Hindawi Publishing Corporation

BioMed Research International

Volume 2015, Article ID 962857, 14 pages
http://dx.doi.org/10.1155/2015/962857

Research Article
Mindfulness Meditation Improves Mood, Quality of
Life, and Attention in Adults with Attention Deficit
Hyperactivity Disorder

Viviane Freire Bueno,1 Elisa H. Kozasa,1,2 Maria Aparecida da Silva,3 Tânia Maria Alves,3
Mario Rodrigues Louzã,3 and Sabine Pompéia1
1
Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros 925, Vila Clementino,
04024002 São Paulo, SP, Brazil
2
Hospital Israelita Albert Einstein, São Paulo, Brazil
3
Instituto de Psiquiatria, Hospital das Clı́nicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

Correspondence should be addressed to Sabine Pompéia; [email protected]

Received 19 August 2014; Accepted 17 November 2014

Academic Editor: Shirley Telles

Copyright © 2015 Viviane Freire Bueno et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Objective. Adults with attention deficit hyperactivity disorder (ADHD) display affective problems and impaired attention. Mood in
ADHD can be improved by mindful awareness practices (MAP), but results are mixed regarding the enhancement of attentional
performance. Here we evaluated MAP-induced changes in quality of life (QoL), mood, and attention in adult ADHD patients
and controls using more measures of attention than prior studies. Methods. Twenty-one ADHD patients and 8 healthy controls
underwent 8 weekly MAP sessions; 22 similar patients and 9 controls did not undergo the intervention. Mood and QoL were
assessed using validated questionnaires, and attention was evaluated using the Attentional Network Test (ANT) and the Conners
Continuous Performance Test (CPT II), before and after intervention. Results. MAP enhanced sustained attention (ANT) and
detectability (CPT II) and improved mood and QoL of patients and controls. Conclusion. MAP is a complementary intervention
that improves affect and attention of adults with ADHD and controls.

1. Introduction related to a mindfulness state [13]. MAP are also beneficial

for many clinical conditions, such as anxiety disorders,
The term “mindfulness” has been used to refer to a wide range
depression, stress-related physical symptoms, fibromyalgia,
of phenomena, such as mindfulness as a state, mindfulness as
chronic pain [14], and attention deficit hyperactivity disorder
a trait, and mindfulness as a type of training or practice [1],
(ADHD) [4–15]; for a review see [16].
as will be employed here. Interventions based on mindfulness
training, such as mindful awareness practices (MAP), involve ADHD is characterized by symptoms of inattention,
intentionally bringing one’s attention to one’s internal and impulsivity, hyperactivity, and affective problems [17–19]. The
external experiences in the present moment, and they often disorder begins in childhood and can persist until adulthood
involve meditation exercises [2, 3]. [17–19] in approximately 50% of patients, and it affects
Mindfulness-based interventions are considered a type of approximately 2–4% of the adult population; see [20].
cognitive training [4] and involve developing strategies that Regarding affect, ADHD is associated with a lower quality
improve attention [5], affective self-regulation [6], and well- of life [21–23], decreased mood and arousal, and low motiva-
being and quality of life [7, 8] in healthy populations [9–11]. tion, all of which can be associated with impaired attentional
Using functional magnetic resonance imaging this type of performance [24, 25] because they relate to cognitive control
practice has been shown to improve cognitive control [12] and (conflict resolution, planning, inhibitory control, and error
to establish a stable pattern of deactivation in brain regions correction) and emotional regulation [26]. In this context,
2 BioMed Research International

MAP could improve the cognitive/affective processes [6, 27, processing in that it modulates focusing of attention, motor
28] that are impaired in adults with ADHD [29, 30]. response selection, and error detection. Hence, performance
Adults with ADHD show impairment in attentional in the ANT and CPT II indicates physiological changes in
performance processes considering the influential model of brain functioning.
Posner and Petersen [31, 32]. According to these authors, the The most accepted treatment for ADHD according
attention system consists of three functional and anatom- to international guidelines (NICE Clinical Guideline 072)
ically different networks: alerting, the process involved in is methylphenidate, which improves symptoms. However,
becoming and staying attentive to one’s surroundings, which other treatments are being sought for a number of rea-
is closely linked to the concept of sustained attention or vig- sons: some patients experience side effects that preclude
ilance; orienting, or directing attention toward the location methylphenidate use; others experience only a 30% reduction
or modality of a specific stimulus; and executive attention, in symptoms [42]; such stimulants are less effective in adults
which is recruited when there is a conflict among multiple than in children (see [20]) and some patients are not willing to
attention cues [31, 32]. These attentional subsystems are undergo pharmacological treatment (see [15]). Because many
classically evaluated using the Attentional Network Test (ANT patients undergoing this type of pharmacological treatment
[33]). This is a computerized behavioral test that consists of still experience functional deficits related to decreases in
the combination of cued reaction time [34] and the flanker self-monitoring, attention, and mood, interventions such as
task [35]. Briefly, the ANT involves determining whether MAP that tackle these problems could be used as adjuvant
arrows presented onscreen are pointing left or right. By treatments [4, 28].
measuring how reaction times are influenced by alerting To our knowledge, however, only two studies [15, 43]
cues, spatial cues, and flanking stimuli (a central arrow was have investigated the affective and attentional effects of MAP
flanked by two arrows pointing either in the same direction in adults with ADHD. Zylowska et al. [15] adapted an
or in the opposite direction as the central arrow), the test eight-week group MAP program for this type of patients
measures the three attentional networks cited above. This task and showed improvements in ADHD symptoms, executive
has determined that executive attention is impaired in adults control (measured using the ANT), and subjective cognitive
with ADHD (see [36]), although other studies have shown flexibility and self-regulation. However, that study had no
no impairment [25]. Because a large body of data has shown control group, so a practice effect cannot be ruled out.
that performance in this task is clearly related to different Additionally, the intervention-induced benefits on subjective
brain systems and regions that regulate attention, impairment measures of mood were due to the social interactions of
can indicate physiological changes in brain functioning (see participating in the group sessions. In effect, Mitchell et
[31, 32]) that cannot be tapped by alterations on subjective al. [43], who included a nonintervention group and used
measures such as questionnaires. the same MAP protocol employed by Zylowska et al. [15],
Another type of computerized attentional test that is found no evidence of improved attentional performance.
widely used to characterize ADHD-induced attentional They did, however, show that mood benefitted from MAP
deficits is Conner’s Continuous Performance Test (CPT II use. A possible explanation for these conflicting attentional
[37]). This test involves a motor response to a series of visual effects is that the type of pharmacological treatment that the
stimuli (letters of the alphabet) and the inhibition of this patients received was not controlled in these studies, which is
response to one type of stimulus (the letter x). This test important when considering that methylphenidate, the most
can be used to measure sustained attention (the ability to widely used medication for this disorder, has acute effects
sustain a consistent focus on continuous activities or stimuli), on attentional performance [44]. Furthermore, these studies
impulsivity, and selective attention (the ability to focus on did not include healthy controls, so they could not indicate
relevant stimuli and ignore competing stimuli, a concept the measures on which the ADHD patients were impaired
related to distractibility). Compared with controls, adults in relation to healthy individuals, nor could they establish
with ADHD make more omission errors on this task [30, 38, whether the effects of MAP are differently effective in ADHD
39], present more variability in their mean reaction time [38] patients and in nonclinical populations.
and the standard deviation of reaction time [30], are worse at Because meditation has also been shown to improve
discriminating between target and nontarget stimuli [30], and cognitive efficiency during attentional tasks in the form of
make more commission errors because of impulsivity or lack less activation in various brain areas [45], it would make
of motor inhibition [38–40]. Using measures obtained from sense that practices such as MAP would lead to enhanced
the ANT that complement the CPT II, one study showed that attentional performance. Hence, we aimed to investigate the
adults with ADHD make more omission errors, have lower effect of the MAP protocol developed by Zylowska et al. [15]
accuracy and vigilance scores, and present greater variability on mood and quality of life (using validated questionnaires),
in responses compared with controls [25]. As with the ANT as well as attention (using the ANT and CPT II) in a
there are many studies that have associated performance in larger sample of adult ADHD patients of both sexes. We
this test with alterations in specific brain systems. Tana et al. controlled for any acute effects of methylphenidate asking
[41], for instance, have shown that performance in this task participants on the drug to abstain from their daily dose for
involves networks consistent with existing models of visual 24 h before the study. We also controlled for practice effects by
object processing and attentional control. Regarding frontal including a control ADHD group that did not participate in
activation, there was a strong activation in the anterior cin- the MAP sessions (the nonintervention group). Additionally,
gulated cortex, which is particularly important for attentional to compare the effects of MAP in healthy controls and ADHD
BioMed Research International 3

