Mindfulness for ADHD systematically reviewed

"According to presented descriptive results, all the studies (100%) showed improvement of ADHD [attention-deficit hyperactivity disorder] symptoms."

That was the standout sentence derived from the findings reported by Hélène Poissant and colleagues [1] who looked at "the available literature concerning MBIs [mindfulness-based interventions] in adult participants with ADHD." Mindfulness by the way, is described as a way of "reconnecting with our bodies and the sensations they experience" with a specific focus on "an awareness of our thoughts and feelings as they happen moment to moment." I'm no expert on mindfulness or mindfulness-based interventions but, from what I gather, the core of such intervention(s) is based around "somatically focused meditative techniques (body scan, sitting meditation, and mindful yoga) that are thought to help participants cultivate nonjudgmental, mindful awareness of present-moment experience." 'Focusing in on the present' seems to be the phrase that springs to mind.

Poissant et al examined the relevant peer-reviewed science on the application of the MBIs to ADHD upto June 2018. They specifically focused on adults with ADHD, and were able to track down "13 studies conducted with 753 adults (mean age of 35.1 years)" for inclusion in their systematic review. They observed that: "All the studies (100%) showed improvement of ADHD symptoms following an MBI." They also mentioned that: "mindfulness meditation training improves some aspects of executive function and emotion dysregulation" as per the findings of some of those studies.

Despite the '100% of studies showing improvement in ADHD symptoms' sentiments, I'm not falling hook, line and sinker for the value of MBIs in relation to ADHD. The main reason is the high risk of bias identified in quite a few of the studies reviewed by Poissant, related to things like performance bias ("blinding of participants and of personnel") and selection bias ("allocation concealment" and "selection bias"). One could argue that the examination of something like MBIs under research conditions is never going to be perfect. Unlike scientific investigation of a medicine, where a placebo can be formulated to look, smell and taste the same, it would be difficult to come up with something to approximate MBI and indeed, approximate what the 'active ingredient' of mindfulness actually is. Similar issues have been talked about on other occasions on this blog (see here).

That all being said, there is something appealing about MBIs both in terms of effect and also the fact that it can be learned by pretty much anyone, is cost-free and probably about as side-effect free as one could get. If such a simple technique helps with any one of the symptoms of ADHD and improves quality of life for those with ADHD, it's got to be something to be considered alongside the myriad of other possible interventions (see here and see here and see here) that *might* offset the risks that follow a diagnosis of ADHD (see here).

Oh, and it appears that mindfulness and ADHD is a topic in the ascendancy [2]...

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[1] Poissant H. et al. Behavioral and Cognitive Impacts of Mindfulness-Based Interventions on Adults with Attention-Deficit Hyperactivity Disorder: A Systematic Review. Behav Neurol. 2019;2019:5682050.

[2] Xue J. et al. A meta-analytic investigation of the impact of mindfulness-based interventions on ADHD symptoms. Medicine (Baltimore). 2019 Jun;98(23):e15957.

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What can physical activity do for ADHD?

In answer to the question posed in the title of this post, I might refer you to the paper by Susanne Ziereis & Petra Jansen [1] who concluded that results of their research study looking at the impact of two 12-week training programs "support the hypothesis that long-term PA [physical activity] has a positive effect on executive functions of children with ADHD [attention-deficit hyperactivity disorder]."

That's the funny thing about birthdays,
they're kind of an annual thing.

With an important starting point that "non-pharmacologic treatment methods would be preferred by parents, children and psychiatrists" when it comes to treating/managing ADHD and its various symptoms, researchers decided to examine whether one or both of two training programs - "a training which focused on the abilities ball handling, balance and manual dexterity" (EG1 group; n=13) and training "in sports without a specific focus" (n=14) - might improve cognitive performance in children diagnosed with ADHD. Said training regimes were compared against a control group (EG2 group; n=16) where no such intervention was used.

