Introduction

What Is Attention Deficit Hyperactivity Disorder (ADHD)?

Attention deficit hyperactivity disorder (ADHD) is a neurological developmental disorder. ADHD is characterized by inattention, hyperactive, and impulsive behavior [1,2,3]. The worldwide prevalence of ADHD is around 5.0% among children and 4.4% among adults [4]. The inception of ADHD happens at around the age of 12 years. Its symptoms endure to persist during adulthood. As per the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the three principal symptoms of ADHD are inattention, hyperactivity, and impulsivity [5].

Children and adolescents suffering from ADHD tend to have difficulty following rules and resisting distractions. They also have difficulty with concentration and continued attention when completing a task. They tend to get restless or nervous and frequently disturb others [6•]. Hence, they have difficulties making friends, and they tend to perform inadequately compared with individuals without ADHD [7, 8].

Prevalence of ADHD in Adolescents

The prevalence of ADHD differs from country to country, with a significantly greater prevalence in the USA than in European countries [9]. Besides, the prevalence of ADHD keeps changing from time to time. For example, the National Health Interview Survey (NHIS) had reported a 33% increase in ADHD prevalence from 1997 to 1999 (5.7%) to 2006–2008 (7.6%) among children and adolescents aged 3 to 17 years [10]. Likewise, as reported by the National Survey of Children’s Health, the prevalence of ADHD was augmented by 42% between 2003 and 2011 among children and adolescents aged 4 to 17 years [11••]. Xu G et al. in 2018 reported that the estimated prevalence of diagnosed ADHD in US children and adolescents has been increased from 6.1 in 1997–1998 to 10.2% in 2015–2016 [12••].

Impact of ADHD in Adolescents

It has been reported that approximately 80–85% of preteens continue to suffer from ADHD symptoms into the adolescent years, and 60% of them continue to have ADHD symptoms into adulthood [13,14,15]. ADHD has a significant impact on day-to-day life of adolescents. For example, adolescents with ADHD have troubles in sustaining attention in usual tasks. They also tend to do poorly in studies [16]. Moreover, they have difficulty in maintaining peer relations and family cohesiveness [17,18,19,20]. If these individuals do not receive proper treatment, untreated patients might have greater rates of risky sexual behaviors [18], suicidal thoughts in college [21], imprisonments [19], car accidents [22, 23], professional difficulties, and medical encumbrance [24]. They also have inferior self-esteem, social functioning, economic achievement, and greater rates of substance use [25].

Treatments of ADHD in Adolescents

The treatment approaches for ADHD in adolescents can be broadly classified into pharmacological and non-pharmacological. For pharmacological treatments, stimulant medications (amphetamine-based or methylphenidate-based preparations) are considered to be gold standard [26]. Non-stimulant medications such as bupropion, atomoxetine, and guanfacine-based preparations have some evidence [27•, 28, 29•]. However, the usage of medications depends on the personal preference of the patients due to various reasons such as cost, side effects, inability to tolerate the medicine, etc. [29•, 30]. Due to these and other reasons at individual level, patients tend to seek non-pharmacological treatments for ADHD. A subset of patient population may be willing to take psychopharmacological treatment but may prefer to add non-pharmacological treatments to counteract the symptoms that are persisting despite the adequate dosage of pharmacological treatment [30]. Some patients prefer non-pharmacological methods to achieve symptom reductions so as to reduce the dosages of pharmacologic treatments, whereas some patients are just holistic minded and prefer to try non-pharmacologic methods before going to pharmacological treatments [30].

