention significantly reduced the attention
problems according to the most involved parents, but not according to the least involved parents and
teachers. The LIP rated a significant reduction in hyperactivity/impulsivity problems, but the MIP and
teachers did not. Self- compassion was a working mechanism of the mindfulness intervention and
mindful awareness was not.
Introduction
Nowadays, children need all kinds of skills to participate in the school, e.g. concentrate, listen and spend hours sitting still. For children who have attention deficit/ hyperactivity disorder (ADHD), this is extremely difficult. Individuals that suffer from ADHD experience life- lasting problems with attention and hyperactivity/impulsivity. These problems interfere with child development and/ or daily life functioning (American Psychiatric Association, 2013). ADHD has a high comorbidity, with for example depression, anxiety, conduct disorder and oppositional disruptive behaviour (Wehmeier, Schacht & Barkley, 2010). The prevalence of ADHD in the Dutch society is high, 2.2- 4.6% (de Graaf, ten Have, van Gool & van Dorsselaer, 2012; Polanczyck et al., 2007), which makes ADHD an important issue. The direct cause of ADHD is unknown, however, there are indications for a neurobiological origin. Children with ADHD seem to have smaller gray matter volumes compared to those without ADHD, seem to have a poorer communication between the prefrontal cortex brain structures, which rely for communication on the neurotransmitters dopamine and norepinephrine. This may result in problems with goal setting, organizing and planning. It is suspected
that children with ADHD have hypoactivity in the prefrontal cortex areas, superior parietal areas, caudate nucleus and thalamus, which results in problems with tasks requiring attention and response inhibition (Modesto- Lowe, Farahmand, Chaplin & Sarro, 2015). ADHD impacts the development and/or daily life functioning of children. They are more likely to engage in risk- and disruptive behaviours and tend to perform worse in social and academic settings. They are at risk for low levels of well- being, self- worth, poor coping skills, a low family involvement and high levels of emotional and somatic symptoms (Riley et al., 2006). Also ADHD is highly heritable, which results in a higher chance of having a parent with ADHD (Faraone et al., 2005).
There is also an impact on the relationship with the parents, which seems to be more stressful. It is more likely that parent- child conflicts occur. Also adolescents with ADHD, tend to be less responsive, more hostile and more avoidant towards their parents. Parents tend to be lenient in some disciplining occasions, whereas they can be harsh in others (Wehmeier et al., 2010). Research showed that parents rated the quality of life of their children as impaired, but children did not (Dankaerts et al., 2010; Riley et al., 2006). The relation between the severity of the
ADHD- related symptoms and/or presence of comorbidity and the perceived quality of life seems to be linear (Dankaerts et al., 2010).
There are also enormous economical and societal costs related to ADHD. In the Netherlands, the medical costs per child with ADHD per year were €1173 and €177 for a control group (Hakkaart- van Roijen, Zwirs, Bouwmans, Tan, Schulpen, Vlasveld & Buitelaar, 2007). Persons with childhood ADHD are two- to three times more likely to be arrested, convicted and incarcerated than controls. Also, the risk of recidivisms is higher (Mohr- Jensen & Steinhausen, 2016). Because of the enormous impact of ADHD on the child, the family and the society, it is important to develop effective treatments.
Currently, medication is the most commonly prescribed treatment. Short- acting methylphenidate (MPH), also known as Ritalin, is the most prescribed medication (Schachter, Pha, King, Langford & Moher, 2001). MPH increases the amount of noradrenaline and dopamine through the reuptake inhibition of the noradrenaline transporters (Rubia et al., 2013). A meta- analysis (N = 24), conducted to analyse the effect of medication, a behavioural treatment or both, showed that both medication as well as the combined conditions were equally effective in the reduction of ADHD- related symptoms, which implies that there was no additive effect of the behavioural intervention (Van der Oord, Prins, Oosterlaan & Emmelkamp, 2007). Another study showed that MPH increases the activation of a key area of cognitive control/saliency detention, that has been found to be decreased in activation in persons with ADHD and has an effect on disorder- relevant functions, namely inhibition, attention and timing (Rubia et al., 2013). Retrospective fMRI studies show that long term medication effects include a more normal basal ganglia structure, more normal striatal function during attention tasks, more normal white matter and cortical thinning development in left bilateral inferior frontal cortex (IFC), premotor and parietal regions. However, retrospective studies cannot determine causality, because the developments can be influenced by factors other than the intake of medication (Rubia et al., 2013).
Medication also has disadvantages. It can cause adverse effects, like decreased appetite, insomnia and stomach ache (Schachter et al., 2001). Moreover, the costs of medication and the medical care involved (Hakkaart- van Roijen et al., 2007). Besides, medication seemed to have little effect on the academic functioning of the children (Van der Oord et al., 2007). Also the use of medication for the long- term was associated with abnormally high levels of striatal DAT, which suggests an adaption of the brain to the medication and a tolerance for long- term medication (Rubia et al., 2013).
An alternative treatment is a behavioural parent training (BPT). In which parents learn techniques to alter the behaviour of their children, by
encouraging positive behaviour and ignoring or altering negative behaviour (Chronis, Chacko, Fabiano, Wymbs & Pelham, 2004). Although BPT has proven to be effective, the level of effectiveness variates greatly (Chronis et al., 2004; Hoofdakker, Nauta, Dijck-Brouwer, van der Veen- Mulders & Sytema, 2012). This seems to be related to a specific gene, DAT1, which impacts the dopamine transporters, which have an impact on the susceptibility of children to the environment (van den Hoofdakker et al., 2012). Furthermore, non- response to BPT is also related to ADHD of the parents, which is likely given the high heritability of ADHD (Faraone et al., 2005; van den Hoofdakker et al., 2012). Given the disadvantages of both interventions, it is important to keep searching for new effective treatments.
New innovative interventions that have shown promising results in the treatment of ADHD and are increasing in popularity, are the mindfulness- based interventions (MBIs). Mindfulness can be thought of as moment- to- moment, non- judgmental awareness, cultivated by paying attention in a specific way, that is, in the present moment, and as non-reactively, as non- judgmentally, and as openheartedly as possible (Kabat- Zinn, 2015). MBIs are expected to have an impact on several levels: the behavioural symptoms of inattention and impulsivity, the neurocognitive deficits of attention and inhibition and the secondary impairments of stress, anxiety and depression (Househam & Solanto, 2016). The basic elements of a MBI are intention, attitude and attention (Zylowska et al., 2008). A meta- analysis aimed at different types of MBIs all aimed at children with different problems, e.g. ADHD, showed that there was a significant improvement of mindfulness and attention (Zoogman, Goldberg, Hoyt & Miller, 2015).