Their results based on "assessments of working memory (WM) and motor performance before, immediately after the first training week and one week after the last session" suggested that there may indeed be some merit in physical activity when it comes to various facets of cognitive performance in their cohort. "After the 12-week intervention period, several measures of the EG1 and EG2s significantly improved over time". The no-intervention control group did not fare as well.

This is of course not the first time that physical activity has been suggested to impact on executive functions as per the mega-review by John Best [2] (open-access). I might also throw in a link to a piece I wrote on this blog last year (2014) on the potential benefits of something like kata training when it comes to psychology and behaviour (see here) as another example where one might expect similar positive changes. I'm also minded to point you to the paper by Halleland and colleagues [3] suggesting we should be looking a little harder for those with ADHD and executive function issues who might benefit from such interventions.

It seems that alongside the very obvious physical benefits to be derived from staying active, mind and behaviour also seem to benefit. A sedentary childhood it seems, does little good to anyone. And since we're on the topic of complementary interventions potentially useful for some cases of ADHD, how about looking at nutrition (see here and see here) as well as exercise?

Some music now to complement any activity you might want to try... You Shook Me All Night Long by AC/DC.

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[1] Ziereis S & Jansen P. Effects of physical activity on executive function and motor performance in children with ADHD. Res Dev Disabil. 2015 Jan 2;38C:181-191.

[2] Best JR. Effects of Physical Activity on Children’s Executive Function: Contributions of Experimental Research on Aerobic Exercise. Developmental review : DR 2010;30(4):331-551.

[3] Halleland HB. et al. Occupational Status Is Compromised in Adults With ADHD and Psychometrically Defined Executive Function Deficits. J Atten Disord. 2015 Jan 2. pii: 1087054714564622.

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Ziereis S, & Jansen P (2015). Effects of physical activity on executive function and motor performance in children with ADHD. Research in developmental disabilities, 38C, 181-191 PMID: 25561359

Autism and optimal outcome: the continuing saga

I think it's fair to say that the paper published by Deborah Fein and colleagues* (discussed in this post and this post) was a bit of a game-changer when it comes to how we view the autism spectrum conditions.

Describing a group of children originally diagnosed as being on the autism spectrum and then "losing all symptoms of ASD in addition to the diagnosis, and functioning within the nonautistic range of social interaction and communication", there was plenty of comment on this optimal outcome study at publication. Some commentators at the time seemed to go out of their way to try and shred this bit of science and reinforce the "autism is always lifelong" line. Even now an expression of doubt remains of any notion of 'autism recovery'. Note my use of the singular - autism - when it comes to describing the condition in those previous sentences.

Is it draughty in here? @ Wikipedia 

In some respects, I can see why the Fein paper was treated the way it was in some quarters. With all the due respects to our thriving media, to say that autism (or at least the diagnosis and diagnostic elements making up the diagnosis) might not in some cases be as set in stone as we all might have first thought, carries a significant risk that autism - all autism - might be just viewed as some passing developmental phase. It's not by the way.

It all boils down to generalisation and, as we've witnessed in recent weeks when it comes to the depiction of mental health (see this headline), how generalisation can often be so very damaging.

To reiterate from the original Fein paper and quote from the accompanying journal editorial** "They conclude, rather modestly, that these results ‘‘substantiate the possibility of optimal outcome,’’ demonstrating that some children with a clear early history and accurate diagnosis of ASD do indeed move into the entirely normal range of social and communication development later in childhood." I've underlined the word 'some' to stress that they weren't generalising to everyone with autism. Some.

After that very long-winded introduction, I'm talking today about some of the follow-up work that has been published on these optimal outcomers in relation to their wider presentation including academic ability. The paper by Troyb and colleagues*** adds to the interest in this group suggesting that when it came to "measures of decoding, reading comprehension, mathematical problem solving, and written expression" the optimal outcomers were more similar to 'typically developing' peers than those with a diagnosis of autism which puts them under the 'high-functioning' description of presentation.