patients, two groups of healthy controls were evaluated, and registered at the ClinicalTrials.gov website (Identifier
one of which participated in MAP and another did not. NCT01738334) and at the Registro Brasileiro de Ensaios
Based on previous publications [9–11, 15, 43], we hypothe- Clı́nicos website (Identifier RBR-8dmcnj). All the partici-
sized that MAP would exert positive effects on attentional pants provided informed consent. Information about the
performance as a proxy for more efficient brain activation included and excluded patients can be found at the beginning
during attention tasks [12, 13, 31, 32, 41, 45] in controls and of the Results.
ADHD patients; we also believed that mood would improve Not all of those who were interviewed were willing to
in both types of participants. Additionally, we hypothesized participate in MAP, and we were unable to recruit a sufficient
that the adults with ADHD would benefit more from the number of participants to allow a randomized study. Hence,
intervention because they have more affective problems and ours was a quasiexperimental pretest-posttest design with
symptoms of inattention and thus would have more room nonequivalent groups in which participants could self-select
for improvement. We also expected MAP to improve quality whether they would or would not participate in the MAP
of life in patients as a result of better mood and attentional intervention.
performance, as has been shown for nonclinical samples Testing took place in the mornings in two one-hour
[7, 8]. sessions separated by approximately 10 weeks (baseline and
endpoint). During this interval, the participants either par-
2. Methods ticipated in the eight-week MAP program or underwent
no intervention (see details below). Patients treated with
2.1. Participants. All the participants were selected according methylphenidate took their daily doses in the morning;
to the following eligibility criteria: age between 18 and 45 on testing days they were asked to take their medication
years, more than 11 years of education, normal or corrected only after the experiment. Note that methylphenidate has
vision, nonverbal intelligence quotient (IQ) within normal a relatively short elimination half-life irrespective of its
range [46] (adapted for local use; see Campos [47]), no formulation, so that 24 h after their last dose the participants
prior experience with meditation practices, and for whom should be free of acute effects of this drug [57].
Portuguese was the native language. Candidates diagnosed Affect was measured using validated questionnaires
with neurological disorders, psychosis, obsessive-compulsive (symptoms of ADHD, mood, and quality of life; see below).
disorder, and Tourette syndrome or who were being treated The attentional tests administered were the ANT and the
with psychoactive drugs for reasons other than ADHD were CPT II. The tests and questionnaires were administered in
not included in the sample. Participants were also excluded if a fixed order and were followed by other measures in part
they scored more than 30 on the Beck Depression Inventory of the sample in the preintervention session (a study that
(BDI [48], adapted for local use by Cunha [49]), which investigated ADHD effects on different types of executive
indicates severe depression [50] and scored more than the functions, Bueno et al. [58]).
mean plus one standard deviation (see Andrade et al. [51] Following Zylowska et al.’s [15, 59] protocol, the mindful
on the Trait Anxiety Questionnaire of the State-Trait Anxiety awareness practices involved weekly two-hour-long group
Inventory [52], adapted for local use by Biaggio and Natalı́cio sessions during eight weeks, as well as daily exercises to be
[53]). performed at home. MAP was conducted on different days
for the ADHD patients and the healthy controls.
2.1.1. ADHD Patients. The patients were all diagnosed with
ADHD using the Structured Clinical Interview of the DSM- 2.3. Mindful Awareness Practices (MAP). The eight-week
IV and fulfilled the diagnostic criteria of the DSM-IV-TR [54]. group program was adapted from clinical models of mindful-
The diagnosis was made by a psychiatrist who specialized ness training [60, 61] by Zylowska et al. [15] and Zylowska [59]
in ADHD. The Adult Self-Report Scale (ASRS; Kessler et to address ADHD-related psychoeducational issues regard-
al. [55], adapted for local use by Mattos et al. [56]) was ing clinical, neurobiological, and etiological symptoms. The
used to classify and quantify ADHD symptoms. Some of material was translated into Portuguese with the permission
the patients were recruited by physicians from an adult of the authors, adapted for use in Brazil for both ADHD
ADHD diagnosis and treatment program (Programa Déficit patients and healthy controls, and was administered by the
de Atenção e Hiperatividade (PRODATH) of the Psychiatric same highly experienced MAP practitioner. The patients and
Institute of the Universidade de São Paulo (FMUSP)). Other controls formed separate groups, and the program involved
ADHD patients responded to calls for participants in the daily exercises to be performed at home (formal meditation
media. and mindfulness in daily living). Each session lasted two and
a half hours. Meditation was performed in a seated position,
2.1.2. Healthy Participants. The healthy controls did not fulfill with an emphasis on daily mindfulness. Each session began
criteria for ADHD but met the other eligibility criteria with a short opening meditation, followed by a discussion
described above. None of the controls took psychoactive about the daily home exercises. After this, new exercises
medication during the study. were introduced and practiced by the group in each session,
followed by a discussion. Each session ended with a review
2.2. Procedure. The study was approved by the Ethics Com- of the home practice exercises for the following week and a
mittee of the Universidade Federal de São Paulo and the group meditation. All the participants received three CDs to
Universidade de São Paulo (CAAE 20530613.3.3001.0068) help them with the home meditation practices, which were to
4 BioMed Research International