MBIs aimed at ADHD showed promising results with respect to reducing ADHD- related symptoms. Zylowska et al. (2008) conducted a study to assess the feasibility of a MBI for ADHD. They concluded that it was a feasible intervention and had a positive effect on conflict attention and set- shifting in participants. Another MBI aimed at externalizing problems, including ADHD, resulted in an improvement on personal goals, attention, awareness, impulsivity, being attuned, social problems, happiness and internalizing- and externalizing problems, which were also maintained at the eight week follow- up (Bögels, Hoogstad, van Dun, de Schutter & Restifo, 2008). An MBI aimed at children with ADHD and their mothers, resulted in a significant increase of the compliance of the child in the mother- child relationship (Singh et al., 2010). Another study (n = 18) showed a significant reduction in ADHD- related symptoms of the children, according to the parents, but not according to the teachers. The ADHD- related symptoms, overreactive parenting and parental stress of the parents were also significantly reduced from pretest to follow-up (Van der Oord, Bögels & Peijnenburg, 2012). Another study showed a
significant reduction in externalizing, internalizing and inattentiveness in participants with ADHD directly after the intervention (Van de Weijer- Bergsma, Formsma, de Bruin & Bögels, 2012). An independent study, conducted by Haydicky, Wiener, Badali, Millgan & Ducharme (2012), found that a MBI reduced adolescent inattentiveness and conduct problems, improved peer relations, reduced parenting stress and increased parental mindfulness. These results were maintained or improved upon after the intervention ended. A meta- analysis by Cairncross & Miller (2016), which included the following studies mentioned above: Haydicky et al. (2013), van de Weijer- Bergsma et al. (2012), van der Oord et al. (2012) and Zylowska et al. (2008), examined the potential benefits of MBI’s for ADHD- related symptoms for adults and children. They concluded that MBI’s significantly reduced inattention in individuals in ADHD. However, there seemed to be a larger reduction in the adult studies, compared to the children. The symptoms of hyperactivity/impulsivity were also significantly reduced, independently of age. Preliminary evidence seems to show the effectiveness of MBIs in reducing ADHD, therefore a subsequent question is: ‘how are these effects established with the MBI?’ i.e. what are the mechanisms of change of the intervention. The mechanisms of change provide an explanation for what makes the intervention work and therefore they are the strength of the intervention and could provide a starting point for the development of new interventions or for the improvement of the MBI. The MBI can be divided into two parts, the intervention aimed at the children and the intervention aimed at the parents, the mindful parenting intervention (MPI). This thesis studied the mechanisms of change of this MPI.
Two possible mechanisms of change for the relation between the type of intervention and perceived stress of the parent are mindful awareness and self- compassion of the parents. The first potential mechanism of change is mindful awareness, which can be defined as ‘paying attention in a particular way: on purpose, in the present moment and non- judgmentally’ (Kabat- Zinn, 2015). Mindful awareness has been shown to be a mechanism of change for several outcome variables in MBI’s aimed at different disorders (e.g. depression) (Bränström, Kvillemo, Brandberg & Moskowits, 2010; Gu, Strauss, Bond & Cavanagh, 2015; Keng, Smoski, Robins, Ekblad & Brantley, 2012; Nyklíček & Kuijpers, 2008). It is expected that an increase in mindful awareness in the parents results in a decrease in perceived stress. Also that there will be a significantly larger increase in mindful awareness in the mindfulness group compared to the medication group, since the parents in the mindfulness group receive a MBI in contrast to the other group.
The second mechanism of change that is studied is self- compassion, which can be defined as:
‘being open to and moved by one’s own suffering, experiencing feelings of caring and kindness toward oneself, taking an understanding, non-judgmental attitude toward one’s inadequacies and failures, and recognizing that one’s own experience is part of the common human experience (Neff, 2003, p. 24). Self- compassion has been shown to be a mechanism of change, i.e. mediator, for mindfulness- interventions aimed at several disorders (Gu et al., 2015; Keng et al., 2012). It is expected that an increase in self- compassion results in a decrease in perceived stress of the parents and that parents that received a MBI will show a significantly larger increase in self- compassion compared to the other parents. It follows that a significantly larger decrease in perceived stress is expected in the parents of the MBI group.
The current study aimed to compare the effectiveness of medication with a MBI. The first research question is: ‘What is the effect of medication versus a mindfulness- based intervention on ADHD- related symptoms in children?’ It is expected that both interventions lead to a reduction in ADHD related symptoms in the children. It is expected that medication establishes a greater effect between pre-test and post- pre-test compared to the MBI. However, it is interesting to see what happens with this difference over time. A second aim was to investigate the working mechanisms of the MPI, therefore the second research question is: ‘Are self- compassion and mindful awareness of the parents working mechanisms of the mindful parenting intervention?’. There is as far as I am aware of, no literature on the mechanisms of change of the MPI aimed at ADHD.
Methods
Children with ADHD, their parents and their teachers participated in a multiple measurements study of the effect of a medication intervention and MBI on the ADHD- related symptoms. The study consisted of three measurement occasions, a pre-test, a post- test and a follow- up measurement after eight weeks. Participants.
All participants were randomly assigned to two groups. One group received a MBI, the other medication. In this study 18 families were included in the medication group and 21 families in the mindfulness group. Both parents of a child were divided in a most involved- and a least involved parent. The parent became automatically most involved if there was only one parent. The most involved parent was present at all the appointments concerning ADHD and participated in the MBI if the child was allocated to this intervention. Furthermore, the most involved parent filled in more questionnaires. The teachers also rated the ADHD- related symptoms in children at pre- and post- test.
The most involved parents in the medication group consisted of 17 females and 1 male and the mindfulness group of 20 females and 1 male. Mean parental age in the medication group was 43.1 (SD =
5.6) and 44.8 (SD = 5.7) in the mindfulness group. The least involved parents in the medication group consisted of 17 males and 1 female and the mindfulness group of 19 males and 2 females. Mean parental age in the medication group was 44.3 (SD = 5.0) and 48.5 (SD = 4.9) in the mindfulness group.
In the medication group, 13 boys and 5 girls were included and in the mindfulness group 13 boys and 8 girls. The mean IQ of the children was 102.1 (SD = 13.2) in the medication group and 105.0 (SD = 10.7) in the mindfulness group. The mean age of the children was 10.8 (SD = 2.9) in the medication group and 11.4 (SD = 2.1) in the mindfulness group. In the medication group, 12 children were in primary- and 6 in secondary education. In the mindfulness group, 14 children were in primary- and 7 in secondary education.
Inclusion criteria were: 1. DSM classification of ADHD. 2. ADHD is verified by the standardized structured DSM interview. 3. IQ > 80. 4. participants are able to participate the first mindfulness session, with a minimum of 6 out of 8 sessions. 5. one or both parents are willing to participate in the MPI. 6. child is between 9 and 18 years of age. 7. participating parents and children have to be able to participate in the booster session 8 weeks after the end of the MBI. Exclusion criteria were: 1. inadequate mastery of the Dutch language by child or parents. 2. suffering from psychosis, schizophrenia or untreated post-traumatic stress disorder. 3. co-morbid conduct problems that are so severe that interaction/ talking between parent and child is not possible. 4. current or previous use of ADHD- medication in the past year. 5. current or previous participation in mindfulness training in the past year. 6. participation in a currently active other psychological intervention. Criteria 2-6 apply to the child only (Meppelink, onderzoeksprotocol, version 3).
