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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"two in five young people scoring above thresholds for emotional problems, conduct problems or hyperactivity"

The quote titling this post - "two in five young people scoring above thresholds for emotional problems, conduct problems or hyperactivity" - comes from the eye-opening findings published by Jessica Deighton and colleagues [1] (open-access available here).

It's based on a study of over 28,000 adolescents here in Blighty: "51.2% of whom were in Year 7 (age 11–12) and 48.8% of whom were in Year 9 (age 13–14) in 97 state-maintained secondary schools across six geographical locations in England."

Said young people were given the "child self-report Strengths and Difficulties Questionnaire (SDQ)" to complete, and the received data were analysed alongside other information collected by the authors "from the National Pupil Database: SEN status; FSM eligibility; child in need status (CIN, this is a child who either (a) is unlikely to achieve/maintain a reasonable standard of health and development without local authority provision; (b) is likely to be impaired without local authority provision; or (c) is disabled); and ethnicity (Asian, Black, Chinese, Mixed, White or any other ethnic group)."

In more detail: "18.4% scored above the abnormal threshold for emotional symptoms, 18.5% for conduct problems, 25.3% for inattention/hyperactivity and 7.3% for peer-relationship problems." Going back to the title of this post, researchers mention how "around two in five young people scoring above ‘abnormal’ thresholds for three of the four problem areas measured (emotional problems, conduct problems and hyperactivity)." They also observed that:

• SEN - special educational needs - status played a role in those figures (those with SEN were consistently more likely to provide an above-threshold response to all the areas measured, particularly peer-relationship problems). 
• Entitlement to free school meals (FSM), a potential marker of deprivation, was also associated with an above-threshold response to all areas.
• "Being male significantly increased the odds of scoring above threshold for behavioural problems and inattention/hyperactivity, whereas being female significantly increased the odds of experiencing emotional symptoms."

There are caveats attached to the Deighton findings; not least the sole reliance on "child self-report data from a very brief assessment tool" without any accompanying further analysis on the presence (or not) of diagnosable psychopathology. But, in the context of the large participant number included for study and that most adolescents aren't likely to 'lie' about their positive responses to items such as "I get very angry and often lose my temper" or "I take things that are not mine from home, school or elsewhere" I'd be inclined to view the Deighton findings as a pretty accurate representation of their 'in the thousands' cohort.

So where next? Well, if we're talking about findings observing that "42.5% scored above threshold for any one of the first three problem scales (emotional symptoms, conduct problems or inattention/hyperactivity)" we have to talk about what services are in place (and should be in place) to support this large group. This, on the basis that, such 'problems' can potentially lead to various other 'adverse' outcomes both in later childhood and beyond. And when I talk about 'support', I mean both support and intervention to help those young adults to manage such issues. All of this set in the context of a continually squeezed financial and resource position (at least here in Blighty).

The other question has to be 'why'? Why have so many young people reported as they have? Deighton et al talk about various factors as potentially being important: "the impact of austerity, increasing experience of academic pressures, reduced rates of sleep and increased use of social media", to a large extent talking about the social environment as playing a significant role. I don't doubt that these external factors and other related variables will play a role in how young people are reporting, but I'm not convinced that the social environment is the only important factor to consider. It's not, for example, beyond the realms of possibility that other genetic and non-genetic variables (i.e. in the physical environment) could also play a role; something I say in the context of a 'growth' in the number of children and young adults being diagnosed with all-manner of different behavioural and/or psychiatric labels (see here and see here for examples).

Something important seems to be going on with our young people (see here and see here). We have to assume that such an issue is not going to resolve itself and may even increase in terms of numbers as time goes on. We really need to find out what factors are behind this and start taking action... like now.

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[1] Deighton J. et al. Prevalence of mental health problems in schools: poverty and other risk factors among 28 000 adolescents in England. Br J Psychiatry. 2019 Jan 30:1-3.

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Intolerance of uncertainty (IU) is "directly related to features of ASD"

Time and time again an important issue keeps cropping up in relation to autism and the various *comorbidity* that seem to be over-represented alongside the diagnosis: the core features of autism seem to be intricately related to the presentation of such *comorbidity*. Indeed, I wonder if the word 'comorbidity' should, on some occasions, really be replaced with something a lot more 'core' à la Mildred Creak for example and their coverage of the topic of anxiety years back...

It's been noted in relation to depression (see here) and anxiety (see here) and even some other 'extremes' of behaviour (see here) and, to be frank, is starting to become a bit of an elephant in the room. I know not everyone is completely enamoured with either the notion that anxiety is a core part of autism [1] or with 'intervening' in relation to altering the presentation of the core features of autism, but the available data is starting to suggest that for some, this could be a primary option if one wants to effectively tackle certain, often very disabling, *comorbidity* (see here).

