Mindfulness techniques for ADHD: stress regulation & neuroeffects

Mindfulness techniques are very suitable for the treatment of ADHD. A meta-analysis found positive results in 11 out of 12 studies in relation to the treatment of ADHD.¹ A meta-analysis found improvements in inattention in adults, while too little data was available for children.² One review found MBSR to be a useful supportive treatment method for ADHD.³ while another meta-analysis found positive indications, but still no robust evidence for the effectiveness of mindfulness techniques for ADHD.⁴

Stress-relieving⁵
Stress-preventing⁶
Mood-lifting⁷
Procrastination-inhibiting⁷⁸ (which is only natural, as procrastination is a symptom of stress)
Executive functions improved⁹
Mindfulness-based treatment improves the core symptoms of attention problems and hyperactivity in ADHD.¹⁰
Mindfulness training targets the autonomic nervous system
In one study, stress management reduced the basal DHEA level and increased the cortisol level. The change in the cortisol-DHEA ratio achieved was stress resistance-promoting.¹¹
It should be noted that, depending on the disorder, the cortisol/DHEA ratio may be imbalanced in one direction or the other.
⇒ DHEA/cortisol imbalance during stress
Psychological stress therapy should always influence the relationship in the direction of a healthy balance. In the case of drug treatment, the direction in which the balance is shifted must first be determined.
- Internal / external
  internal: it’s up to me personally (me, my)
  external: it’s the circumstances (the others, out there)
- Stable / variable
  stable: it is unchangeable (always, never)
  variable: I can influence it
- Global / specific
  global: it is always and everywhere like this (everywhere, lawfulness)
  specific: the cause lies in this case itself (here, this time)Mindfulness trains a change in perception. It trains you to no longer immediately attribute the perceived event, but to let it stand on its own. This enables a less frightening and threatening perception, which can massively reduce stress as a consequence.
According to a meta-analysis, different forms of therapy improved various symptoms in ADHD (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, from 1 high)¹²
- Depression
  - Cognitive behavioral therapy (medium to large Effect size)
    - 0.52 SMD in follow-up in group comparison
    - 0.74 SMD in follow-up subjectively for affected person
  - Neurofeedback
    - Ineffective in group comparison
    - Subjectively slightly more effective than cognitive behavioral therapy
  - DBT
    - Ineffective in group comparison
    - Subjectively moderately effective, worse than cognitive behavioral therapy
  - MBSR
    - Ineffective in group comparison
    - Subjectively moderately effective, even worse than DBT
- Anxiety symptoms
  - Cognitive behavioral therapy (medium to large Effect size)
    - 0.73 SMD in follow-up in group comparison
    - 0.74 SMD in follow-up subjectively for affected person
  - Neurofeedback
    - Ineffective in group comparison
    - Subjectively more effective in the long term than cognitive behavioral therapy
  - MBSR
    - Ineffective in group comparison
    - Subjectively moderately effective, ineffective in the long term
  - DBT
    - Completely ineffective
- Self-worth
  - Cognitive behavioral therapy (medium to larger Effect size)
    - Ineffective in group comparison
    - 1.404 SMD in follow-up subjectively for affected person
  - Neurofeedback
    - Ineffective in group comparison
    - Subjectively more effective in the long term than cognitive behavioral therapy
  - MBSR
    - Ineffective in group comparison
    - Subjectively moderately effective, ineffective in the long term
  - DBT
    - Completely ineffective
- Quality of life
  - Cognitive behavioral therapy (medium to large Effect size)
    - Ineffective to slightly effective in group comparison
    - 0.57 SMD in follow-up subjectively for affected person
  - MBSR
    - Subjectively very good in the short term
  - DBT
    - Very good in the short term compared to the group, ineffective in the long term
    - Subjectively moderately effective in the short term, weakly effective in the long term
- Emotional dysregulation
  - Cognitive behavioral therapy (medium to large Effect size)
    - 0.64 SMD in follow-up in group comparison
    - 0.73 SMD in follow-up subjectively for affected person
  - MBSR
    - Weakly effective in the short term compared to the group, not known in the long term
    - Subjectively very effective in the short term, not known in the long term
Mindfulness meditation reduced ADHD symptoms (hyperactivity and inattention), but breathing techniques did not, while both techniques reduced stress.¹³
Mindfulness training still showed positive effects on children with ADHD in the parent evaluation 6 months later¹⁴
A meta-analysis came to the conclusion that mindfulness techniques are a helpful supplement in the treatment of ADHD.¹⁵

How mindfulness works

Roughly speaking, the technique of mindfulness involves creating a virtual distance from perceived circumstances. In simple terms, mindfulness means separating perception and its immediate evaluation for oneself. You are trained to perceive very consciously what is happening and at the same time not to relate the events to yourself, i.e. not to take them as a reason for a reaction, but merely to observe the effect of the events on yourself with interest. This stops the automatism of the immediate impact of perceptions on one’s own state of mind.