The paper by Eigsti & Fein**** likewise reported that when it came to pitch discrimination (see here for more details) "Unlike an ASD group, which shows heightened pitch discrimination, the Optimal Outcome group's abilities do not differ from those of typically developing controls". This based on the suggestion that pitch sensitivity might be enhanced among (some of) those with high-functioning autism*****.

If one were to base the judgement of optimal outcome on these studies alone, you may very well get the impression that autism was just a passing phase for these children, and seemingly left little or no mark on their subsequent development and performance skills.

But things are never so straight forward. And to think that autism - defined as a disorder of early development - with its heightened risk of a range of other comorbidities, even if now removed from the developmental equation would not have some bearing on future development is perhaps a little too narrow a view to take.

Take for example another paper by Troyb and colleagues***** looking at executive functioning (EF) in those optimal outcomers. Another rather long quote I'm afraid: "Despite their average performance, however, the OO [optimal outcome] and TD [typically developing] groups differed on measures of impulsivity, set-shifting, problem-solving, working memory, and planning, suggesting that the OO group does not have the above-average EF scores of the TD group despite their high-average IQs". In other words, allowing for the still quite small numbers of participants in these studies and their cognitive functions, issues seem to remain, at least in childhood.

If I were to get even more 'psychological' with this topic, I might also show you the paper from Naigles and colleagues****** whose title - 'Residual difficulties with categorical induction in children with a history of autism' - sums up my argument that the more visible aspects of autism might indeed have vanished into the diagnostic ether, but that does not mean that typical developmental service has just resumed. Likewise based on the data from the paper by Kelley and colleagues******* on residual language issues (in areas of pragmatic and semantic language comprehension) and that from Tyson and colleagues******** on language and verbal memory in optimal outcomers.

I'm not trying to reverse my original assertion that the Fein paper was a game-changer based on these evidence. I still see the work of Fein and colleagues as being potentially, some of the most important work ever done on autism; big words I know. I still also see those optimal outcomers as carrying some of the most important data about autism. And harking back to my highlighting the singular term 'autism', how the optimal outcomers are some of the strongest evidence yet for the concept of 'the autisms' which I seemingly keep going on about in every post.

But alongside, there is the realisation that autism is potentially much more than just the triad (or dyad) of symptoms that we've diagnostically boiled it down to. Optimal outcome? The mum in this newspaper article talks about "shadows left behind from his autism". I was also, for example, going to do a separate post based on the paper by Leonard and colleagues********* in relation to motor development and autism. Something along the lines of how even Kanner in his original writings about autism, hinted that autism might be so much more than just a triad of symptoms. But since I'm here already with this rather long blog post, let's just say autism, sorry the autisms, might be so much more than what we currently call it.

I'm going to close this post with a few things I'd still like to see from the optimal outcome data. The obvious question is: who are the optimal outcomers and indeed, what makes them different from other children on the autism spectrum? I'm not necessarily just talking about overt clinical presentation or scores on some psychometric tool but rather biologically, genetically, epi-genetically, microbiomic-ally(?) who are they and what makes them optimal outcomers?

I'd like to know more about the ways and means they went towards their path of optimal outcome. Are we talking about some spontaneous arrest of autistic traits similar to what might be expected in an infection-based model of presentation or something rather more gradual? Are we talking about the effects of early behavioural intervention, pharmacotherapeutic intervention and/or all those myriad of so-called complementary 'biomedical' interventions?

Perhaps more in the long-term, I'd like to know how does optimal outcome translate into the 'real world' when it comes to transitioning from child to adult. Does it mean a better shot at good educational achievement, a decent job, a living wage, independent living, the option of a family, a healthy life relatively free of medication or ill-health? And what happens to the various comorbidities?

Questions still remain about optimal outcome in relation to autism. But I'm not taking anything away from the pretty comprehensive picture that is already being drawn about optimal outcome occurring in cases of autism.

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* Fein D. et al. Optimal outcome in individuals with a history of autism. J Child Psychol Psychiatry. 2013 Feb;54(2):195-205.