be conducted at home for five minutes on weeks one and two, the total score (29 items) and then transformed into 100-point
10 min on weeks three to five, and 15 min on weeks six to eight scales. Higher scores indicate better quality of life.
[15]. The participants kept a diary detailing their meditation at
home which allowed us to measure the frequency of the home 2.5. Attentional Tests
exercises. At the end of the program, the participants were
asked to rate their level of satisfaction with the intervention 2.5.1. Attentional Network Test (ANT [33]). This task was
on a 10-point scale (0 = totally unsatisfied; 10 = totally carried out exactly as described in the original work by
satisfied). Fan et al. [33] and took approximately 25 min. Briefly, each
trial began with the presentation of a fixation point on the
computer screen on which participants were instructed to
2.4. Cognitive and Subjective Ratings fix their eyes throughout the trial. After 400 to 1600 ms,
2.4.1. Subjective Rating Questionnaires an asterisk (cue) could be presented for 100 ms to direct
attention to certain areas of the screen that did or did not
coincide with the area in which the targets were presented.
Adult ADHD Self-Report Scale (ASRS [55], Adapted for Local There were four cue manipulations (see below). Four hundred
Use by Mattos et al. [56]). This questionnaire consists of 18 milliseconds after trials with cues, the target stimulus was
items evaluated on a five-point scale ranging from never (no presented. This target stimulus was a central arrow presented
symptoms) to very often (maximum symptoms). Half of the in a horizontal row including two flanker arrows to either
items evaluate the intensity of usual symptoms of inattention, side of the target. These arrows could point either left or
and the other items evaluate hyperactivity/impulsivity symp- right. The participants’ task was to indicate the direction in
toms. which the central arrow was pointing by using the right or
left button of the mouse. These flankers could point in the
Beck Depression Inventory (BDI [49], Adapted for Local Use
same direction as the target arrows (congruent condition,
by Cunha [49]). This is a scale that contains 21 statements
which facilitates responses) or in the opposite direction
regarding symptoms and attitudes related to depression. Each
(incongruent condition, which makes the correct response
statement is rated on a four-point scale ranging from neutral
more difficult). The target stimulus remained onscreen for
to maximum severity. Respondents were asked to rate how
a maximum of 1700 ms or until the participants responded.
they felt in the previous week.
There was also a control condition that used lines as targets
State-Trait Anxiety Inventory (STAI-T [52], Adapted for Local instead of arrows.
Use by Biaggio and Natalı́cio [53]). This is a self-evaluation Four types of cues conditions influenced task difficulty:
scale that contains 20 statements pertaining to anxiety symp- no cue, a condition in which only the fixation point was
toms rated on a four-point scale (1 = never; 4 = always). presented and remained on the screen; central cue, in which
an asterisk was presented at the same location as the fixa-
Positive and Negative Affect Schedule—Expanded form tion point (this cue involves alerting because it orients the
(PANAS-X [62], Adapted for Local Use by Peluso [63]). This attention to one location); double cue, in which asterisks were
questionnaire consists of a list of 60 different feelings and presented simultaneously above and below the fixation point
emotions. Respondents were asked to rate the extent to (alerting is involved, but the spatial location is broader than
which they had these moods during the past week using a in the following condition); and spatial cue, in which the
five-point scale (1 = very little or not at all; 5 = extremely). asterisk always occurred in the same spatial location as the
Combinations of these ratings yield two higher-level target (both alerting and orienting are involved).
dimensions (positive affect and negative affect, including The dependent measures were the difference in hit reac-
10 feelings each) and 11 lower-order affective levels: fear, tion times (RT), that is, when correct responses were given,
sadness, guilt, hostility, shyness, fatigue, surprise, joviality, between the trials in which there were no cue and a double
self-assurance, attentiveness, and serenity. The scores for cue (as a measure of alerting), the difference in hit RT
each dimension were calculated by adding the ratings of all between the trials in which there were a central cue and a
emotions included in each level and dividing the total by spatial cue (orienting), and the difference in hit RT between
the number of emotions in each dimension, so that scores the trials in which there were congruent and incongruent
ranged from 1 to 5. flankers (as a measure of executive control/conflict). Addi-
tionally, we analyzed other measures that are typical of the
Adult ADHD Quality of Life Questionnaire (AAQoL [64], CPT II [37] following Lundervold et al. [25]: (a) reaction
Adapted for Local Use by Mattos et al. [23]). This scale consists time and accuracy: the mean hit RT and the number of
of 29 items rated on a five-point Likert scale (0 = not at hits and omission errors; (b) variability in response: the
all/never; 5 = extremely/very often; each point receives a score of standard error of the mean hit RT (hit RT SE) and variability
25) that evaluate the level of difficulty in performing activities SE: the standard deviation of the 3 standard error values
of daily life grouped into four different areas: life productivity calculated for each block; (c) sustained attention/vigilance
(11 items), psychological health (6 items), life outlook (7 for interstimulus intervals (ISI) of 400 ms: the slope of the
items), and relationships (5 items). Scores for negatively change in RT and in the standard error of the RT between
worded items were reversed. Item scores were summed and blocks (hit RT block change and hit SE block change,
divided by item count to generate scores for each area and resp.).
BioMed Research International 5

55 patients were screened 20 controls were screened

7 were excluded:
2 had their BDI score higher than 30 All controls were included
5 used psychoactive substance other than methylphenidate

Initiated the study

48 patients (34 on methylphenidate): 20 controls:

24 meditation 10 meditation
24 no intervention 10 no intervention

5 dropouts 3 dropouts
3 meditation 2 meditation
2 no intervention 1 no intervention

Completed the trial

43 patients (30 on methylphenidate): 17 controls:
21 meditation (14 on methylphenidate) 8 meditation
22 no intervention 9 no intervention

Figure 1: Flowchart of the participants (patients with ADHD and controls).

Before the participants began the task, they underwent a intervention and session (there were no interactions of
training session involving 24 trials. The task consisted of three these factors with health status; see below) the magnitude
blocks with 96 trials each, separated by a short interval. In of effects was determined through effect-size calculations
each block, the following conditions were randomized: 4 cue (Hedges g [65]) following the general rules of thumb to
conditions × 2 target locations × 2 target directions × 3 flanker classify effects sizes as small (<0.5), medium (between 0.5
conditions × 2 repetitions. and 0.8), and large (>0.8). These calculations were conducted
using change scores (the mean post- minus preinterven-
2.5.2. Conner’s Continuous Performance Test (CPT II [37]). tion scores of participants who underwent MAP and those
This task lasts 14 min and consists of 6 blocks in which all who did not, divided by the pooled change-score standard
letters of the alphabet are presented individually in random deviation), following Mitchell et al. [43]. To assess whether
order on a computer screen for 250 ms each, with random MAP-associated alterations in mood/ADHD symptoms were
ISIs of 1, 2, or 4 s. Participants are instructed to press a key related to attentional enhancement, we calculated the Pearson
whenever a letter is presented, except in the case of the product moment correlations between the change scores
letter x (presented 36 times among the 324 letters presented), for attentional measures that benefitted from the MAP and
for which they should inhibit the motor response. The change scores in depression, anxiety, and ADHD symptoms
following measures were recorded: the number of omission (ASRS).
and commission errors, the mean hit RT, the variability of
standard error (variability of SE), the standard error of the 3. Results
mean hit RT (hit RT SE), detectability (𝑑󸀠 ), response style (𝛽),
perseverative responses (reaction time less than 100 ms), the We screened 55 patients, and seven were excluded (two
slope of the change in RT and in the standard error of RT because their BDI scores were higher than 30 and five
between blocks (hit RT block change and hit SE block change, because they used psychoactive substances other than
resp.), and the slope of change in RT and in the standard error methylphenidate). All 20 screened controls were included
of RT as a function of the ISI (hit RT ISI change and hit SE ISI in the study. Our final sample consisted of 48 patients (34
change, resp.). on methylphenidate) and 20 controls (see the flowchart in
Figure 1). Twenty-one patients (11 men) and eight controls (3
2.6. Statistical Analyses. The level of significance was 𝑃 ≤ men) showed interest in participating in the MAP program.
0.05. We used general linear models (GLM) followed by The subjects who did not undergo the MAP intervention
Tukey’s honest significant difference test (HSD) for unequal between the two testing sessions included 22 ADHD patients
size samples when factors interacted. The factors and levels (12 men) and nine controls (4 men). Thirteen of the patients
will be detailed in the Results. Only significant GLM and had never been medicated for ADHD either by choice or
post hoc effects will be described below. When two or because their condition had not been previously identified;
more factors interacted, only the higher-order effects will be seven of those patients participated in the MAP program.
described. For measures that showed interactions between The remainder of the patients used methylphenidate in stable
6 BioMed Research International