Non-pharmacological Treatment Options for Adolescents with ADHD

Non-pharmacological interventions play a major role in the treatment of ADHD in adolescents. Adolescents with ADHD tend to have conflicts with their parents [31]. For example, teens may desire for more freedom and independence from their parents. Moreover, there may be forced interactions between the adolescents with ADHD and their parents as both may strive to accomplish their goals. Barkley et al. has established a four-factor model to differentiate these interchanges that comprise: “1) the adolescent’s characteristics; 2) parent characteristics; 3) family environment and stressors and 4) parenting practices” [32••]. Barkley and Robin have also developed and verified a manualized therapy to tackle teen-parent conflict [32••]. Their approach basically includes educating parents and adolescents on how ADHD affects the adolescent’s functioning and their interactions; and this way, they educate parents to “choose their battles” and reward positive behavior of the adolescent. Their approach is helpful for both parents and adolescents to understand on what to expect from one another, apply a problem-solving approach to discuss disagreements, and understand to utilize more effective communication skills by avoiding usage of ultimatums or negative comments [32••, 33]. The treatment approach comprises problem-solving communication training (PSCT) and behavior therapy (BT) with more emphasis on BT and has been moderately effective in improving conflict between adolescents with ADHD and their parents [32••]. It has been also reported that several components of BT comprising organizational skills have shown beneficial effects individually as well as in the school setting [34]. Another non-pharmacological treatment option for ADHD is mindfulness. In next few sections, effect of mindfulness for the treatment of ADHD in adolescents will be discussed.

What Is Mindfulness?

Mindfulness is a practice based on “Zen Buddhism.” It is a prevalent way of self-calming and self-regulating [35]. Jon Kabat-Zinn defined “mindfulness” as “paying attention in a particular way, on purpose, in the present moment, and nonjudgmentally” [36•]. It can also be interpreted as attending present moment without wanting to change the experience. The words such as non-judgemental awareness or loving awareness are often used to describe mindfulness [36•].

Effect of Mindfulness in Adolescents with ADHD

Mindfulness training helps individuals with ADHD to improve their attention in such a way that they gain awareness of how their mind becomes distracted. This way mindfulness helps them achieve self-regulatory skills. With mindfulness training, they can identify what is causing the distraction and can shift their attention back to their activity. Mindfulness training has been incorporated with therapeutic techniques to treat ADHD. Several types of mindfulness-based programs have been used such as mindfulness-based stress reduction [37•], mindfulness-based cognitive therapy [38,39,40], and acceptance and commitment therapy [41].

Various studies have reported beneficial effects of mindfulness-based interventions (MBIs) on children and adolescents diagnosed with or presenting symptoms of ADHD. For example, MBIs have been reported to reduce parent-rated inattention, hyperactivity, and impulsivity [42••]. MBIs have also been beneficial in reduction of internalizing and externalizing problems [38, 43]. Moreover, MBIs have been correlated with increased active engagement in instruction and augmentation of cognitive processes, comprising sustained attention [38, 43, 44].

The mindfulness training (MT) model combines features of mindfulness-based cognitive therapy and mindfulness-based stress reduction. Various studies have reported benefits of MT model in children and adolescents with ADHD [38, 39, 42]. MT was originally based on mindfulness-based cognitive therapy for the treatment of depression [6•]. In order to treat children and adolescents with ADHD, the following modifications have been made in MT model: a repeated assortment of breath meditation (e.g., focus on the feelings of breathing), concentrated short activities (such as yoga, mindful listening, mindful eating), sensory-based movement activities and empirical learning behaviors, extremely organized sessions (such as detailed agendas, mindfulness homework), and reinforcement of participation of parents through training and psychoeducation along with involvement in necessary activities at home [6•].

What Is the Rationale Behind Use of Mindfulness Training for the Treatment of ADHD?