Procedure
Two institutions were included in this research, in Amsterdam and Roermond, each provided both interventions. Children and their parents were thoroughly informed on the procedure of the research and the randomization. If parent(s) and child agreed to participate in the research, an intervention was randomly assigned, followed by a pre-test. Subsequently, after an eight- week intervention, a post-test was conducted. Thereafter, the mindfulness group received an eight-week rest period, in which they were encouraged to practice mindfulness, followed by a booster session combined with a follow- up test. The medication group continued their medication for eight weeks followed by a follow-up test. Figure 1 describes the research procedure. This study was approved by the medical research ethics committee, in Dutch ‘medische ethische toetsing commissie (METC). The METC number is 2013_383.
Figure 1. The design of the study and measurement
occasions.
The mindfulness- based intervention.
The MBI MYmind was developed at the University of Amsterdam. It is based on Mindfulness- Based Cognitive Therapy (MBCT) and on Mindfulness- Based Stress Reduction Training (MBSR, van der Oord, et al., 2012). Before the start of the intervention, the participants were assigned to either a child (4-6 participants) or an adolescence group (6-8 participants). Also children and their parents met the trainers, to discuss problems they faced, the potential benefits of the MBI, expectations of the intervention, motivation, and the importance of doing homework (van der Oord et al., 2012; van de Weijer- Bergsma et al., 2011).
During the training, children and parents participated in separate groups. Each group, was guided by one or two trainers, which were extensively trained in mindfulness. Furthermore, there were extensive manuals, in which the exercises were described (van der Oord et al., 2012). The training consisted of eight weekly sessions of 1.5 h (Bögels et al., 2008; van der Oord et al., 2011; van de Weijer- Bergsma et al., 2011).
During the training, each session was characterized by an overall theme, for both parents and children. The themes for each session are described in table 1. Participants learned different types of mindfulness exercises, e.g. sitting meditation and body scan (van de Weijer Bergsma et al., 2011). After each session participants received homework, which was described in handouts. Children received points for the completion of homework and compliance during sessions. They received an award for points (van der Oord et al., 2012). Besides this reward system, other measures were taken to enhance children’s motivation and attention: 1. The sessions were similar, highly structured and predictable. 2. group rules were established. 3. a 10-minute break during each session (van der Oord et al., 2012).
Mindful parenting intervention
The MPI was developed for parents experiencing stress due to the challenging upbringing of their child. The amount of stress experienced influences the way of upbringing and the relation with their children and
pre-test medication (8 weeks) post-test MPH (8 weeks) Follow-up pre-test mindfulness (8 weeks) post-test No training (8 weeks) Booster sessie + follow up
their partner. MPI provides another approach of upbringing, especially for parents that suffer from a psychological disorder themselves (Bögels & Restifo, 2013). The parents learn several skills: to be mindfully aware, to be deliberately and fully present in the moment with their child in a non-judgmental way, to take care of themselves, mentally, to accept their child and its challenges and finally they learn not to react to
problem behaviour of their child (van der Oord et al., 2012).
Child training (CT)
The child training is focussed at the enhancement of attention, awareness and self- control. The children learn to apply the exercises in different settings (van der Oord et al., 2012).
Table 1.
The theme and exercises of each session (van der Oord et al., 2012; Bögels & Restifo, 2013).
Session Child- group Theme Child- group Exercises Parent- group Theme Parent- group Exercises 1. From mars Man from mars exercise;
sitting and breathing meditation.
Nurture on the automatic pilot
Man from mars exercise; Psycho-education on
ADHD/mindfulness; breathing meditation.
2. My body Breathing meditation; body- scan; body awareness exercises; yoga- exercises.
Nurture with a beginner’s mind
Breathing meditation; body- scan.
3. My breath Breathing meditation; breath awareness exercises; body- scan; yoga- exercises.
Making contact with your body as a parent
Body- scan; breathing space; breath & body- awareness meditation.
4. Distraction Breathing meditation; distraction awareness exercises; body- scan; yoga- exercises.
Responding vs. reacting to parenting stress
Breath and body awareness meditation; psycho- education stress & automatic responding; exercise awareness of positive interaction with child; breathing space.
5. Automatic responding
Breathing meditation; group- evaluation with parents; breathing space; awareness of automatic responding exercises; body- scan; yoga-exercises.
Parenting habits and scheme’s
Breathing meditation; group evaluation with children; breath and hearing meditation; psycho- education responding to stressful situations with child; using breathing space in stressful situations. 6. Up to now Breathing mediation;
repetition learned skills; breathing space in difficult situations; body- scan; hearing meditation; yoga- exercises.
Conflicts and parenting
Breathing meditation; exercise breathing space in stressful situation with child; body- scan.
7. Practice Breathing meditation; meditations and yoga with children as instructors; looking meditation; body-scan.
Love and boundaries
Breathing meditation; breathing space in stressful situation with child.
8 On my own Together with parents, children lead all types of meditation and yoga; a mindfulness schedule for the next two months is
composed.
Mindful on your way through parenting.
Children as instructors for all types of meditation and yoga; composing of a mindfulness- schedule; evaluation training.
Measures.
Dependent variables.
ADHD-related symptoms.
Parents and teachers reported on the ADHD- related symptoms of the children with the disruptive behaviour disorder rating scale (DBD-RS). This questionnaire measures the ADHD-, ODD- and CD symptoms of children between 6-16. It consists of 42
items, which can be answered on a 4-likert-scale, with answers ranging from ‘not at all’ to ‘a lot’. In this study the subscales: attention problems and hyperactivity/impulsivity problems were used. Both consisted of 9 items. This test has a good reliability and validity (alpha range = .88-.94) (Van der Oord et al., 2012). Internal consistency was good, and test- retest reliability was also high, r = 0.80 (Nederlands
jeugdinstituut, 2010). In this study, internal consistencies for the attention scale were good to excellent, with α = 0.78 at pre-test, α = 0.85 at post- test and α = 0.91 at follow up and also good for the hyperactivity/impulsivity scale, with α = 0.84 at pre- test, α = 0.87 at post- test and α = 0.85 at follow up.
Perceived stress.
The perceived stress of parents is measured with the 10-items perceived stress scale (PSS). This questionnaire assesses the degree to which situations in one’s life over the past month are appraised as stressful. The items can be answered with a 5- likert- scale, with answers ranging from ‘never’ to ‘very often’. This questionnaire has a problem with the internal reliability of the items (r = .60). The test- retest reliability is strongest for shorter time periods. The questionnaire has a reliability and validity of (r = .85) (Cohen, 2006). In this study the internal consistency was good, with α = 0.80 at pre-test, α = 0.78 at post- test and α = 0.87 at follow- up.
Expected mediators of change.
Mindful awareness.