doses for 2 to 60 months (mean ± SD: 16.9 ± 19.8 months), in the participants who underwent MAP, both in relation to
fourteen of whom took part in the MAP. baseline and compared with the participants in the noninter-
Two ADHD participants and two healthy controls allo- vention condition. There were no interactions between health
cated to the MAP intervention dropped out of the study for status, session, and intervention (𝑃 values > 0.08), indicating
personal reasons. Their data were excluded from the analyses. that there were no significant differences between the ADHD
Three control participants (two from the MAP group) did patients and controls. This information will be detailed below.
not attend the reevaluation after the intervention period, The analysis of the ADHD symptoms evaluated by
and their data were excluded. Our final sample consisted ASRS (Table 2) showed health status effects for inattention
of twenty-one ADHD patients (11 men) and eight controls (𝐹(1,56) = 137.41; 𝑃 < 0.001) and hyperactivity-impulsivity
(3 men) who participated in MAP and twenty-two ADHD (𝐹(1,56) = 32.87; 𝑃 < 0.001), with ADHD patients reporting
patients (12 men) and nine controls (4 men) who underwent more symptoms than the controls did. In both cases, there
no intervention. No adverse events associated with MAP was also an interaction between intervention and session.
were brought to the experimenters’ attention. The doses of For inattention (𝐹(1,56) = 20.23; 𝑃 < 0.001), the interaction
methylphenidate of the patients taking medication did not was explained by the fact that, before the intervention,
change during the study. Fourteen patients (8 men) taking the participants who were willing to undergo MAP had
medication were in the intervention group, and sixteen (10 more symptoms than those who were not willing to do
men) were in the nonintervention group. so, while the opposite was true after the intervention (𝑃
values < 0.05); there were no session differences among the
3.1. Comparison of the Demographical Variables and Nonver- participants who did not participate in MAP, while symptoms
bal IQ (Preintervention) of Patients and Controls (Table 1). decreased among those who participated in MAP (𝑃 < 0.01).
Demographic information was analyzed using group as Inattention was the only measure that indicated a difference
factor (ADHD patients who participated in MAP, ADHD at baseline between those who were willing to participate
patients who did not participate in MAP, healthy controls in MAP and those who were not. The effect size on change
who participated in MAP, and healthy controls who did scores for those who did and did not participate in MAP
not participate in MAP). There were no differences between was large (𝑔 = −1.3). Figure 2 shows the effect sizes of
groups in demographic variables and IQ (all 𝑃 values > 0.16). all the measures for which there was an interaction between
Therefore, differences in attentional performance and subjec- session and intervention.
tive measures could not be attributed to these characteristics. For hyperactivity-impulsivity scores, there was also an
interaction between session and intervention (𝐹(1,56) = 7.83;
3.2. Home Practice and Satisfaction with MAP. See Table 1. 𝑃 = 0.01). At baseline, there were no significant differences
between intervention groups. Additionally, there were no
3.3. Effects of the MAP Intervention on Subjective Measures significant differences between the participants who did not
(Table 2). For each dependent measure, GLMs were used undergo MAP. Conversely, at the endpoint, those who par-
which included session (baseline = before the eight-week ticipated in MAP reported fewer symptoms compared with
intervention or nonintervention period; endpoint = after that their baseline scores and with those who did not participate
period) as a within-subject repeated measure factor; health in MAP (𝑃 < 0.01). The effect size on the change scores for
status (ADHD patients or healthy controls) and intervention those who participated in MAP and those who did not was
(MAP or no intervention) were used as between-subjects large (𝑔 = −0.8).
factors. We focused on the following effects: the interactions For the depression and anxiety scores obtained from
of intervention (MAP and no intervention) and session the BDI and STAI-T, respectively (Table 2), we found the
(baseline and endpoint) to determine whether participants same pattern of GLM and post hoc effects that we found
willing to participate in MAP differed at baseline from for hyperactivity-impulsivity symptoms on the ASRS. There
those who were not and whether at the endpoint session was a main effect of health status, indicating that the ADHD
measures were improved by MAP; the main effect of session patients showed more symptoms on the BDI (𝐹(1,56) = 11.83;
to determine practice effects; the main effects of health status 𝑃 < 0.001) and STAI-T (𝐹(1,56) = 27.26; 𝑃 < 0.001). We
to show the measures in which patients and controls differed; also found an interaction between session and intervention
and the interaction of health status, intervention, and session for the BDI (𝐹(1,56) = 5.79; 𝑃 = 0.02) and STAI-T
to determine if the MAP was differently effective in patients (𝐹(1,56) = 5.59; 𝑃 = 0.02), which indicated no significant
and controls. difference between conditions at baseline and a MAP-related
Regarding the questionnaires used in this study, overall, improvement at endpoint compared with baseline and with
the patients reported more symptoms of ADHD, depression, the participants who did not undergo intervention (𝑃 values
anxiety, negative mood, and worse quality of life compared < 0.05), with no significant differences between sessions in
with controls. Most of the variables under investigation the nonintervention condition. Effect sizes for the BDI and
were sensitive to the MAP intervention, and in the majority STAI-T measure considering the change scores of those who
of cases this factor interacted with session. With a single participated in MAP and those did not were medium (𝑔 =
exception (subjective inattention on the ASRS), there were no −0.7) and large (𝑔 = −0.8), respectively.
baseline differences between the participants who did and did Regarding the PANAS-X (Table 2), there was a main effect
not participate in MAP. At the endpoint, positive mood and of health status for most variables, which indicated worse
quality of life increased and negative symptoms decreased mood in the ADHD patients (negativeaffect: 𝐹(1,56) = 9.54,
BioMed Research International 7

Table 1: Mean (standard deviation) of demographic information per group (control and patients with attention deficit hyperactivity disorder
(ADHD) submitted to mindful awareness practices (MAP) or to no intervention) and statistical comparison between them, times of at-home
practice, and rating of satisfaction with the programme in the groups submitted to the MAP.

No intervention MAP No intervention

Variable MAP control 𝑃
control ADHD ADHD
(𝑁 = 8)
(𝑁 = 9) (𝑁 = 21) (𝑁 = 22)
Demographics
Gender (men/women) 3/5 4/5 11/10 12/10
Age (years) 26.9 (3.9) 28.7 (5.5) 31.2 (7.5) 31.7 (7.8) 0.32
Education (years) 16.0 (2.8) 15.9 (2.0) 14.6 (2.4) 15.1 (3.2) 0.53
IQ Raven (number correct) 54.4 (1.7) 52.2 (7.4) 52.6 (3.7) 49.4 (7.4) 0.16
At-home practices (min)∗
Week 1 15.6 (11.2) 32.9 (17.6)
Week 2 21.3 (7.9) 19.8 (14.1)
Week 3 31.3 (18.1) 48.1 (27.3)
Week 4 37.5 (10.4) 52.9 (48.8)
Week 5 45.0 (10.7) 50.5 (42.8)
Week 6 54.4 (15.9) 49.7 (50.7)
Week 7 45.0 (16.0) 42.9 (57.6)
Week 8 48.8 (10.6) 33.6 (20.6)
Satisfaction (1–10 score) 9.3 (0.9) 9.3 (0.9) 0.82
∗
No effect of health status or interaction with week, but there was an effect of week [𝐹 (7, 189) = 4.35; 𝑃 < 0.001]: practice in weeks 3–8 > weeks 1-2 (𝑃 < 0.001).