Mindfulness-based treatment options have been reported to be beneficial for various mental health treatment targets [45,46,47]. Mindfulness meditation at the intervention level involves focusing attention on any specific task (e.g., breathing pattern) and refocusing on it again after any sort of distraction. This may help the patients with ADHD to be more attentive on one particular task/object at a time [48•]. Practicing mindfulness requires a regulation of attention and conflict detection, and this has been considered as a regulatory approach to attention that advances executive processes [49]. Like any other skill, the skill of attending to one task gets enhanced with practice, and this improves overall attention. As poor attention is a one of the core symptoms of ADHD, mindfulness may help to strengthen this aspect in patients with ADHD. Figure 1 represents a schematic indicating how mindfulness is beneficial for improving the attention and thus the treatment of ADHD. Various studies have reported that practicing mindfulness improves attention. For example, one study evaluated the effect of 5 days (20 min per day) of meditation against relaxation [50•]. This study reported that the participants in the meditation group could detect conflict significantly in a significantly greater manner during an attentional task than the participants in relaxation group. Another study reported similar outcomes where participants underwent 4 days of meditation training (20 min per day) and reported better outcomes on working memory and executive functioning compared with the participants in an active treatment comparison group [51•]. Several neuroimaging studies have suggested that mindfulness meditation stimulates neuroplastic modifications in brain areas correlated with attentional functioning that are usually impaired in patients with ADHD. For example, the anterior cingulate cortex region is involved with attentional processing in ADHD [52, 53] and detecting any conflict related to mismatched information [54]. Mindfulness studies have shown to improve the functions of this region [51•].

Fig. 1
figure 1

Mindfulness training for the treatment of ADHD. Mindfulness training helps to improve inattention and emotional regulation. Inattention is one of the core symptoms of ADHD. Hence, mindfulness training is useful for the treatment of ADHD.

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In addition to poor attention, the other areas affected in ADHD are emotional dysregulation/impulsivity and physical hyperactivity. It is well-known that patients with ADHD have difficulties in regulating their emotions, which contribute to substantial impairment [55,56,57]. Mindfulness training is reported to improve emotion regulation [58]. Mindfulness teaches patients to notice emotional states as momentary and transient phenomenon, which can be responded to in a non-reactive or considerate manner. Hence, it helps patients resist impetuous desires to act out on their emotions and thus reduces the emotional impulsivity that is associated with ADHD [56]. As mindfulness will be strengthening the aptitude to regulate emotions in patients, it is a good non-pharmacological treatment option. One study has reported that 5 days of meditation training (20 min per day) improved emotional measures such as depression, anger, and anxiety [50•]. Another study has discovered that 5 weeks of mindfulness training (5–16 min per day) leads to modifications in frontal electroencephalographic asymmetry configurations that is related with positive, approach-oriented emotions [59].

Neuroimaging studies have also revealed that overlapping brain regions are associated for emotion dysregulation in patients with ADHD [56] and mindfulness meditation. Certain regions in the brain such as the prefrontal cortex, hippocampus, and amygdala were correlated with enhancement in emotion regulation following mindfulness training [54]. It is important to note that these regions are also recognized to have their involvement in emotional functioning in patients with ADHD [56]. This section has explained that both inattention and emotional regulation can be improved by mindfulness training, and it explains why mindfulness training should be used for the treatment of adolescents with ADHD.

Outcomes of Mindfulness Treatment in Adolescents with ADHD

Mindfulness training can be implemented in different manners. For example, an adolescent with ADHD would receive mindfulness training, or along with the patient, the caregiver is also given simultaneous mindfulness training as well.

In one of the earliest studies by Zylowska et al., adolescents (n = 8; age group, 15–18 years) with ADHD received mindfulness training and were compared with a separate group of adults with ADHD [60••]. This study reported that despite of good attendance and higher satisfaction with the mindfulness treatment among the adolescents, there was a predisposition for inferior compliance with at-home practice compared with adults with ADHD.

In a study by Haydicky et al., male adolescents (n = 60; age group, 12–18 years) received a 20-week mindfulness training program, which also combined fundamentals of CBT and mixed martial arts [61]. These adolescents were compared with a waitlist control group. Various subgroup analyses in this study have established that mindfulness improves parent-rated externalizing behavior, monitoring skills, and social problems but does not cause improvement in symptoms of ADHD, parent report of executive functioning, social problems, externalizing symptoms, and self-reported measures of social problems. It is essential to remember that this study had a small sample size and there was a lack of random assignment to treatment conditions. Moreover, there was a lack of an active treatment comparison group.