In other words

You realize that everything is still happening in the same way, but that it no longer poses an immediate existential threat. It happens, and yet you go on living. The subjective threat of what is happening is reduced.

This technique makes sense if the automated stress regulation has previously been misdirected in such a way that events are attributed too directly to oneself.

Attribution styles

There are different attribution styles,¹⁶ how perceived circumstances are explained. Example:
A student fails an exam.
The following reaction options (i.e. attribution styles) are conceivable:

I’m just too stupid. (Internal - stable - global)
I really didn’t learn anything for this exam. (Internal - variable - specific)
This time I was just unlucky. (External - variable - specific)
They always give me the stupidest tasks. (External - stable - global)

Summarized attribution dimensions result in specific interpretations:¹⁷

Internal-stable: ability
Internal-variable: Effort
External-stable: task difficulty
External-variable: Luck/Pitch
- Pessimistic attribution style: failures are attributed internally, globally, stably
- Optimistic attribution style: failures are attributed externally, specifically, unstably

We assume that a global internal attribution style makes people susceptible to perceiving experiences in a threatening and fearful way.
Fearful and threatening perceptions quickly lead to cortisolergic stress.

1. Neurophysiological mechanisms of action of mindfulness techniques (here: MBSR)
2. Types of mindfulness techniques

1. Neurophysiological mechanisms of action of mindfulness techniques (here: MBSR)

Mindfulness training is able to sustainably reduce cortisol levels.¹⁸
In generalized anxiety disorder, there is an overactivation of the amygdala with ambivalent signals and a poor functional connection between the amygdala and ventrolateral PFC. MBSR reduces the overactivation of the amygdala for neutral faces more than stress management. MBSR, but not stress management, caused greater activation of the ventrolateral PFC and also improved the connection between the ventrolateral PFC and the amygdala. All changes coincided with the improvements in anxiety symptoms, indicating causal effects. The previously negative coupling of the amygdala with the activity of the ventrolateral PFC, as known in emotion reduction, changed to a positive coupling. MBSR appears to bring about substantial changes in brain regions that are relevant for emotion regulation.¹⁹
The functional activity of the amygdala decreased and the connectivity of the amygdala with the PFC improved. In addition, the deactivation of the amygdala after emotional stimuli was faster.²⁰
Since MBSR has been shown to be very effective for ADHD, we assume that there is an analogous improvement in communication between different areas of the brain.
Further studies show the effects of MBSR on neuronal activity.²¹
Mindfulness-based meditation technique may be superior to relaxation training in terms of long-term normalization of cortisol response.²²
MBSR appears to be able to improve the emotional self-regulation of people with ADHD.²³
MBSR may improve ADHD symptoms not so much through improved mindfulness skills or improved self-compassion, but through improved inhibition.²⁴

2. Types of mindfulness techniques

Mindfulness-based stress reduction (MBSR) according to Kabat Zinn²⁵
A combined MBCT and MBSR therapy showed the same results after 8 weeks as are known from long-term meditation practice.²⁰
Stress management (possibly less effective than MBSR)¹⁹
Yoga
- Yoga was moderately effective²⁶²⁷
- Yoga appears to improve the core symptoms of ADHD in children, according to several meta-analyses.²⁸²⁷²⁹³⁰
Meditation²⁰
- Zen meditation
  increased serotonin levels in the brain in the long term
- In experienced meditators, an increase in cortical thickness in the right insula and the frontal lobes has been demonstrated.³¹
- During mindfulness meditation, more gray matter was observed in areas of the brain typically used during meditation in intensive meditators (2 hours a day for more than 8 years). People with ADHD are the right insula, which is involved in introspective attention (“interoceptive awareness”), the left inferior temporal gyrus and the right hippocampus.³²
- A meta-analysis found evidence of the effectiveness of meditation techniques in children, adolescents and adults.³³ The results are said to indicate a stronger effect on inattention than on impulsivity/hyperactivity.
Biofeedback
Relaxation massages
Massage therapy resulted in a 31% reduction in the cortisol response to stress and an increase in dopamine and serotonin of around 30%.³⁴
Massage therapy is said to be able to outperform the effect of methylphenidate.³⁵
Shiatsu
Qigong
Tai chi chuan
- A meta-analysis found a consistently positive effect of tai chi on ADHD symptoms, although the quality of the studies was rather low.²⁷
Respiratory therapy
Progressive muscle relaxation according to Jacobson
Feldenkrais
Sound massages
Archery or other shooting sports (with slight positive effects on ADHD)³⁶
Mindfulness apps
also for your cell phone, which you always have with you anyway to take advantage of short breaks.³⁷