Mindful awareness of the parents was measured with the five facets mindfulness questionnaire (FFMQ). The questionnaire consists of 24 questions, which can be answered on a 5- Likert- scale. The answers ranging from never or almost never true to (almost) always true. In this study the internal consistency was good, with α = 0.77 at pre- test, α = 0.83 at post- test and α = 0.85 at follow- up.
Self-compassion.
Self- compassion of the parents was measured with the self- compassion scales (SCS). This questionnaire consists of 12 items, which can be answered on a 7-likert scale, with answers ranging from ‘seldom or never’ to ‘almost always’. In this questionnaire the internal consistency was excellent, with α = 0.86 at pre-test, α = 0.89 at post- test and α = 0.91 at follow up.
Data analysis.
First, the two groups were compared on key characteristics, such as gender, education and IQ, with a chi-squared test for categorical variables and an independent samples t- test for continuous variables. Second, the effectiveness of both interventions on the ADHD- related symptoms was assessed. Due to the longitudinal design and the manner of data collection, the longitudinal multilevel model was the best method for this analysis, due to the dependency of the data that was collected. The data was dependent since the data
was collected at two institutes, the data has been collected for both parents and teachers about the same child and the measurement occasions are about the same individual.
The multilevel models were selected with a backwards model selection process, using an unstructured covariance structure. First, the process was used to assess the inclusion of co-variables in the model. Possible co-variables were the age of the child, the gender of the child, the preference of treatment of the parent, a clinical score on attention problems and on hyperactivity/impulsivity problems of the parent in models with parents. The age of the child, the gender of the child and the type of education of the child in the models which involved teachers. After the final model was established, the covariance structure with the best fit for the data was assessed. The best fitting covariance structure for all models was the compound symmetry covariance structure. The first order auto regressive model was used for the repeated measures part of the model, which takes the effect of time into account. According to this structure, the further the measurements are apart in time, the smaller the covariance between those points is expected to be. The fit of the different models was compared with a chi-squared test. If the fit of a new model was significantly worse, the previous model was used for the analysis. For the assessment of the effectiveness of the interventions, 16 models were used.
The second part of this thesis was dedicated to the mediation analysis. The sample was somewhat small for this type of analysis. However, due to the fact that this was an exploratory study, to be repeated with a larger sample, this was disregarded for now. The model that was examined is described in figure 2. First the relation between the type of intervention (MBI or medication) and the change in perceived stress was assessed, this is called the total effect (c). The relation between the type of intervention and the change in perceived stress does not need to be significant to perform the mediation analysis (Rucker, Preacher, Tormala & Petty, 2011). Secondly, difference scores between pre-test and follow-up of the supposed mediators, self- compassion and mindful awareness, were added to the equation. If the confidence interval of each of the presumed mediators does not contain 0, it can be concluded that the presumed mediator is in fact mediating the relation between the type of intervention and the change in perceived stress of the parent.
Figure 2. Mindful awareness and self- compassion of
the parents as hypothetical mediators of the relation between the type of intervention and perceived stress of the parents.
Results
Characteristics of the groups
With respect to the characteristics of the most involved parents there were no significant differences between groups regarding gender, X² (1) = 0.01, p = 0.911, being the biological parent, X² (1) = 0.88, p = 0.348, the highest level of education, X² (6) = 8.32, p = 0.216, the clinical score on attention problems of the parent in childhood, X² (1) = 2.70, p = 0.100 and hyperactivity/impulsivity problems, X² (1) = 0.93, p = 0.334, preference for type of intervention before the start of the intervention, X² (4) = 5.07, p = 0.281, and age, t (36) = .90, p = 0.375. These results imply that the groups do not differ on these characteristics.
With regard to the least involved parents, there were no significant differences between groups regarding gender, X² (1) = 0.22, p = 0.643, being the biological parent, X² (1) = 1.81, p = 0.179, the highest level of education, X² (6) = 2.73, p = 0.842, the clinical score on attention problems of the parent in childhood,
X² (1) = 0.00, p = 0.973 and hyperactivity/impulsivity
problems, X² (1) = 2.99, p = 0.084. However, there was a significant difference between groups with respect to the age of the parent, t (36) = -2.7, p = 0.012, with parents in the mindfulness group being older. Furthermore, there was a significant difference between groups with regard to the preference for intervention, X² (4) = 11.67, p = 0.020, where the parent in the mindfulness group had a stronger preference for mindfulness compared to the parents in the medication group. There were also no significant differences between groups with regard to the location of treatment (Amsterdam or Roermond), X² (1) = 0.04,
p = 0.842, for the most involved parent and also not
for the least involved parent, X² (1) = 0.04, p = 0.847. With respect to the characteristics of the children there were no significant differences between groups regarding gender, X² (1) = 0.46, p = 0.496, IQ,
t (34) = 0.71, p = 0.522, primary- or secondary
education, X² (1) = 0.00, p = 1.00, the grade in primary
education, X² (4) = 8.83, p = 0.065, the grade in secondary education, X² (3) = 3.75, p = 0.290, the level of secondary education, X² (2) =2.75, p = 0.154. However, there was a significant difference in age, t (37) = 0.80, p = 0.046, with children in the medication group being older.
Type of ADHD did not differ between groups according to parent-, X² (2) = 2.93, p = 0.231, and children’s ratings X² (2) = 1.23, p = 0.539. Most children were rated with a predominantly inattentive or combined ADHD type.
Of the available data (n = 19) 9 (47%) children had a comorbid anxiety disorder, of which social phobia occurred most frequently (33%), followed by separation disorder (22%), specific phobia (22%), generalized anxiety disorder (22%) and generalized anxiety disorder (11%). Furthermore, 3 (16%) children experienced a mild depressive episode, of which 2 were in the past and 1 currently and 1 (5%) child experienced insomnia.
Furthermore, with regard to the preference of treatment of the parents (n = 78), 76 % of the parents had a preference for the mindfulness intervention, 17% of the parents had no preference and 8 % had a preference for the medication intervention.
The parents reported on their own ADHD-related symptoms with the ZVAH. In childhood 51% of all the parents (n = 78) had a clinical score on attention problems and 24% on hyperactivity/impulsivity problems. At the start of the intervention, 36% of all the parents had a clinical score on attention problems and 22% on hyperactivity/impulsivity problems. There was a significant reduction of the score on attention problems of the most involved parents in the mindfulness group over time, F (2, 27) = 8.05, p = 0.002, but not in the medication group, F (2, 28) = 1.62, p = 0.216. Furthermore, there was a significant reduction in the score on hyperactivity/impulsivity problems of the parents in the mindfulness group, F (2, 33) = 9.52, p = 0.001, but not in the medication group, F (2, 31) = 2.86, p = 0.072.