** Ozonoff S. Editorial: Recovery from autism spectrum disorder (ASD) and the science of hope. J Child Psychol Psychiatry. 2013 Feb;54(2):113-114.

*** Troyb E. et al. Academic abilities in children and adolescents with a history of autism spectrum disorders who have achieved optimal outcomes. Autism. 2013 Oct 4.

**** Eigsti IM. & Fein DA. More Is Less: Pitch Discrimination and Language Delays in Children with Optimal Outcomes from Autism. Autism Res. 2013 Aug 8. doi: 10.1002/aur.1324.

***** Troyb E. et al. Executive functioning in individuals with a history of ASDs who have achieved optimal outcomes. Child Neuropsychol. 2013 Jun 3.

****** Naigles LR. et al. Residual difficulties with categorical induction in children with a history of autism. J Autism Dev Disord. 2013 Sep;43(9):2048-61.

******* Kelley E. et al. Residual language deficits in optimal outcome children with a history of autism. J Autism Dev Disord. 2006 Aug;36(6):807-28.

******** Tyson K. et al. Language and Verbal Memory in Individuals with a History of Autism Spectrum Disorders Who Have Achieved Optimal Outcomes. J Autism Dev Disord. 2013 Aug 28.

********* Leonard HC. et al. Motor development in children at risk of autism: A follow-up study of infant siblings. Autism. 2013 Oct 7.

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Troyb E, Rosenthal M, Eigsti IM, Kelley E, Tyson K, Orinstein A, Barton M, & Fein D (2013). Executive functioning in individuals with a history of ASDs who have achieved optimal outcomes. Child neuropsychology : a journal on normal and abnormal development in childhood and adolescence PMID: 23731181

Road crossing behaviour and ADHD

Do you remember your Green Cross Code? If you lived in the UK during the 1970s or 1980s you'll probably remember the towering figure of Dave Prowse, he of Darth Vader, as the Green Cross Code Man and his message about pedestrian safety when crossing the road.

Over the years quite a bit of Government information and education combined with a fair bit of nudge theory has helped to improve child safety whilst crossing our ever busier roads. The fact remains however that quite a few children do still get hit by cars when crossing the road. The reasons why are complicated. Drivers not adhering to the speed limit, children being children and running across the road without looking. Lots of reasons. With all the recent chatter on wandering and autism (including that new ICD code), one could perhaps also see how specific groups of children might be at an increased risk of injury as a result of things like crossing the road.

A new-ish study* published in the journal Pediatrics looked at road crossing behaviour in children diagnosed with ADHD. The study by Stavrinos and colleagues used an artificial 'virtual' environment to analyse the road-crossing behaviours of 78 children (aged 7-10 years), half of whom were diagnosed with ADHD (ADHD-combined type), half of whom served as asymptomatic controls. Their results:

• Children from both groups looked left and right before crossing. They also waited before crossing.
• Children from the ADHD group tended to pick riskier places to cross, for example between parked cars.
• The ADHD group had more 'close calls', so picking more risky moments to cross than the non-ADHD group.

The authors note that the children with ADHD were "...looking.. but they are failing to see". A few explanations have been put forward to account for the results; ranging from medication wearing off to problems with executive functioning (things like planning behaviour and impulse control). One perhaps can't rule out the artificial nature of the experimental conditions as potentially also having some bearing on the results; a danger-free road crossing virtual experiment is a little different from the 'real' world. Whatever the reason for the results, there are perhaps some important lessons that can be gleaned from such research. How we structure our roads and their surrounding environment, our developing educational material and strategies specifically for those with ADHD and other developmental conditions about risk in this and other similar situations, and also how we build our cars and educate our drivers to ensure that, should the worst happen, the car gives as much protection to the pedestrian as possible.

In the end remember: stop, look, listen think.

* Stavrinos D. et al. Mediating factors associated with pedestrian injury in children with Attention-Deficit/Hyperactivity Disorder. Pediatrics. July 2011