Promising initial outcomes can be achieved if along with adolescents with ADHD, and their parents also receive mindfulness training. In one of the MYmind studies, it has been reported that when 14 adolescents with externalizing disorders and their parents received mindfulness training, there were improvements in self-reported externalizing behaviors, attention problems, personal goals, social problems, happiness, and mindful awareness. Similar outcomes were also observed at 8-week follow-up [38]. Moreover, self-reported internalizing symptoms and self-reported thinking problems also improved significantly after the treatment.

Another MYmind program study was conducted on 10 adolescents (age group, 11–15 years) with ADHD and their parents [39]. During this study, within-group evaluations were done right after the mindfulness training, at 8-week follow-up and at 16-week follow-up. This study noted that there were statistically significant enhancements in externalizing behavior (paternal report), parental stress (paternal report), and parental over-reactivity (maternal report). There were also improvements in attention problems (paternal report), internalizing problems (paternal report), metacognition (a component of executive functioning, paternal report), and behavioral regulation (a component of executive functioning, tutor report). However, these improvements were not statistically significant but approached significance during data analysis. At the time of 8-week follow-up, significant improvement in attention problems (as per the adolescent report) was reported. Improvements were also reported as per the paternal report for behavioral regulation, externalizing behaviors, metacognition, and parental stress. At 16-week follow-up, only adolescent assessments were collected. At 16 weeks, the enhancements in externalizing behaviors came close to gain statistical significance. Two computerized sustained attention tasks (a visual sustained attention task and an auditory sustained attention task) were given to the participants at post-treatment and both follow-ups. On a visual sustained attention task, adolescents showed an improvement in reaction speed; however, this was not sustained at either follow-up. When participants performed an auditory sustained attention task, the quantity of incorrect alarm responses diminished significantly, and this was sustained for both follow-up evaluations. At 8-week follow-up, the number of misses enhanced; however, it was not maintained at 16-week follow-up.

Haydicky et al. implemented the MYmind program to adolescents (n = 18; age group, 13–18 years) with ADHD and a discrete group for their parents (n = 17) [62]. This study focused on various assessments that included 4 weeks pre-treatment (baseline), pre-treatment, end of treatment, and 6-week follow-up. Parents’ and adolescents’ evaluations of inattentive, hyperactive/impulsive, conduct disorder, oppositional defiant disorder, symptoms of anxiety, and depression were also considered. Moreover, functional impairment was measured by acquiring parent-reported details of learning, executive functioning, and peer relations problems along with adolescent report of learning and family relations problems. According to the parent report, mindfulness training improved peer relations and symptoms of conduct disorder, whereas inattentive symptoms were close to achieving statistical significance. However, these outcomes were not significantly different at the time of follow-up. Improvements for adolescent report of depression, anxiety, and internalizing symptoms were also reported. Parent report of improvement in depression was also observed that was close to statistical significance. Supplementary assessments of parenting stress, family functioning, and mindfulness were also measured. Among the 12 parental stress outcomes, two outcomes improved at post-treatment, and three outcomes improved at follow-up. The findings of this study reported that mindful parenting enhanced the outcomes at post-treatment but not at follow-up, whereas parental acceptance enhanced only at the time of follow-up. The findings from different studies as mentioned here in this review demonstrate that that mindfulness training in adolescents diagnosed with ADHD is achievable and acceptable. None of the studies have reported any negative side effect of mindfulness. Hence, mindfulness is effective as well as safe and tolerable treatment modality.

Summary

This review has provided details on why mindfulness should be considered for the treatment of ADHD in adolescents. Current literature has reported benefits on mindfulness meditation training in adolescents diagnosed with ADHD and have provided preliminary support suggesting its effectiveness, safety, and tolerability in these patients. The efficacy is more robust if parents also receive the mindfulness training along with adolescents. Although the current literature is showing promising results on mindfulness as an effective non-pharmacological treatment modality in adolescents with ADHD, more systematically rigorous trials are required, predominantly larger randomized controlled trials and evaluation of long-term effects with valid measures.