Another potential example is offered in the findings reported by Roma Vasa and colleagues [2] who, looking at nearly 60 children diagnosed with an autism spectrum disorder (ASD) compared with 30-odd not-autism controls, reported that various [core] aspects of autism seemed to be related to intolerance of uncertainty (IU); but specifically "emotion dysregulation was the only significant predictor of IU."

IU is a concept rising in importance when it comes to autism (see here). As the name suggests, it's all about the negative effect(s) following uncertainty (i.e. not knowing) (some have talked about 'threat' as being important), and how anxiety in particular, seems to be cardinal symptom following such uncertainty and onward, the often disabling effects that arise from it (see here).

"These findings suggest that IU is directly related to features of ASD possibly due to shared genetic, neurological, or psychological underpinnings." Well that just about covers all the bases(!) but really the conversation should be moving to 'what can be done to mitigate IU and its effects?' Vasa, in another study [3], provides some more basic options when it comes to tackling anxiety in the context of autism, but specifically with IU in mind, we must wait [4] and wonder...

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[1] Montazeri F. et al. Network Analysis of Anxiety in the Autism Realm. J Autism Dev Disord. 2018. Jan 30.

[2] Vasa RA. et al. Relationships between autism spectrum disorder and intolerance of uncertainty. Autism Res. 2018 Jan 7.

[3] Vasa RA et al. Assessment and Treatment of Anxiety in Youth With Autism Spectrum Disorders. Pediatrics. 2016 Feb;137 Suppl 2:S115-23.

[4] Rodgers J. et al. Towards a Treatment for Intolerance of Uncertainty in Young People with Autism Spectrum Disorder: Development of the Coping with Uncertainty in Everyday Situations (CUES©) Programme. J Autism Dev Disord. 2017 Dec;47(12):3959-3966.

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"Theory of mind is not theory of emotion"

A rather interesting paper by Beth Oakley and colleagues [1] (open-access might be available here) appeared recently providing a "cautionary note on the Reading the Mind in the Eyes Test" [2], one of the premier assessments thought to offer a performance-based measure "involving mental state attribution and complex facial emotion recognition from photographs where only the eye region of the face is available."

Most people with some knowledge about autism research history will have heard about the proposal that Theory of Mind (ToM) - a term often used to cover that "mental state attribution" - might be affected in cases of autism (see here) and indeed, how careers and reputations have been made on such a generalisation. These days ToM is less and less being talked about as the heterogeneity of the autism spectrum becomes better understood and how specificity in particular, has proved to be an Achilles' heel for the concept (see here).

One of the emerging ideas to account for some of the results obtained using the Reading the Mind in the Eyes test (RMET) in cases of autism is that alexithymia - a construct characterised by an inability to describe or understand emotions - might actually be the more important issue than autism per se. The idea being that alexithymia can co-occur alongside some autism and that for those presenting with that combination, ToM and assessments like RMET might be problematic.

So Oakley et al delved a little deeper into some of the hows and whys of some of the RMET results obtained with autism in mind and whether "the RMET indexes emotion recognition, associated with alexithymia, or ToM, associated with ASD [autism spectrum disorder]." They did it on the basis of examining a small group of participants diagnosed with an ASD (n=19) alongside 24 participants without autism. Alexithymia was assessed using "the 20-item Toronto Alexithymia Scale (TAS–20)." Autism symptoms severity was measured using the Autism Spectrum Quotient (50) (oh dear..) and "current functioning" in the autism group was assessed using the gold-standard that is the Autism Diagnostic Observation Schedule (ADOS) (more like it).

Results: well bearing in mind the small participant numbers and the need for further independent replication of the findings, "Reading the Mind in the Eyes Test (RMET) performance was unaffected by autism spectrum disorder... but was negatively impacted by alexithymia." Indeed, we are told that: "Six ASD and eight control participants met the criterion for severe alexithymia, with a score of 61 or above on the 20-item Toronto Alexithymia Scale (TAS–20)." Further: "in individuals with ASD and comorbid alexithymia, it is alexithymia, rather than ASD per se, that impairs emotion recognition performance."

I probably don't need to say too much more about this line of research and its important implications outside of perhaps the requirement to screen for alexithymia as and when autism is diagnosed. Insofar as the idea of an "alexithymia hypothesis of emotion-related deficits in ASD", this does sound like a tantalising option but again, I'd be slightly reluctant to go all-in with yet another grand theory for autism given the trials and tribulations that psychological theories in particular have faced over the years with autism in mind. As to other potential impacts from work such as this, well, assertions that a lack of empathy might the root of all evil (see here) also made by proponents of ToM might do well to take on board a role for alexithymia in any future judgements...