𝑃 < 0.001; positive affect: 𝐹(1,56) = 4.88, 𝑃 = 0.03; sadness:

𝐹(1,56) = 4.95, 𝑃 = 0.03; joviality: 𝐹(1,56) = 10.08, 𝑃 < 0.001;
1.6
1.4
self-assurance: 𝐹(1,56) = 4.72, 𝑃 = 0.03; attentiveness: 𝐹(1,56) =
1.2
15.80, 𝑃 < 0.001; fatigue: 𝐹(1,56) = 4.41, 𝑃 = 0.04; and
serenity: 𝐹(1,56) = 14.05, 𝑃 < 0.001). For these same variables,
(Hedges g)

1
0.8 plus shyness and fear, we also found interactions between
0.6 session and intervention (negative affect: 𝐹(1,56) = 7.49,
0.4 𝑃 = 0.01; g = −0.7; positive affect: 𝐹(1,56) = 18.13, 𝑃 < 0.001;
0.2 𝑔 = 1.3; sadness: 𝐹(1,56) = 7.92, 𝑃 = 0.01; 𝑔 = −0.6; joviality:
0 𝐹(1,56) = 7.82, 𝑃 = 0.01; 𝑔 = 0.7; self-assurance: 𝐹(1,56) = 9.05,
𝑃 < 0.001; 𝑔 = 0.9; attentiveness: 𝐹(1,56) = 6.50, 𝑃 = 0.01;
PANAS-X-negative affect
PANAS-X-positive affect

PANAS-X-self-assurance

AAQoL-relationships
PANAS-X-fear
PANAS-X-sadness

PANAS-X-fatigue

ANT-hit RT block change

CPT II-commission errors
BDI-depression

PANAS-X-attentiveness

AAQoL-psychological health

AAQol-total quality of Life

PANAS-X-shyness
ASRS-inattention
ASRS-hyperactivity-impulsivity

AAQoL-life outlook
STAI-anxiety

PANAS-X-joviality

PANAS-X-serenity
AAQoL-life productivity

CPT II-detectability

𝑔 = 1.0; fatigue: 𝐹(1,56) = 4.80, 𝑃 = 0.03; 𝑔 = −0.8; serenity:

𝐹(1,56) = 7.13, 𝑃 = 0.01; 𝑔 = 0.8; shyness: 𝐹(1,56) = 10.24,
𝑃 < 0.001; 𝑔 = −1.0; fear: 𝐹(1,56) = 9.25, 𝑃 < 0.001;
𝑔 = −0.5). The pattern of post hoc effects was the same as
that observed for hyperactivity-impulsivity symptoms on the
ASRS and depression and anxiety scores (𝑃 values < 0.05).
Regarding quality of life assessed with the AAQoL ques-
tionnaire (Table 2), there was a main effect of health status
for all variables, indicating worse quality of life in the ADHD
Affective
measures
Attentional
measures patients (life productivity: 𝐹(1,56) = 30.45, 𝑃 < 0.001;
psychological health: 𝐹(1,56) = 16.50, 𝑃 < 0.001; life outlook:
Figure 2: Effect sizes (Hedges g) of affective and attentional 𝐹(1,56) = 21.20, 𝑃 < 0.001; relationships: 𝐹(1,56) = 24.64, 𝑃 <
measures for variables for which there was an interaction of session
0.001; total quality of life: 𝐹(1,56) = 35.17, 𝑃 < 0.001). There
and intervention factors considering change scores (post- minus
were also interactions between session and intervention for
preintervention period). Dotted lines indicate medium effect sizes
(𝑔 > 0.5) and large effect sizes (𝑔 > 0.8). ASRS: Adult Self- all domains (life productivity: 𝐹(1,56) = 19.06, 𝑃 < 0.001;
Report Scale, BDI: Beck Depression Inventory, STAI: trait anxiety of 𝑔 = 1.3; psychological health: 𝐹(1,56) = 8.67, 𝑃 < 0.001;
the State-Trait Anxiety Inventory, PANAS-X: Positive and Negative 𝑔 = 0.9; life outlook: 𝐹(1,56) = 14.73, 𝑃 < 0.001; 𝑔 = 1.0;
Affect Schedule—Expanded Form, AAQoL: Adult ADHD Quality relationships: 𝐹(1,56) = 8.76, 𝑃 < 0.001; 𝑔 = 0.9; total quality
of Life Questionnaire, ANT: Attentional Network Task, CPT II: of life 𝐹(1,56) = 28.13, 𝑃 < 0.001; 𝑔 = 1.5). These effects
Conner’s Continuous Performance Test, and Hit RT: reaction time followed the same general pattern described above, that
of correct responses. is, no significant difference between conditions at baseline,
8 BioMed Research International
Table 2: Mean (standard deviation) scores on the Adult ADHD Self-Report Scale (ASRS), Beck Depression Inventory (BDI), State-
Trait Anxiety Inventory (STAI-T), Positive and Negative Affect Schedule—expanded form (PANAS-X), and Adult ADHD Quality of Life
Questionnaire (AAQoL) per group (control and patients with attention deficit hyperactivity disorder (ADHD) submitted to mindful
awareness practices (MAP) or to no intervention) at baseline and after the intervention period (endpoint) and significant effects.

Meditation No intervention Meditation No intervention

Control Control ADHD ADHD Significant
Measure
(𝑁 = 8) (𝑁 = 9) (𝑁 = 21) (𝑁 = 22) effects
Baseline Endpoint Baseline Endpoint Baseline Endpoint Baseline Endpoint
ASRS
Inattention 15.5 (3.3) 11.9 (3.4) 10.0 (2.8) 11.1 (5.1) 29.4 (3.9) 21.9 (5.1) 27.4 (5.9) 26.2 (4.9) H; S × I
Hyperactivity-
14.6 (4.1) 11.3 (3.5) 10.8 (4.4) 11.9 (3.2) 21.9 (7.1) 17.9 (5.6) 23.1 (6.9) 21.9 (6.5) H; S × I
impulsivity
Depression (BDI) 10.0 (8.2) 4.6 (2.7) 4.0 (3.0) 4.1 (2.0) 14.0 (7.9) 10.6 (9.5) 12.4 (7.7) 12.6 (8.2) H; S × I
Anxiety (STAI-T) 42.9 (6.2) 37.1 (3.3) 35.4 (3.9) 34.9 (8.5) 53.7 (11.7) 45.5 (11.3) 52.2 (11.2) 51.6 (10.2) H; S × I
PANAS-X
Negative affect 2.1 (1.1) 1.4 (0.2) 1.5 (0.4) 1.5 (0.4) 2.2 (0.8) 1.8 (0.7) 2.3 (0.7) 2.4 (0.8) H; S × I
Positive affect 2.5 (0.8) 3.2 (0.9) 3.0 (0.5) 3.0 (0.5) 2.3 (0.6) 2.6 (0.7) 2.7 (0.8) 2.4 (0.7) H; S × I
Fear 2.0 (1.0) 1.3 (0.2) 1.4 (0.2) 1.7 (0.6) 1.9 (0.7) 1.6 (0.7) 2.0 (0.6) 2.0 (0.6) S×I
Hostility 1.9 (0.8) 2.6 (3.8) 1.4 (0.4) 1.4 (0.2) 2.1 (0.9) 1.7 (0.7) 2.1 (0.8) 2.1 (0.7)
Guilt 2.0 (0.9) 2.6 (3.8) 1.5 (0.4) 1.7 (0.7) 2.0 (0.9) 1.5 (0.5) 2.0 (0.9) 2.2 (1.0)
Sadness 2.0 (0.7) 1.3 (0.3) 1.4 (0.4) 1.6 (0.8) 2.2 (1.1) 1.8 (1.1) 2.1 (1.0) 2.4 (2.1) H; S × I
Joviality 2.7 (0.9) 3.3 (1.1) 3.0 (0.6) 2.7 (0.5) 2.2 (0.6) 2.5 (0.9) 2.5 (0.8) 2.2 (0.7) H; S × I
Self-assurance 2.1 (0.6) 2.7 (0.9) 3.3 (1.2) 3.2 (1.2) 2.0 (0.5) 2.7 (1.0) 2.5 (0.9) 2.4 (0.7) H; S × I
Attentiveness 3.1 (0.8) 3.3 (0.7) 3.3 (0.7) 3.4 (0.5) 2.2 (0.7) 2.8 (0.7) 2.5 (0.9) 2.4 (0.8) H; S × I
Shyness 2.2 (1.0) 1.4 (0.4) 1.9 (0.6) 1.7 (0.4) 2.0 (0.8) 1.3 (0.4) 2.1 (0.8) 2.0 (0.8) S×I
Fatigue 2.6 (1.3) 2.0 (0.5) 2.1 (0.8) 2.0 (0.7) 2.9 (0.7) 2.3 (1.0) 2.5 (0.7) 2.6 (0.9) H; S × I
Serenity 2.7 (0.6) 3.2 (0.6) 2.9 (0.6) 3.0 (0.7) 2.2 (0.6) 2.7 (0.7) 2.4 (0.7) 2.3 (0.5) H; S × I
Surprise 1.6 (0.7) 1.6 (0.7) 1.7 (0.8) 1.5 (0.5) 1.5 (0.6) 1.7 (0.8) 1.9 (0.9) 1.7 (0.6)
AAQoL
Life productivity 64.5 (15.5) 77.8 (10.2) 63.4 (21.2) 61.3 (19.6) 34.4 (13.2) 57.1 (10.4) 38.4 (20.4) 43.3 (17.0) H; S × I
Psychological health 60.9 (16.4) 65.3 (13.1) 64.4 (17.2) 58.3 (17.9) 39.5 (15.1) 57.7 (17.5) 39.4 (19.1) 42.2 (16.2) H; S × I
Life outlook 56.3 (12.2) 76.4 (13.0) 66.0 (9.7) 67.5 (10.2) 48.2 (16.1) 60.4 (16.4) 45.9 (16.9) 43.2 (15.5) H; S × I
Relationships 63.1 (20.2) 71.3 (14.3) 70.0 (16.4) 65.6 (18.1) 43.1 (15.9) 60.7 (13.2) 43.4 (18.9) 44.1 (15.0) H; S × I
Total quality of life 61.2 (12.5) 72.7 (9.3) 66.0 (14.3) 63.2 (12.5) 41.3 (11.8) 59.0 (12.1) 41.8 (14.1) 43.2 (11.9) H; S × I
H: effect of health status (ADHD versus controls); S: effect of session (baseline versus endpoint) or practice effect; I: effect of intervention (MAP versus no
intervention); ×: interaction of factors (𝑃 values < 0.05). See text for details on the statistical analysis.