Example of a mindfulness exercise: letting go for 100 breaths

Procedure:

Find a quiet place where you are undisturbed
Lie down / sit down comfortably
Close your eyes
Pay attention to your own breath
Each time you let go of your breath, count backwards from 100 to zero, one number for each time you let go of your breath.
Every time you let go of your breath, make sure that your belly lets go completely relaxed. And starting from the belly, Consequences, the whole body relaxes with the release of the breath.
(There are two types of breath: Active inhalers and active exhalers; the respective passive side is to let go of the breath)
Each time you release your breath, concentrate on feeling how your stomach relaxes
Recap the exercise text (below) during the exercise
If necessary, background noise of the sea (this also masks possible street noise); if necessary, headphones with sound recording of the spoken text, if necessary earplugs, if alone for yourself, and remember text silently

In group: Leader speaks meditation text;
Length: participants keep their eyes closed as long as it works; those who stop open their eyes, wait quietly or, if necessary, read something until (most of) the others have finished; leader then ends the presentation of the meditation text

Exercise text:

You are here
Feel your body
You don’t have to do anything now
You can be with yourself
You can only feel yourself now
You don’t have to do anything else
Nobody wants anything from you
Feel your breath
Relax your belly as you let go of your breath
and the rest of the body with the stomach
Feel what it feels like when your stomach relaxes
Try to let go completely, with each release of breath
There are thoughts
Let them come
Take notice of them
Do they have a color, a shape?
Look at her coming
Do not follow them
Let them go again
Watch them disappear
You are here
You feel your body
You feel yourself
If trouble comes, watch it
Make yourself aware of her wish. What does she want? Have to do something? Want to think? To look at problems? What does the wish that is there want?
Feel it
Don’t deny him, don’t follow him
Look at him, watch him
Feel the desire
How does this urge feel?
Does it have a sound, a smell?
What does it feel like outside of this desire?
You are relaxed
And let go of your belly every time you let go of your breath
And observe what you are feeling or thinking right now
Feel your body
Feel your feelings
Observe what you feel
Do not Consequences the feeling, just observe it
And let it go again
When unrest comes, watch how it comes
Don’t call them here
If it is there, notice it, feel it
Do not follow her
How does it feel?
Does it have a sound, a movement?
Look at them
She may be
She has no right to determine you
Let them go again
You are here
Feel your body
You don’t have to do anything now
You can be with yourself
You can only feel yourself now
You don’t have to do anything else
Nobody wants anything from you
All thoughts that come can wait
when they are important, they come back
Now you are the most important thing
Everything else has its time later

(continue)..
..
..

The exercise aims to ensure that feelings/thoughts/inner restlessness are not denied = not suppressed.
It is easier not to follow something that is not suppressed. This naturally requires an inner position outside the pressure.
I want the feeling/thought to be there - and they don’t define me.
I am beside them, not through them.
Feelings / thoughts are there and they are not me.
They are a part of me, and only a part.
I am not these thoughts and feelings, I have them.
I have them, not they have me.

The questions about color, form and sound are aimed at viewing feelings and thoughts as something from outside, as something third, thereby separating them from oneself and not being controlled by them.

The learning steps should / could be:
Learning to perceive, to perceive and feel yourself as an alternative and separate from these thoughts and feelings. Learning to feel this “me” as an alternative.
Learning to evoke the alternative safely.
Strengthen the alternative until it is a greater option.
Let the alternative grow to such an extent that you can feel it as a basis, sense it and live it permanently at some point.

Training path:
(Introduction to transformation in daily routine)

First times with optimal medication
Increase in difficulty depending on progress with less and less / at the edge / end of medication effectiveness
To without medication (if possible)
Initially in your own ritual, in a specific, quiet place, possibly at a fixed time
Later less and less isolated, sometimes spontaneously
To the middle of the day

Mindfulness techniques (+++)

1. Neurophysiological mechanisms of action of mindfulness techniques (here: MBSR)¶

2. Types of mindfulness techniques¶

1. Neurophysiological mechanisms of action of mindfulness techniques (here: MBSR)

2. Types of mindfulness techniques