The comparison between the effectiveness of both interventions
Table 2 represents the descriptive statistics of the ADHD- related symptoms of the children. For the most involved parents, the main effect of type of intervention on attention problems was not significant,
F (1, 38) = 2.22, p = 0.144, which implies that the
impact of the medication- and the MBI on the attention problems is similar. The score on attention problems over time as rated by the MIP is depicted in figure 3. The co-variables that were included in the model did not have a significant effect on the score on attention problems, C-ATT, F (1, 38) = 0.29, p = 0.596, and gender, F (1, 38) = 1.15, p = 0.290. 𝑏1 𝑏2 𝑎2 𝑎1 Δ Mindful- awareness Δ Perceived stress Δ Self- compassion Type of intervention c 𝑐′
Figure 3. The relation between the average score on
attention problems, the type of intervention and the measurement occasion. The bars represent the 95% confidence intervals.
The main effect of type of intervention on hyperactivity/impulsivity problems as rated by the most involved parents was not significant, F (1, 38) = 0.66, p = 0.422, which implies that both interventions had a similar impact on the hyperactivity/impulsivity problems. Figure 4 shows the score on hyperactivity/impulsivity problems as rated by the MIP over time. Both co-variables that were added to the model did not have a significant effect on the score on hyperactivity/impulsivity problems, AGE, F (1, 38) = 0.66, p = 0.690, and C-HI, F (1, 38) = 2.56, p = 0.118.
Figure 4. The relation between the average score on
hyperactivity/impulsivity problems, the measurement occasion and the type of intervention. The bars represent the 95% confidence intervals.
The main effect of type of intervention on the score on attention problems as rated by the least involved parents was not significant, F (1, 38) = 0.66,
p = 0.420, which implies that there is no difference in
the reduction of attention problems between interventions. Figure 5 shows the score on attention problems as rated by the LIP over time. Furthermore, the co-variables that were included in the final model did have a significant effect on the score on attention
problems, gender, F (1, 38) = 9.90, p = 0.005, and C-HI, F (1, 38) = 4.36, p = 0.043, indicating that these factors influenced the score on attention problems for children.
Figure 5. The relation between the average score on
attention problems, the measurement occasion and the type of intervention. The bars represent the 95% confidence intervals.
The main effect of type of intervention on the score on hyperactivity/impulsivity problems was not significant, F (1, 38) = 0.45, p = 0.507. Which implies that the difference in effect between interventions is negligible. Figure 6 shows the score on hyperactivity/impulsivity problems as rated by the LIP over time. The co-variable, C-HI, that was included in the model did not have a significant effect on the score on hyperactivity/impulsivity problems, F (1, 38) = 3.64, p = 0.064.
Figure 6. The relation between the average score on
hyperactivity/impulsivity problems as rated by LIP, the measurement occasion and the type of intervention. The bars represent the 95% confidence intervals.
The main effect of type of intervention on the score on attention problems as rated by the teachers was not significant, F (1, 40) = 9.24, p = 0.884. Which implies that there is no difference in effectiveness of the interventions in the reduction of the score on attention problems.
Table 2.
The descriptive statistics of the ADHD- related symptoms of the children, rated by different assessors.
Note. ATT = attention problems; HI = hyperactivity/ impulsivity problems; LIP = least involved parent; MIP
= most involved parent; M = mean; N = number of participant; SD = standard deviation; T0 = pre- test; T1 = post- test; T2 = follow- up.
Figure 7 represents the score on attention problems over time. The co-variable gender did have a significant effect on the score on attention problems, F (40) = 9.34, p =0.004.
Figure 7. The relation between the average score on
attention problems as rated by teachers, the measurement occasion and the type of intervention. The bars represent the 95% confidence intervals. The main effect of type of intervention on the score on hyperactivity/impulsivity problems was not significant, F (1, 40) = 0.01, p = 0.935. Which implies that there is no difference in effectiveness between interventions. Figure 8 represents the score on hyperactivity/impulsivity problems over time. The main effect of the co-variable gender was not significant, F (1, 40) = 2.62, p = 0.113. The coefficients of the models used to assess the ADHD-related symptoms are described in table 3.
The results of the medication intervention
According to the most involved parents, there was a main effect of time on the attention problems, F (2, 25) = 19.5, p < 0.001, d = 2.03. The score on attention problems at follow-up was significantly reduced compared to pre-test, t (19) = 5.50, p < 0.001. The score on attention problems was not
reduced between post-test and follow-up, t (32) = 0.62,
p = 0.539.
Figure 8. The relation between the average score on
hyperactivity/impulsivity problems, the measurement occasion and the type of intervention. The bars represent the 95% confidence intervals.
The main effect of time on the hyperactivity/impulsivity problems was also significant, F (2, 28) = 19.07, p < 0.001, d = 2.00. From pre-test to follow- up the hyperactivity/impulsivity problems significantly reduced, t (23) = 5.75, p < 0.001. A further reduction did not occur between post-test and follow-up, t (28) = 1.07, p = 0.292.
According to the least involved parents, there was a main effect of time on the score on attention problems,
F (2, 28) = 16.87, p < 0.001, d = 1.94. There was a
significant reduction between pre-test and follow-up, t (18) = 4.70, p < 0.001. No further significant reduction occurred between posttest and followup, t (32) = -0.44, p = 0.666. Furthermore, there was a main effect of time on the score on hyperactivity/impulsivity problems, F (2, 36) = 28.56, p < 0.001, d = 2.52. There was a significant reduction between pre-test and follow-up, t (19) = 7.10, p < 0.001. This change did not occur between post-test and follow-up, t (25) = 0.50, p = 0.624.
Medication intervention Mindfulness- based intervention MIP (N = 18) LIP (N = 18) Teacher (N = 24) MIP (N = 21) LIP (N = 21) Teacher (N = 19) Test M SD M SD M SD M SD M SD M SD T0- ATT 17.0 6.4 15.8 4.8 6.7 4.5 17.3 3.6 13.2 4.8 5.6 4.8 T1- ATT 11.1 5.7 9.7 4.9 2.8 3.9 13.6 5.0 12.6 5.2 4.7 4.9 T2- ATT 10.4 6.0 10.2 4.4 12.7 6.3 11.2 4.9 T0- HI 10.4 5.8 10.9 4.4 3.3 4.2 9.5 5.8 8.9 5.9 3.3 4.6 T1- HI 6.8 3.4 6.8 3.0 1.7 3.7 8.5 6.1 7.5 6.2 2.4 4.3 T2- HI 6.1 3.9 6.4 3.5 8.0 5.6 6.4 5.4
Table 3.
The regression coefficients of the models comparing the two interventions.
Note. ATT = attention problems; C-ATT/C-HI = clinical score of the parent on attention or
hyperactivity/impulsivity problems in childhood; HI = hyperactivity/impulsivity problems; INT = intervention; MPH = medication; T = time; * p < 0.05 and ** p < 0.01.