and improvement after MAP at endpoint compared with (𝐹(1,56) = 11.57; 𝑃 < 0.001), accuracy (𝐹(1,56) = 31.33; 𝑃 <
baseline and with participants who did undergo intervention 0.001), omission errors (𝐹(1,56) = 50.55; 𝑃 < 0.001), hit
(𝑃 values < 0.001); additionally, there was no significant RT SE (𝐹(1,56) = 7.29; 𝑃 = 0.01), and hit SE block change
difference in performance between sessions in participants (𝐹(1,56) = 4.90; 𝑃 = 0.03).
who did not participate in MAP. However, there were also positive effects of the MAP
intervention irrespective of health status (see Figure 2 for the
3.4. Effects of MAP on Attentional Performance Measures
(Table 3). We employed the same GLMs and factors that effect sizes of the intervention). The intervention interacted
were used to evaluate affective measures. The pattern of with session for the hit RT block change measure (𝐹(1,56) =
effects on attention performance differed from the pattern 8.16; 𝑃 = 0.01; 𝑔 = −0.9). The pattern of post hoc contrasts
of effects on affective ratings. On the ANT, there were no was the same as that observed for most of the affective
effects of health status alone and no interaction between this measures: there were no significant differences between
factor and others. Regarding the effects of session (practice conditions at baseline, but at endpoint the MAP intervention
effects), we obtained various indications that the task was improved scores compared with baseline and with the scores
sensitive to practice effects because performance was better of the participants who did not participate in the intervention
at the endpoint than at baseline for the variables executive (P values < 0.05), which were not statistically different at both
control/conflict (𝐹(1,56) = 12.80; 𝑃 < 0.001), hit RT sessions.
Table 3: Mean (standard deviation) scores on the Attentional Network Task (ANT) and the Conners Continuous Performance Test (CPT II) per group (control and patients with attention
deficit hyperactivity disorder (ADHD) submitted to mindful awareness practices (MAP) or to no intervention) at baseline and after the intervention period (endpoint) and significant effects.
Meditation No intervention Meditation No intervention
BioMed Research International

Control Control ADHD ADHD Significant

Measure
(𝑁 = 8) (𝑁 = 9) (𝑁 = 21) (𝑁 = 22) effects
Baseline Endpoint Baseline Endpoint Baseline Endpoint Baseline Endpoint
ANT
Alerting 33.6 (22.2) 43.8 (28.8) 33.4 (21.4) 35.8 (27.0) 32.0 (29.0) 39.3 (19.7) 37.4 (28.8) 46.0 (27.1)
Orientation 29.3 (11.6) 30.1 (13.8) 16.8 (14.4) 26.4 (22.7) 29.8 (30.5) 32.1 (21.2) 32.2 (41.0) 26.6 (23.8)
Executive control/conflict 114.8 (38.9) 88.1 (38.0) 198.2 (68.2) 114.3 (55.2) 184.6 (98.5) 140.1 (77.2) 150.7 (64.9) 107.5 (69.9) S
Hit RT (ms) 535.1 (75.5) 488.8 (46.8) 612.2 (114.6) 597.1 (142.1) 577.4 (123.0) 537.4 (90.2) 546.4 (101.8) 511.9 (89.8) S
Accuracy (number) 274.9 (9.6) 284.0 (4.3) 274.8 (8.1) 278.1 (9.0) 272.0 (11.4) 278.5 (9.3) 273.4 (9.9) 277.0 (9.1) S
Omissions (number) 5.4 (3.3) 3.0 (3.0) 5.3 (3.4) 3.8 (3.1) 7.2 (4.5) 4.4 (3.5) 7.0 (3.4) 4.6 (3.3) S
Hit RT SE 16.1 (6.2) 13.2 (7.7) 18.6 (4.9) 15.9 (17.3) 16.4 (14.0) 11.3 (7.4) 20.2 (11.3) 11.9 (6.6) S
Variability of SE 1.3 (1.0) 1.4 (1.6) 1.9 (1.1) 2.1 (1.5) 2.1 (1.6) 1.6 (1.6) 2.3 (1.8) 1.6 (1.1)
Hit RT block change −17.8 (17.4) −26.1 (13.4) −18.5 (25.1) −10.1 (31.1) −5.5 (22.9) −19.7 (16.0) −12.4 (22.0) −1.9 (15.6) S×I
Hit SE block change −0.18 (0.66) −1.18 (1.50) −1.01 (1.74) −0.99 (2.12) −0.18 (2.36) −1.29 (1.54) 0.08 (1.60) −0.93 (2.18) S
CPT II
Omission errors (number) 1.4 (2.0) 0.0 (0.0) 1.7 (2.7) 1.1 (1.3) 2.4 (4.3) 2.1 (3.2) 3.8 (7.6) 2.8 (5.7)
Commission errors (number) 9.1 (4.0) 4.5 (3.6) 7.2 (4.4) 7.7 (4.4) 15.1 (7.8) 10.6 (8.4) 12.5 (9.8) 12.9 (9.7) H; S × I
Hit RT (ms) 385.8 (76.0) 407.0 (55.0) 408.5 (68.5) 396.9 (64.3) 386.3 (75.0) 397.1 (69.3) 376.9 (115.6) 378.2 (67.8)
Variability of SE 5.9 (1.5) 5.1 (2.3) 7.6 (1.9) 7.8 (4.7) 7.9 (3.6) 8.4 (8.4) 9.7 (8.8) 9.8 (12.5)
Hit RT SE 5.2 (1.6) 5.0 (1.6) 5.5 (1.4) 5.4 (2.0) 6.0 (2.2) 5.8 (3.0) 6.5 (2.6) 6.2 (3.7)
Detectability (𝑑󸀠 ) 0.9 (1.3) 1.3 ( 0.4) 1.1 (0.4) 1.0 (0.3) 0.7 (0.4) 0.9 (0.5) 0.9 (0.7) 0.8 (0.6) H; S × I
Hit RT block change −0.014 (0.035) −0.013 (0.028) −0.003 (0.021) −0.003 (0.017) 0.001 (0.034) −0.004 (0.025) −0.011 (0.030) −0.003 (0.027)
Hit SE block change −0.030 (0.059) 0.033 (0.058) 0.021 (0.065) 0.004 (0.081) 0.001 (0.063) 0.016 (0.060) 0.002 (0.103) 0.001 (0.066)
Hit RT ISI change 0.058 (0.014) 0.061 (0.011) 0.046 (0.039) 0.052 (0.040) 0.046 (0.043) 0.050 (0.043) 0.066 (0.030) 0.058 (0.035)
Hit SE ISI change −0.015 (0.120) 0.019 (0.077) −0.019 (0.100) −0.006 (0.112) −0.030 (0.099) −0.017 (0.133) 0.002 (0.104) 0.027 (0.117)
Response style (𝛽) 0.6 (0.8) 0.7 (0.6) 0.9 (0.8) 1.7 (1.5) 1.1 (2.4) 0.7 (0.6) 1.0 (1.1) 0.5 (0.4)
Perseverations 0.0 (0.0) 0.0 (0.0) 0.4 (0.7) 0.4 (0.7) 0.7 (1.5) 2.4 (5.9) 1.8 (3.6) 1.7 (3.4)
Hit: correct responses; RT: reaction time; SE: standard error of the mean; ISI: interstimulus interval; H: effect of health status (ADHD versus controls); S: effect of session (baseline versus endpoint) or practice effect;
I: effect of intervention (MAP versus no intervention); ×: interaction of factors (𝑃 values < 0.05). See text for details on the statistical analysis.
9
10 BioMed Research International