Minus any charges of plagiarism, I leave you with the general summary from Oakley and colleagues:

"This study suggests that a highly popular test of the ability to detect what someone else is thinking—the Reading the Mind in the Eyes Test—is instead a test of the ability to recognize another person’s emotional expression. This is important because it suggests that patients who perform badly on this test may still be able to understand another person’s mental state and that, conversely, patients who perform well on this test may still have difficulties in mental state understanding."

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[1] Oakley BF. et al. Theory of mind is not theory of emotion: A cautionary note on the Reading the Mind in the Eyes Test. J Abnorm Psychol. 2016 Aug;125(6):818-23.

[2] Baron-Cohen S. et al. The “Reading the Mind in the Eyes” Test: Complete Absence of Typical Sex Difference in ~400 Men and Women with Autism. PLoS ONE. 2015; 10(8).

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Oakley BF, Brewer R, Bird G, & Catmur C (2016). Theory of mind is not theory of emotion: A cautionary note on the Reading the Mind in the Eyes Test. Journal of abnormal psychology, 125 (6), 818-23 PMID: 27505409

Supporting siblings of children with autism too

A weekend not wasted...

The idea that a diagnosis/label of autism may have repercussions for quite a few more people than just the person diagnosed is not a new one.

Without trying to generalise nor stigmatise, the process of working up to and receiving a diagnosis on the autism spectrum can often have profound consequences for family life. Parents typically shoulder quite a lot of the additional duties that follow from a diagnosis (and indeed before diagnosis) but other family members also have to play their part. When it comes to the possible 'impact' of receipt of an autism diagnosis on some of those other family member, science is starting to come around to the idea that siblings in particular, might need a little more support.

So it was found in the paper by Brian Lovell & Mark Wetherell [1] who reported findings based on the examination of "the psychophysiological impact of childhood ASD [autism spectrum disorder] on siblings." Looking at a variety of measures including those measuring depressive symptoms and cortisol levels, researchers compared values for "25 siblings of children with ASD (and their mothers) and a control group of 20 siblings of neuro-typical children (and their mothers)." They found that depressive symptoms were elevated for the ASD sibling group but when it came to cortisol measurements "groups were comparable on all cortisol indices." They concluded by suggesting that more needs to be done to tackle the "greater emotional problems and overall depressive symptoms" noted in the ASD sibling group. Cortisol, I might add, has been talked about with autism in mind before (see here) bearing in mind 'issues' emerging as to when the best time for collection should be with autism in mind [2].

There are a couple of ways that such results can be interpreted. One could argue that the increased frequency of 'emotional issues' and depressive symptoms noted in the ASD sibling group might well be associated with their sibling ASD label and much of what comes with it. Again avoiding any sweeping stigmatisation of autism, this is a serious matter and reiterates how the impact of autism goes well beyond that of personal experience when it comes to affecting family and other loved ones.

The other way one could interpret this data is by suggesting that within the scope of the broader autism phenotype (BAP) - that is, the idea that around the diagnostic edges of autism there may be a spectrum of more subtle presentations (see here) - [some] siblings may already be more prone to emotional and/or depressive issues on the basis of how depression for example, shows some pretty strong links to autism (see here for example). Without any psycho-babble explanations, one could foresee how an increased tendency towards depressive symptoms or depression might be to some degree compounded by the lived experience of having a sibling diagnosed with ASD; particularly if and when there is significant disruption to typical family life. I might also acknowledge that autism does not normally reside in some sort of diagnostic vacuum (see here) so one has to be mindful that other behaviours outside of autism might also be contributory to any additional family stress.

Irrespective of the whys and wherefores, the idea that other family members may require additional support as well as children/adults diagnosed with an ASD is paramount. As I've previously discussed on this blog, support can take many guises (see here) as this authorship team have previously discussed [3]; some of which could be transferable to siblings too. Other research has looked at issues such as family adaptation [4] and I'm minded to bring in the concept of resilience too. That also having a sibling diagnosed with ASD may be a significant influence on career choices of unaffected siblings (unaffected in terms of symptom presentation) is an additional variable to take into account, save any charges of me painting a too one-sided, negative picture of the possible familial effects of autism.

The picture included in this post by the way, represents a nearly full weekend attempt by some of my brood to muster enough 'snow' to put together this marvellous fellow. Don't you just love winter?

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[1] Lovell B. & Wetherell MA. The psychophysiological impact of childhood autism spectrum disorder on siblings. Res Dev Disabil. 2015 Dec 22;49-50:226-234.

[2] Sharpley CF. et al. Is afternoon cortisol more reliable than waking cortisol in association studies of children with an ASD? Physiol Behav. 2015 Dec 21. pii: S0031-9384(15)30217-1.

[3] Lovell B. et al. With a little help from my friends: psychological, endocrine and health corollaries of social support in parental caregivers of children with autism or ADHD. Res Dev Disabil. 2012 Mar-Apr;33(2):682-7.

[4] O'Brien S. Families of Adolescents with Autism: Facing the Future. J Pediatr Nurs. 2015 Dec 19. pii: S0882-5963(15)00352-8.

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Lovell B, & Wetherell MA (2015). The psychophysiological impact of childhood autism spectrum disorder on siblings. Research in developmental disabilities, 49-50, 226-234 PMID: 26720849

Thomas the Tank Engine and autism

'They're two, they're four, they're six, they're eight, shunting trucks and hauling freight'. Ask a person in the average UK  (or other) street what these words mean and, assuming they haven't got children, most won't have a clue. Ask a parent with young(ish) children and you might get an altogether different response.

When thinking about autism spectrum conditions and their representation in the media and popular press, there are a few 'symbols' which come to mind. Most people would be familiar with the 'jisgaw piece' [previously] used by organisations like the National Autistic Society (NAS) and Autism Speaks. I assume the jigsaw piece is meant to represent... well, I don't know what it is meant to represent to tell you the truth. Autism as a puzzle, an enigma? The jigsaw of life? Some might say it may be representative of 'not fitting it'. I don't offer any opinion either way but assume that your interpretation will depend on your perception, experience, politics and viewpoint.

One of the other, more enduring symbols of autism, at least here in the UK, is that childhood favourite Thomas the Tank Engine. The NAS have entered into a bit of a partnership with the makers of Thomas over the past few years selling various Thomas things including pins and cards in aid of the NAS. Because I am not sure if everyone knows about Thomas, let me enlighten you. Thomas is a train with a face on the front of the engine. You can see a picture of him and his many friends here (alas, there is no Paul engine). His various adventures have been translated from the books by the Rev. Wilbert Awdry, who coincidental would have celebrated his 100th birthday in the next few days, to a very successful children's TV series.. two versions of it in fact. Thomas also famously courted the attention of a Beatle.

Just so you know Thomas and his friends are a very popular, well-loved series here in the UK and perhaps further afield across many different groups not just those children with autism or other developmental diagnoses. It is with autism in mind, that Thomas and his friends have perhaps found their biggest fan base; the question is why?

I will state for the record that I am not trying to provide any definitive answer as to why Thomas and friends are so popular. Every child (autistic or not) has their own little 'obsessions' as part of growing up; fads which change according to what they see, watch, read, are exposed to; and also fads because of what other people (peers) see, watch read and are exposed to. Lisa Jo Rudy over at autism.about discussed Thomas and autism a while back as did the NAS following their research into the subject.

The collective findings suggest that there are quite a few reasons why children with autism seem to have such an affinity to Thomas including:

• The clear storylines; something goes wrong in every episodes but is put right in the end.
• The friendly faces on the engines with exaggerated responses used to denote happy, sad, angry, etc.
• Thomas is a train, and quite a few children with autism like things like trains (mechanical, predictable, lots of lines, wheels, etc).

There are a few patterns emerging from these and the other reasons put forward for liking Thomas. 'Predictability' is probably one of the biggest themes; a bit like watching an episode of that 1980s classic 'the A-Team' and their 'we'll get captured and locked in a shed with lots of tools to make a tank' routine coupled with being the only soldiers of fortune who don't actually shoot anyone despite using automatic weapons every week! Ah yes, predictability at its 1980s best.

Whilst I can't say for sure on the new Thomas series, the old series apparently never showed the mouths of the engine faces move when speaking for one reason or another. Given the various research on face processing in autism, I wonder if perhaps this might also be a key point in how relaxing Thomas and friends come across and the issue of cross-modal parallel processing (as described by this study). On this topic, and without getting 'too psychological', I wonder if the Disney Cars for example, might show a similar or different response to children with autism given their very pronounced facial movements including the mouth (teeth and tongue) when talking?

Whatever the reason, the popularity of Thomas and friends has been sort of exploited from a therapeutic perspective to autism in the series 'The Transporters' and evaluated experimentally in areas of emotion recognition.

If only all TV could be so educational...