According to the teachers there was a main effect of time of the medication intervention on the attention problems, F (1, 21) = 19.71, p < 0.001, d = 1.94. There was a significant main effect of time on the hyperactivity/impulsivity problems, F (1, 21) = 8.59,
p = 0.008, d = 1.28, which implies that there was a
reduction in ADHD- related symptoms due to the medication intervention according to the teachers. The results of the mindfulness- based intervention According to the most involved parents, there was a significant main effect of time on the score on attention problems, F (2, 26) = 10.89, p < 0.001, d = 1.44. There was a significant reduction between pre-test and follow-up, t (21) = 4.05, p = 0.001, however not between post-test and follow- up, t (39) = 0.73, p = 0.473. The main effect of time on the score on hyperactivity/impulsivity problems was not
significant, F (2, 28) = 2.21, p = 0.128, d = 0.65. These results imply that the MBI reduced the attention problems but not the hyperactivity/impulsivity problems.
According to the least involved parents, the main effect of time on the score on attention problems was not significant, F (2, 38) = 2.28, p = 0.116, d = 0.71. There was a significant main effect of time on the score on hyperactivity/impulsivity problems, F (2, 26) = 4.07, p = 0.029, d = 0.95. There was a significant reduction between pre-test and follow- up, t (18) = 2.84, p = 0.011. But not between post- test and follow- up, t (37) = 1.37, p = 0.179. These results imply that there was a reduction in hyperactivity/impulsivity problems and not attention problems.
Table 4.
The clinical and sub- clinical score of the children on the ADHD- related symptoms.
Most involved parent Least involved parent Teacher MPH (N = 18) MBT (N = 21) MPH (N = 18) MBT (N = 21) MPH (N = 21) MBT (N = 19) ATT (%) HI (%) ATT (%) HI (%) ATT (%) HI (%) ATT (%) HI (%) ATT (%) HI (%) ATT (%) HI (%) Pre-test C 50 11 62 19 33 17 29 14 5 0 5 5 SC 28 22 24 10 50 17 14 19 10 5 16 10 Post-test C 11 0 38 10 17 0 24 19 5 0 5 5 SC 11 6 10 10 5 0 19 0 0 10 0 0 Follow-up C 11 0 33 10 11 0 10 5 SC 11 11 14 10 11 0 19 14
Note. ATT = attention problems; C = within clinical range; HI = hyperactivity/impulsivity problems; MBT =
mindfulness based intervention; MPH = medication; N = number of participants; SC = within sub-clinical range. Most involved parent Least involved parent Teacher
Specification ATT HI ATT HI ATT HI
Fixed effects Intercept 𝛽00 14.0 (1.5) ** 13.7 (3.6) ** 11.6 (1.2) ** 5.5 (1.2) ** 5.9 (1.0) ** 3.1 (1) ** T (𝛽10) T0 5.3 (0.8) ** 1.4 (0.7) 2.1 (1.0) 2.6 (0.8) ** 0.8 (0.8) 0.8 (0.6) T1 0.6 (0.7) 0.6 (0.6) 1.2 (1.1) 1.1 (0.8) INT (𝛽01) MPH -2.3 (1.5) -2.2 (1.6) -1.5 (1.4) 0.6 (1.6) -1.6 (1.3) -0.6 (1.3) C-ATT (𝛽02) -0.9 (1.7) 2.2 (1.1) * Gender (𝛽03) -1.8 (1.7) -3.4 (1.2) ** -3.7 (1.2) ** -2.0 (1.3) C-HI (𝛽02) 2.7 (1.7) 3.2 (1.7) Age (𝛽03) -0.5 (0.3) T*INT (𝛽11) T0*MPH 2.9 (1.0) ** 3.6 (1.5) * 1.9 (1.1) 2.9 (1.1) * 1.0 (0.8) T1*MPH 0.2 (0.9) -1.7 (1.6) -0.7 (1.1) Random effects
Level 1 intercept variance 14.4 (6.0) * 5.0 (1.4) ** 10.9 (2.3) ** 6.0 (1.4) ** 5.9 (3.1) 4.2 (3.2) Level 2 intercept variance 6.6 (3.5) 8.6 (2.3) ** 3.1 (1.4) * 7.7 (2.1) ** 5.3 (0.0) 5.8 (0)
According to the teachers the main effect of time on the score on attention problems was not significant,
F (1, 19) = 1.40, p = 0.251, d = 0.54. The main
effect of time on the score on hyperactivity/impulsivity problems was also not significant, F (1, 19) = 2.06, p = 0.167, d = 0.66. These results imply that there was no reduction in ADHD- related problems after the MBI according to the teachers.
The clinical score at pre-test compared to post- test and follow- up.
The score on the DBD-RS can be converted into a clinical score. There are three possible outcomes, within the clinical range, within the subclinical range and not within the clinical range. The clinical scores as rated by the most involved-, the least involved parent and the teacher are represented in
table 4. It can be seen that overall the clinical score on attention problems reduced over time.
Results of the mediation analysis
The descriptives of the mediation components are represented in table 5. The change in perceived stress between pre-test and follow- up was significantly correlated with change in mindful awareness between pretest and follow up, r = -0.46, p = 0.001 and with change in self- compassion of the parent between pretest and follow up, r = -0.34, p = 0.012. The correlation between the change in self- compassion and the change in mindful awareness was not significant, r = 0.21, p > 0.05, which implies that there is no dependence between the two presumed mediators, therefore, the dependence does not need to be accounted for in the mediation model.
Table 5.
Descriptives of the variables included in the mediation model.
Medication (N = 24) Mindfulness (N = 30) Change scores T2 – T0
Intervention effect Pre-test Post- test Follow-up Pre-test Post-test Follow-up MPH MBT
M SD M SD M SD M SD M SD M SD M SD M SD F (1, 54) p -value PS 13.3 5.7 11.9 4.4 11.6 5.9 13.7 4.3 11.0 4.1 11.0 5.1 -1.7 6.0 -2.7 3.8 0.10 .750 MA 86.0 9.3 86.3 9.5 86.3 10.9 85.7 8.3 87.4 9.9 88.8 9.5 0.4 7.8 3.2 5.4 0.20 .657 SC 4.9 0.9 4.8 1.0 5.0 1.0 4.6 1.0 5.1 0.9 5.2 0.9 0.1 0.8 0.6 0.7 0.05 .083
Note. M = mean; MA = mindful awareness; MBT = mindfulness- based training; MPH = medication; N =
number of participants; PS = perceived stress; SC = self- compassion; SD = standard deviation; T0 = pre- test; T1 = post- test; T2 = follow-up.
The mediation model that was analysed is depicted in figure 2 in the method section. First, the relation between the independent variable, type of intervention, and the dependent variable, score on mindful awareness between pre-test and follow- up, was examined. Type of intervention did not significantly influence the score on mindful awareness, β = 2.87, p = 0.12. Which implies that the type of intervention did not matter for the change in mindful awareness.
Second, the relation between the dependent variable, change in self- compassion from pre-test to follow- up, and the independent variable, type of intervention was examined. The type of intervention did significantly influence the score on self- compassion, β = 0.47, p = 0.027. This implies that the type of intervention influenced the change in self-compassion, where the parents in the mindfulness group experienced a larger increase in self- compassion than the parents in the medication group. Third, the total effect: the effect of type of intervention on the change in perceived stress was examined. Type
of intervention did not significantly influence the change in perceived stress, β = -1.02, p = 0.456. This implies that type of intervention did not influence the change in perceived stress.