Regarding the CPT II (Table 3), a main effect of health sole effect does not reflect an actual difference in the profile
status was found for commission errors (𝐹(1,56) = 6.88; of the participants who did and did not undertake MAP.
𝑃 = 0.01) and detectability (𝐹(1,56) = 4.06; 𝑃 = 0.05); Regarding subjective ratings of mood, the ADHD
the ADHD patients displayed worse scores, as expected. patients reported more ADHD symptoms, depression, and
Furthermore, there was an interaction between session and anxiety, as well as more negative and less positive affect
intervention for both of these variables (commission errors compared with healthy controls, as expected [24, 25]. MAP
𝐹(1,56) = 8.74; 𝑃 < 0.001; 𝑔 = −0.9; detectability 𝐹(1,56) = improved these symptoms in the ADHD patients, in accor-
13.24; 𝑃 < 0.001; 𝑔 = 1.1), again with the same post hoc dance with the results of Mitchell et al. [43] and Zylowska
beneficial effects of MAP that were described for affective et al. [15], and in the healthy controls, as reported by Astin
measures and hit RT block change on the ANT. [9], Jha et al. [10], and van den Hurk et al. [11]. Both the
Changes in depression and anxiety scores did not cor- participants with ADHD and the healthy control participants
relate with performance changes in any of the attentional found the intervention rewarding, as determined by their
changes (𝑃 values > 0.15). Low correlations were found high satisfaction ratings, and both groups were motivated
between ADHD symptoms and attentional measures: inat- by MAP based on both their attendance of the weekly
tention ratings correlated with commission errors (𝑅 = 0.38; sessions and the frequency and extent of their home practices.
𝑃 = 0.003) and detectability (𝑅 = −0.29; 𝑃 = 0.02), while In comparison, the mood ratings of the participants who
hyperactivity-impulsivity ratings correlated with commission did not participate in the MAP program did not change
errors (𝑅 = 0.35; 𝑃 = 0.006) and detectability (𝑅 = −0.30; between sessions. This indicates that the affective state was
𝑃 = 0.02). stable during the period during which the program took
place. Furthermore, the experience of having completed
4. Discussion the questionnaires previously did not alter the participants’
subjective ratings, so test-retest reliability seems to have been
Overall, we found that the adults with ADHD had worse adequate for these measures.
affective ratings, quality of life, and attentional performance Regarding the assessment of quality of life with the
compared with controls and that MAP improved measures AAQol, which focuses on ADHD problems, we also showed
in all of these parameters, in accordance with our hypothesis. that the ADHD patients had worse ratings than the con-
However, these effects did not show significant differences trols did, as is commonly found [20], corroborating our
between controls and patients, a finding that we did not hypothesis. Additionally, the interaction between session
expect given the larger number and greater intensity of and intervention mirrored the above-mentioned beneficial
negative symptoms in the patients. Most of the MAP-induced MAP-induced effect on mood; the patients and controls
effects reached large effect sizes, which attests to the clinical reported greater life productivity and psychological health,
importance of our findings. a better outlook on life, and improved relationship issues
First, we should address a possible difference between after the intervention, and all effects sizes were large. This
the individuals who were willing to participate in MAP finding also confirms findings that nonclinical populations
and those who were not. We found only one difference experience improved quality of life after mindfulness training
at baseline between these groups of individuals, which did [7, 8].
not interact with health status; therefore, we believe that Concerning performance on attentional tasks, like others,
our quasiexperimental design, though not ideal, did not we observed that the ADHD patients showed impairment
negatively impact our main findings of the beneficial effects on the CPT II measures commission errors, an indication
of the MAP. Among the 21 subjective measures evaluated of impulsivity [38–40], and detectability, or the ability to
at baseline, the ADHD patients and healthy controls who distinguish relevant from irrelevant information [30], which
wanted to participate in the intervention (meditation ADHD is related to the concept of executive control [26]. The classic
and meditation control, resp.) rated themselves similarly ANT measures were not impaired in the ADHD patients at
to those who did not want to participate (no intervention baseline. This finding supports those of Lundervold et al.
ADHD and no intervention control, resp.). These measures [25] but differs from those of Lampe et al. [36], who showed
were related to the scores of ASRS measures of inattention, executive deficits, which we found using the CPT II. Hence,
hyperactivity-impulsivity, Beck Depression, STAI anxiety, it seems ideal to use both of these tasks to evaluate executive
PANAS-X measures of negative affect, positive affect, fear, attentional deficits in ADHD.
hostility, guilt, sadness, joviality, self-assurance, shyness, Concerning the attentional effects of MAP, the CPT II
fatigue, serenity, and surprise, as well as the quality of life measures that were impaired in ADHD patients at base-
measures, that is, life productivity, psychological health, life line compared with controls (i.e., commission errors and
outlook, relationships, and total quality of life, except that detectability) were improved by the intervention. Nonethe-
the meditation ADHD and meditation control (intervention less, these effects were not specific to ADHD patients and
groups) reported being less attentive compared with the were also observed in the controls (interaction of inter-
no intervention ADHD and no intervention control groups vention and session). These results indicate better MAP-
in the PANAS-X attentiveness score. However, there was induced regulation of behavior and/or self-control of impul-
no objective indication of worse attentiveness among these sive tendencies [66] with the consequential potential for
individuals on any of the 22 objective attentional measures improving attention and emotion [6, 27]. These attentional
on the ANT and CPT II measures. Hence, we believe that this changes, though, are most likely not wholly secondary to
BioMed Research International 11

improvements in mood and ADHD symptoms, considering such as conflict resolution and emotional regulation. This fits
that correlations were not present or low. This confirms nicely with the improvement in affect found here.
that MAP can alter brain functioning related to attentional Thus, a series of our findings indicated that the ANT and
performance [12, 13, 31, 32, 41, 45]. CPT are complementary in the present setting and should
Despite repetition of the attentional tasks (baseline and be used together when evaluating MAP and/or ADHD
endpoint), we did not find any measure on the CPT II that attentional effects. The measures were differently sensitive to
exhibited practice effects (main effect of session with no inter- practice effects; CPT measures derived from ANT data indi-
action with other factors), indicating that results were not cated MAP-induced improvement in sustained attention that
contaminated by a lack of test-retest reliability. In contrast, the CPT did not, and the variables on the CPT that indicate
various variables obtained from the ANT were susceptible to executive functioning were positively affected by MAP, while
repetition, as Ishigami and Klein [67] found, including the those variables on the ANT were not. One possible reason for
executive/conflict measure, for which performance improved this is that these tasks have different characteristics. One main
at endpoint compared with baseline. Various other measures difference is that, in the ANT paradigm [33], the participant
derived from the ANT that are classical CPT II measures (see must respond to all trials; therefore, impulsivity, which is
[25]) were also improved at endpoint (hit RT, hit RT SE, hit SE one of the main symptoms of ADHD [17–19], cannot be
block change, omission errors, and accuracy) irrespective of shown. In other words, commission errors and detectability
health status. Hence, MAP’s positive executive effects on the cannot be determined in this task, and these variables are
ANT in ADHD patients, as reported by Zylowska et al. [15], susceptible to ADHD and were sensitive to improvement
may have been caused by practice and not the intervention with MAP. Another aspect of the ANT is that it involves
itself. Note that these authors only compared performance a fixed time interval of 400 ms between the cues and the
between baseline and after MAP in ADHD patients and target. This increases the predictability of the need to respond,
did not include a nonintervention control group. In contrast which is unlike the CPT, in which interstimulus intervals
and in agreement with our results, Mitchell et al. [43], who vary. This is important because it has been shown that adults
controlled for practice effects, found that the same MAP with ADHD have deficits related to the estimation of time
protocol that was used here and by Zylowska et al. [15] had intervals [69], which may contribute to the usefulness of
no beneficial effect on the classic ANT measures. Mitchell et the CPT for detecting their attentional problems [37], as we
al. [43] also failed to find MAP-induced effects on the CPT II, found here. On the other hand, this lack of variability in the
in contrast with our findings; this difference may be related interstimulus intervals of the ANT may have enabled MAP-
to a lack of power, as their sample of ADHD patients was induced sustained attention improvement to be detected.
smaller. One possible hypothesis for the comparable improvement
Despite these practice effects, we did show objective in mood, quality of life, and attentional performance between
beneficial changes resulting from MAP on a variable that was the ADHD patients and healthy controls after MAP is that
not evaluated in the latter studies. The measure hit RT block our control group was small. With a larger sample, differences
change, which was derived from the ANT data, improved might have become apparent. Additionally, these similar
after the MAP intervention, and this can be attributed to results between groups may have resulted from the use of
increases in the ability to sustain attention or vigilance [31, a treatment program that was developed specifically for
32], an ability that is impaired in adults with ADHD [68] and adults with ADHD (see details in Zylowska et al. [15] and
seems to improve after mindfulness practices [5]. However, Zylowska [59]). Thus, the intervention used in our study
this effect is not commonly found when the CPT II is used may have led to specific improvement in aspects that are
[38]. Interestingly, this effect was not shown for the analogous impaired in this clinical condition. It is therefore possible that
measure obtained from the CPT data, or for the alerting other mindfulness programs may lead to different attentional
variable of the ANT, a concept that is highly similar to performance improvements in healthy adults, as found by
sustained attention/vigilance (see [43]). Hence, it seems to Tang et al. [70]. This is especially true considering that
be useful to calculate CPT measures using the ANT results, the effects found here for the control group indicated that
as proposed by Lundervold et al. [25], because doing so attention has room for improvement by MAP, even in healthy
increases the likelihood of detecting susceptibility to practice individuals.
effects and changes in attentional performance. There were limitations to our study apart from the small
There are indications that mindfulness practices can number of control participants. Like Zylowska et al.’s [59]
improve executive attention in inexperienced meditators, study, our study was not a randomized trial, as would have
especially after short-term programs (see [5]), but we did not been ideal, because we were not able to recruit a sufficiently
find such improvements using the ANT. However, we did large sample of subjects who fit the eligibility criteria and
show a MAP-induced improvement in the CPT II variables were willing to practice meditation. Likewise, in our study,
detectability and commission errors, in contrast with some the experimenter was not blind to the treatment, as seems
studies that used this task (see [5]). These measures are related to have occurred in Zylowska et al.’s work. However, we
to the concept of executive attention because they involve believe that this did not compromise our data because the
discriminating relevant from irrelevant visual signals, as well ADHD patients and controls who agreed to participate in the
as inhibitory processes [26]. According to Fernandez-Duque intervention and those who did not did not differ in terms
et al. [26], this type of executive functioning relates to better of demographic variables or IQ or on any subjective measure
metacognitive monitoring, which involves control processes except inattention.
12 BioMed Research International

It can also not be excluded that the awareness of par- [4] S. Baijal and R. Gupta, “Meditation-based training: a possible
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Conflict of Interests 2010.
[12] U. Kirk, X. Gu, A. H. Harvey, P. Fonagy, and P. R. Montague,
The authors declare no conflict of interests with respect to the “Mindfulness training modulates value signals in ventromedial
authorship and/or publication of this paper. prefrontal cortex through input from insular cortex,” Neuroim-
age, vol. 100C, pp. 254–262, 2014.
Acknowledgments [13] J. A. Brewer, J. H. Davis, and J. Goldstein, “Why is it so hard
to pay attention, or is it? Mindfulness, the factors of awakening
This research was supported by FAPESP (courtesy of a and reward-based learning,” Mindfulness, vol. 4, no. 1, pp. 75–80,
fellowship grant to the first author, Project no. 2011/08547-3), 2013.
Associação Fundo de Incentivo à Pesquisa, and Coordenação [14] S. E. Lakhan and K. L. Schofield, “Mindfulness-based therapies
de Aperfeiçoamento de Pessoal de Nı́vel Superior (CAPES). in the treatment of somatization disorders: a systematic review
Sabine Pompéia received a research grant from Conselho and meta-analysis,” PLoS ONE, vol. 8, no. 8, Article ID e71834,
2013.
Nacional de Pesquisa (CNPq). All of the above are nonprofit
organizations that sponsor research in Brazil. The authors [15] L. Zylowska, D. L. Ackerman, M. H. Yang et al., “Mindfulness
thank Stephen Little for conducting the mindfulness prac- meditation training in adults and adolescents with ADHD: a
feasibility study,” Journal of Attention Disorders, vol. 11, no. 6,
tices.
pp. 737–746, 2008.
[16] T. Krisanaprakornkit, C. Ngamjarus, C. Witoonchart, and N.
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