Fourth, both mediators, mindful awareness and self- compassion, were entered in the model. The effect of change in mindful awareness on the change in perceived stress was significant, β = -0.31, p = 0.002, meaning that an increase in mindful awareness resulted in a significant reduction in perceived stress of the parent. Furthermore, there was a significant effect of change in self- compassion on the change in perceived stress, β = -1.75, p = 0.035. Which implies that an increase in self- compassion results in a reduction of perceived stress of the parent. Moreover, the relation between the type of intervention and perceived stress was still not significant after the inclusion of the presumed mediators, β = 0.69, p = 0.589. Figure 9 shows the multiple mediator model between pre-test and follow-up.
Figure 9. The multiple mediator model between
pre-test and follow- up.
The total effect of the type of treatment on perceived stress, without the influence of the presumed mediators was not significant, 95 % CI [-3.76, 1.71]. The confidence intervals of the indirect effects show that self- compassion had a mediating effect between the type of intervention and the perceived amount of stress, 95% CI [-2.23, -0.12] and mindful awareness did not, 95% CI [ -2.56, 0.03]. The indirect effects did not significantly differ from each other, 95% CI [-1.64, 1.33]. When the mediators were added to the model, the direct effect, which accounted for the effect of the presumed mediators, was still not significant [-1.85, 3.22].
Discussion
This study compared the effectiveness of medication to the effectiveness of a MBI in reducing ADHD-related symptoms of children, which were rated by parents and teachers. Furthermore, two presumed working mechanisms of the MBI, self- compassion and mindful awareness of the parents, were assessed. There was no difference in effectiveness between the two interventions. However, medication did significantly reduce all ADHD-related symptoms according to all assessors, and the MBI did not. The time of impact of both interventions was between pre-test and post- test.
An interesting finding is the difference in rating between the most and the least involved parents. The most involved parents rated a significant reduction in attention problems whereas the least involved parents did not. However, the reverse was true for hyperactivity/impulsivity problems: the least involved parents rated a significant reduction in hyperactivity/impulsivity problems whereas the most involved parent did not. A possible explanation for this difference in assessment is the gender of the parent that was assessing, which was mostly female in the most involved parent group
and mostly male in the least involved parent group. This could influence the results in several ways. First, mothers engage more in reading or learning with their child and fathers engage more in rough play (John, Halliburton & Humphrey, 2013). This could result in a different perception of the reduction, since they become more or less apparent in different types of play. Moreover, mothers tend to be more at home than fathers, so they might observe more hyperactivity/impulsivity behaviour. An explanation for the lack of reduction of attention problems according to the least involved parent might be that the IQ of the child has a moderating effect on the perception of attention problems by the parent: if the IQ of the child is higher, the observation of attention problems in the child is more difficult (Sollie, Larsson & Mørch, 2013). Since all children that were included in the study had an IQ > 80 and fathers might engage in less behaviour where attention is apparent, this might affect the perception of the attention problems.
Another interesting finding is that the score on ADHD- related symptoms was rated significantly lower by teachers compared to parents. These findings are in line with the results of a study by Antrop, Roeyers, Oosterlaan and van Oost (2002). They provide several explanations for this phenomenon. It might be caused by the different settings the children are in (school and home). In different settings different problems might be more prominent and more occurring. Also, teachers tend to have more experience with age appropriate behaviour, which could result in a better distinction between problematic- and age-appropriate behaviour. The teachers were not actively involved in the MBI, while parents were. This could mean that teachers assessed the reduction in ADHD- related symptoms more objectively compared to parents. Teachers were more actively confronted with the medication intervention, since the medication is often taken at school, which might cause a bias towards the effectiveness of medication.
Corresponding with findings from other research (Gu et al., 2015; Keng et al., 2012), we found that self- compassion was a working mechanism of the MBI for perceived stress of the parents. Since self- compassion is directly targeted in the MPI, this means the intervention is effective in that area. However, we did not find evidence for mindful awareness as a working mechanism. This is striking since the parents receive MPI and the parents in the medication group do not and the MBI directly targets mindful awareness. A possible explanation for the lack of mediation are the attention problems of parents. 55% of the parents that participated in the MBI had a clinical score on attention problems at the start of the intervention. This might have affected the increase in mindful awareness, since it might interfere with the ability 𝑏1 = -0.31 ** 𝑏2 = -1.75 * 𝑎2 = 0.47 * 𝑎1 = 2.87 Δ Mindful- awareness Δ Perceived stress Δ Self- compassion Type of intervention c = -1.02 𝑐′= 0.69
to pay attention in a mindful way. This theory is supported by the results, since the increase in mindful awareness of parents without attention problems was on average 6.6 points between pre-test and follow-up and the increase was on average 0.8 points for parents with attention problems, t (18) = 2.26, p = 0.037. This suggests that the MBI is less effective for parents with ADHD-related symptoms, similar to the behavioural parent training. However, the difference in increase was only visible in the mindful awareness and not in the amount of self- compassion which could indicate that the difference in effectiveness is restricted to mindful awareness.
Most of the participating children had the predominantly inattentive variant of ADHD. This might have an effect on the results of the MBI, since it seems that the presence of inattentiveness has an impact on the increase in mindful awareness of the parents, this might also apply to children.
Another interesting finding is the reduction of ADHD- related symptoms in the parents that participated in the MBI and not in the medication group. A lot of the parents that participated in the study (56%) had a clinical score on either attention problems or hyperactivity/impulsivity problems. The presence of ADHD- related symptoms in parents affects the severity of ADHD- related symptoms in children, which are more severe if the parent has ADHD (Agha, Zammit, Thapar & Langley, 2013). The presence of ADHD in the parents might have affected the effectiveness of the MBI, since the intervention might be less effective for parents with ADHD, since they are less receptive for an intervention. However, ADHD in parents might also increase the effect, since the symptoms were reduced due to the intervention, which might affect the structure parents are able to provide for their child. This could mean that parental ADHD- related symptoms are a possible working mechanism of the MBI. Singh et al. (2010) found that a MPI alone already established an effect in the ADHD- related symptoms of the children.
The results of the effectiveness of the interventions on the ADHD- related symptoms might have been influenced by the preference for- and expectation of the intervention of the parents. Most of the parents (76%) that participated in the study had a strong or slight preference for the MBI. Furthermore, some of the parents that participated in the study came to the institutions especially for the MBI. Therefore, there might be a bias towards the MBI and its effect due to high expectations of the parents (Constantine, Arnkoff, Glass, Ametrano & Smith, 2010).
This study has several weaknesses. The sample size was relatively small, however, since the aim of this study was to provide preliminary results as a precursor of a larger study, this is less relevant. Furthermore, the comorbidity could not be taken
into account, since the information concerning comorbidity was incomplete. The available information showed that nearly 74 % of the children suffered from comorbid internalizing disorders (mainly anxiety disorders), therefore it might be useful to add a session aimed at these symptoms. Finally, the information on the type of ADHD was limited.
The study also has several strong points. The manner of data collection: the randomization of the children and their parents over the two interventions resulted in comparable groups with regard to characteristics of the children and their parents and preference for intervention. The randomization makes the inference on the outcomes stronger, in spite of the small sample size. Furthermore, since the ADHD- related symptoms were rated by three different informants, the evidence for the conclusions that can be derived from the results is much stronger. Moreover, the MBI is given at only two locations, which results in a highly consistent treatment. The psychologists that give the MBI are trained according to internationally acknowledged standards and receive regular supervision. A standardized trainer’s manual is used, which increases the similarity and the quality of the interventions.
These results show that the MBI is a relevant intervention for ADHD to study. Future research could study the additional effect of a MBI on a medication intervention. Another interesting finding is the lack of increase in mindful awareness due to attention problems. Future research should study other possible working mechanisms of the MBI, for example the ADHD- related problems of the parents, the mindful awareness in the children, self- compassion in the children and emotion regulation. The results of this study show that a MBI is a promising intervention for children with ADHD and their parents, which implies that MBIs could be incorporated in the daily treatment practice.
Conclusion
According to all assessors, there was no difference in reduction of ADHD- related symptoms between the two interventions. Furthermore, there was a significant reduction of the attention- and hyperactivity/impulsivity problems in the medication group, this reduction occurred in the first 8 weeks and stabilized in the next 8 weeks. MBI reduced the attention problems according to the most involved parents, but not according to the least involved parents and the teachers. Moreover, the MBI reduced the hyperactivity/impulsivity problems according to the least involved parents, but not according to the most involved parents and the teachers. In line with the medication group, reductions became apparent in the first eight weeks and remained stable thereafter. Self- compassion
proved to be a working mechanism of the MBI between pre-test and follow- up, but mindful awareness did not.
References.
American Psychiatric Association (2013).
Diagnostic and statistical manual of mental disorders (DSM-5), Washington, D.C.: American
Psychiatric Association.
Bögels, S. M., Hoogstad, B., Dun, L. van, Schutter, S. de, & Restifo, K. (2008). Mindfulness Training for Adolescents with Externalizing Disorders and their Parents. Behavioural and cognitive psychotherapy, 36, 193-209. doi:10.1017/S1352465808004190.
Bögels, S. M. & Restifo, K. (2013). Mindful ouderschap. Een praktische gids voor hulpverleners. Houten, Netherlands: Lannoo Campus.
Bränström, R., Kvillemo, P., Brandberg, Y. & Moskowits, J. T. (2010). Self- report Mindfulness as a Mediator of Psychological Well- being in a Stress Reduction Intervention for Cancer Parients – A Randomized Study. Annals of behavioral
medicine. 39, 151-161. doi: 10.1007/s12160-010-9168-6.
Chronis, A.M., Chacko, A., Fabiano, G.A., Wymbs, B.T. & Pelham, Jr., W.E. (2004). Enhancements to the Behavioral Parent Training Paradigm for
Families of Children with ADHD: Review and
Future Directions. Clinical Child and Family
Psychology Review, 7(1), 1- 27. doi:
1096-4037/04/0300-0001/0.
Cairncross, M. & Miller, C.J. (2016). The Effectiveness of Mindfulness- Based Therapies for ADHD: A Meta- Analytic Review. Journal of
Attention Disorders, 1-17.
doi: 10.1177/1087054715625301.
Dankaerts, M., Sonuga-Barke, E.J.S.,
Banaschewski, T., Buitelaar, J., Döpfner, M.,
Hollis, C., Santosh, P., Rothenberger, A.,
Sergeant, J., Steinhausen, H., Taylor, E., Zuddas, A. & Coghill, D. (2010). The quality of life of
children with attention deficit/hyperactivity
disorder: a systematic review. Europian child
adolescent psychiatry, 19, 83-105.
doi:10.1007/s00787-009-0046-3.
Faraone, S.V., Perlis, R.H., Doyle, A.E., Smoller, J.W., Goralnick, J.J., Holmgren, M.A. & Sklar, P. (2005). Molecular Genetics of Attention-Deficit/Hyperactivity Disorder. Advancing the Neuroscience of ADHD, 57, 1313-1323. doi:10.1016/j.biopsych.2004.11.024.
Graaf, R. de, Have, M. ten, Gool, C. van, Dorsselaer, S. van. (2012). Prevalentie van psychische aandoeningen en trends van 1996 tot 2009; resultaten van NEMESIS-2. Tijdschrift voor
psychiatrie, 54(1), 27-38.
Gu, J., Strauss, C., Bond, R., Cavanagh, K. (2015). How do Mindfulness- Based Cognitive Therapy and Mindfulness- Based Stress Reduction Improve Mental Health and Wellbeing? A Systematic Review and Meta- Analysis of Mediation Studies.
Clinical Psychology Review, 37, 1- 12. doi:
0.1016/j.cpr.2015.01.006.
Hakkaart- van Roijen, L., Zwirs, B.W.C., Bouwmans, C., Tan, S.S., Schulpen, T.W.J., Vlasveld, L. & Buitelaar, J.K. (2007). Societal Costs and Quality of Life of Children Suffering from Attention Deficient Hyperactivity Disorder (ADHD). European Child Adolescent Psychiatry,
16, 316-326. doi: 10.1007/s00787-007-0603-6.
Haydicky, J., Wiener, J., Badali, P., Millgan, K. & Ducharme, J.M. (2012). Evaluation of MBCT for Adolescents with ADHD and Their Parents: Impact on Individual and Family Functioning. Journal of
Child and Family Studies, 24, 75-94. doi:
10.1007/s10826-013-9815-1.
Van den Hoofdakker, B.J., Nauta, M.H., Dijck- Brouwer, D.A.J., van der Veen- Mulders, L. & Sytema, S. (2012). Dopamine Transporter Gene Moderates Response to Behavioral Parent Training in Children With ADHD: A Pilot Study.
Developmental Psychology, 48(2), 567-574. doi:
10.1037/a0026564.
Househam, A.M. & Solanto, M.V. (2016). Mindfulness as an intervention for ADHD. The
ADHD report, 24(2), 1-13.
John, A., Halliburton, A. & Humphrey, J. (2013). Child-mother and child-father play interaction patterns with pre-schoolers. Early Child Development and Care, 183 (3-4), 483-497. doi:
10.1080/03004430.2012.711595.
Kabat- Zinn, J. (2015). Mindfulness. Mindfulness.
6, 1481-1483. doi: 10.1007/s12671-015-0456-x.
Keng, S., Smoski, M.J., Robins, C. J., Ekblad, A.G. & Brantley, J.G. (2012). Mechanisms of Change in Mindfulness-Based Stress Reduction: Self- Compassion and Mindfulness as Mediators of Intervention Outcomes. Journal of Cognitive
Psychotherapy, 26(3), 270-280.doi:
