Mindfulness Meditation Training for Attention-Deficit/Hyperactivity Disorder in Adulthood: Current Empirical Support, Treatment Overview, and Future Directions

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Patient #1's Beck Depression Inventory score decreased from 19 at week 1 to 6 at week 8, a change exceeding 30% symptom reduction.

“Patient #1 went from a score of 19 in the moderately to severely depressed range at week 1 on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) to a score of 6 in the non-depressed range at week 8—this change in depressive symptoms also exceeds 30% symptom reduction.”

• cites Beck, Ward, Mendelson, Mock, & Erbaugh, 1961Not checked yet

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Patient #2 showed lower symptom severity in weeks 2-3, stable scores at week 4, a rise in weeks 5-6, and a gradual decline in weeks 7-8.

“Patient #2, in contrast, reported a decrease in symptom severity scores at weeks 2 and 3, which held consistent by week 4. By week 5 and 6, she noticed an increase in symptoms, which then gradually decreased over the course of weeks 7 and 8.”

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Both case patients described becoming more aware of their ADHD behaviors.

“It is interesting to note that both patients reported increased awareness of their ADHD behaviors.”

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Patient #1's total ADHD symptom severity score started at 34, increased at weeks 3 and 4, decreased at weeks 5 and 6, then increased week-by-week until treatment end, ending similar to week 1.

“Patient #1 reported an increase in symptoms at week 3 and week 4 (see Figure 1). Despite that symptom severity scores decreased at weeks 5 and 6, they began to increase week-by-week from that point until the end of treatment.”

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  “At the conclusion of treatment, Patient #1 yielded symptom severity scores similar to week 1.”

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At post-treatment, Patient #1 had an ADHD symptom severity score of 33, while Patient #2 had a score of 8.

“Whereas the symptom severity score was 33 for Patient #1 at post-treatment (item average of 1.83 with response options ranging from 0 to 3), Patient #2 yielded a score of 8 (item average of 0.44 with response options ranging from 0 to 3).”

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Four days of meditation (20 min/day) improved visuo-spatial processing, working memory, and executive functioning compared with an active treatment.

“Similar findings have been reported following four days of meditation training (20 minutes per day) on visuo-spatial processing, working memory, and executive functioning against an active treatment comparison group (Zeidan, Johnson, Diamond, David, & Goolkasian, 2010).”

• cites Zeidan, Johnson, Diamond, David, & Goolkasian, 2010 sourceNot checked yet

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The default mode network is implicated in ADHD and associated with poorer attentional regulation in ADHD.

“The default mode network is implicated in ADHD (Fair et al., 2010) and is associated with poorer attentional regulation in ADHD (Castellanos et al., 2008).”

• cites Fair et al., 2010 sourceNot checked yet

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• cites Castellanos et al., 2008 sourceNot checked yet

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Mindfulness meditation training is feasible and acceptable in child and adolescent ADHD samples.

“Overall, these findings in child and adolescent samples are promising and demonstrate that mindfulness meditation training in this ADHD population is feasible and acceptable.”

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Mindfulness meditation training has received increasing clinical interest and empirical support among nonpharmacological options for adult ADHD.

“Among available nonpharmacological treatment options, mindfulness meditation training has received increasing clinical interest and empirical support.”

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Mindfulness-based training currently has promising preliminary empirical support for adults with ADHD and is increasingly used in clinical settings.

“Mindfulness-based training is an example of an intervention that is gaining promising preliminary empirical support and is increasingly administered in clinical settings.”

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Methodological limitations in child and adolescent studies limit generalizability and indicate a need for larger, more rigorous trials.

“However, methodological issues pertaining to small samples, the use of multiple outcome variables, a lack of active treatment comparison groups (or any comparison group in most studies), a lack of accounting for the effects of pharmacotherapy, atypical sample composition (e.g., high IQ and parental education levels), and short follow-up assessment periods (i.e., none beyond 16 weeks) limit general”

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A meta-analysis of 209 treatment studies found mindfulness-based therapies yield moderate effect sizes in within-group pre-post, waitlist, and active comparisons, and do not differ from behavioral and pharmacological interventions.

“One recent meta-analysis of 209 treatment studies indicated that mindfulness-based therapies yield moderate effect sizes in within group pre-post comparisons, comparisons with waitlist control groups, and when compared to other active comparison groups, while not differing from behavioral and pharmacological interventions (Khoury et al., 2013).”

• cites Khoury et al., 2013 sourceNot checked yet

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Systematic reviews and meta-analyses indicate mindfulness-based treatments are effective for a variety of mental health treatment targets, though more rigorous trials are needed.

“Systematic reviews and meta-analyses indicate that, despite the need for more methodologically rigorous trials, mindfulness-based treatments are effective for a variety of mental health treatment targets”

• cites Bohlmeijer, Prenger, Taal, & Cuijpers, 2010 sourceNot checked yet

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• cites Chiesa & Serretti, 2011Not checked yet

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• cites Fjorback, Arendt, Ornbol, Fink, & Walach, 2011 sourceNot checked yet

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The practice requires top-down regulation of attention and conflict detection, which can be seen as improving executive processes.

“That is, this practice requires top-down regulation of attention and conflict detection, which can be thought of as a regulatory approach to attention that improves executive processes (Chiesa, Calati, & Serretti, 2011).”

• cites Chiesa, Calati, & Serretti, 2011Not checked yet

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In a MYmind study with 18 adolescents with ADHD and 17 parents using a within-groups design, pre-post comparisons showed improvement in parent-reported conduct disorder symptoms and peer relations, while parent-reported inattentive symptoms approached significance.

“Pairwise comparisons of pre- and post-treatment indicated an improvement in conduct disorder symptoms (parent report) and peer relations (parent report), while inattentive symptoms (parent report) approached statistical significance (p < .10).”

• cites Haydicky, Schecter, Wiener, & Ducharme, in pressNot checked yet

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In that study, at 8-week follow-up, attention problems improved significantly by adolescent report and were maintained by paternal report; paternal report showed improvements in externalizing behaviors, metacognition, behavioral regulation, and parental stress.

“At eight-week follow-up, improvement in attention problems was significant according to adolescent report and was maintained for paternal report. In addition, improvements were noted according to paternal report for externalizing behaviors, metacognition, behavioral regulation, and parental stress.”

• cites van de Weijer-Bergsma et al., 2012 sourceNot checked yet

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In that study, the treatment group improved ADHD and executive functioning symptoms assessed via questionnaires, electronic diary, and clinician-rated interviews, and self-reported emotion dysregulation improved, with large effect sizes for significant findings.

“However, the treatment group did yield improvement in ADHD and executive functioning symptoms assessed via questionnaires, electronic diary, and clinician rated interviews. In addition, self-reported emotion dysregulation improved as well. Effect sizes for all statistically significant findings were large.”

• cites Mitchell et al., in pressNot checked yet

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In four 8-year-old boys with ADHD, a mindfulness intervention following a multiple baseline design produced greater on-task behavior based on descriptive visual analysis, and parent and teacher ratings indicated decreases in hyperactive behaviors but no changes in inattention.

“Participants exhibited greater on-task behavior following the intervention based on descriptive visual analysis of observational data. Though parent and teacher ratings indicated decreases in hyperactive behaviors, changes in inattention were not observed.”

• cites Carboni, Roach, & Fredrick, 2013Not checked yet

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Because mechanisms of mindfulness overlap with features and brain areas identified in ADHD, there is a rationale for mindfulness-based treatment for ADHD.

“given that a purported mechanism of change in mindfulness training overlaps with features that are identified in ADHD and are associated with similar areas of the brain, there is a rationale for a mindfulness-based approach to treatment for ADHD.”

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In a pilot study of modified 10-week MBCT in 11 adults with ADHD, pre-post comparisons showed improvements in self-reported total ADHD symptoms, trait mindfulness, and quality of life, and laboratory task performance on one of three executive functioning measures, conflict detection, improved.

“Pre-treatment and post-treatment comparisons indicated improvements in self-reported total ADHD symptoms, trait mindfulness, and quality of life. In addition, laboratory task performance on the one of the three outcome measures of executive functioning (i.e., conflict detection) improved.”

• cites Hepark, Kan, & Speckens, 2014Not checked yet

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In a MYmind study with 22 children with ADHD and 21 parents using a within-group waitlist design, inattentive and hyperactive-impulsive symptoms improved at post-treatment and 8-week follow-up for parent ratings of child behavior and parent ratings of their own behavior.

“Inattentive and hyperactive-impulsive symptoms improved at post-treatment and eight-week follow-up for parent ratings of child behavior and parent ratings of their own behavior.”

• cites van der Oord, Bogels, & Peijnenburg, 2012 sourceNot checked yet

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The Zylowska et al. 2008 feasibility study lacked a control group, had a small adolescent sample, and atypical high IQ and socioeconomic status.

“limitations include a lack of a control group, a small sample of adolescents, and atypical characteristics of the sample (e.g., high IQ and socioeconomic status).”

• cites Zylowska et al., 2008 sourceNot checked yet

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In that study, teacher ratings of inattention improved at post-treatment but not follow-up; teachers did not report a significant change in hyperactive-impulsive symptoms.

“Teacher ratings of inattention improved at post-treatment, but not follow-up. Teachers did not report a statistically significant change in hyperactive-impulsive symptoms.”

• cites van der Oord et al., 2012 sourceNot checked yet

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Difficulties in emotion regulation have been identified in ADHD and often contribute to significant impairment.

“difficulties in emotion regulation have been identified in ADHD and often contribute to significant impairment (Barkley & Fischer, 2010; Barkley & Murphy, 2010; Mitchell, Robertson, Anastopolous, Nelson-Gray, & Kollins, 2012).”

• cites Barkley & Fischer, 2010Not checked yet

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• cites Barkley & Murphy, 2010Not checked yet

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• cites Mitchell, Robertson, Anastopolous, Nelson-Gray, & Kollins, 2012Not checked yet

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In a MYmind study with 10 adolescents with ADHD and 11 parents, at post-treatment significant improvements emerged for externalizing behavior by paternal report, parental stress by paternal report, and parental overreactivity by maternal report.

“At post-treatment, statistically significant improvements emerged for externalizing behavior (paternal report), parental stress (paternal report), and parental overreactivity (maternal report).”

• cites van de Weijer-Bergsma, Formsma, de Bruin, & Bogels, 2012 sourceNot checked yet

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In the same study, adolescents with elevated inattentive ADHD symptoms in treatment improved parent-rated social problems versus waitlist, but not parent-rated executive functioning, externalizing, or ADHD symptoms.

“males with elevated inattentive ADHD symptoms in the treatment group (n = 15) improved on parent-rated social problems relative to the waitlist group (n = 18), but not on parent report of executive functioning, externalizing symptoms, or ADHD symptoms.”

• cites Haydicky et al., 2012Not checked yet

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In a randomized study of MAPs for ADHD, adults with ADHD stratified by medication status were assigned to treatment (n=11) or waitlist (n=9); results showed null findings on four laboratory executive functioning tasks.

“Results indicated null findings on four laboratory tasks assessing executive functioning”

• cites Mitchell et al., in pressNot checked yet

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In a pooled adolescent and adult sample, pre-post improvements occurred in self-reported ADHD symptoms and 4 of 12 attention, working memory, and cognitive inhibition tasks, with no significant age effects.

“Pre-post improvements in self-reported ADHD symptoms and test performance on four out of 12 diverse tasks measuring attention, working memory, and cognitive inhibition were noted in a pooled sample of adolescents and adults with no significant age effects on the measured outcomes.”

• cites Zylowska et al., 2008 sourceNot checked yet

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In the same study, adolescents with elevated hyperactive-impulsive ADHD symptoms in treatment improved parent-rated social problems and monitoring skills versus waitlist, with null differences on one of two executive functioning subscales and no differences on externalizing, ADHD, or self-report measures.

“males with elevated hyperactive-impulsive ADHD symptoms in the treatment group (n = 12) improved on parent-rated social problems and monitoring skills (a component of executive functioning) relative to the waitlist group (n = 17). Null differences emerged on one of two subscales measuring parent-rated executive functioning symptoms.”

• cites Haydicky et al., 2012Not checked yet

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In a randomized study of 26 adults with ADHD in a mindfulness group and 24 in a waitlist, self-reported ADHD symptoms, mindfulness, and quality of life improved for the mindfulness group but not the waitlist group.

“Self-report of ADHD symptoms (inattentive symptoms, hyperactive-impulsive symptoms, and ADHD Index), mindfulness, and quality of life improved for the mindfulness group, but not the waitlist control group.”

• cites Schoenberg et al., in pressNot checked yet

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The Haydicky et al. 2012 study had a small ADHD sample, nonrandom assignment, a heterogeneous intervention, no active comparison, and a selected male learning disorder sample.

“In addition to small sample size for the ADHD group, lack of random assignment to treatment conditions, a heterogeneous intervention (i.e., mindfulness was a component of an intervention that introduced other treatment modalities), and lack of an active treatment comparison group, this was a selected sample of male adolescents diagnosed with a learning disorder and comorbid ADHD.”

• cites Haydicky et al., 2012Not checked yet

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In adolescents with learning disorder and comorbid ADHD, a 20-week mindfulness plus CBT plus martial arts program improved parent-rated externalizing behavior, particularly oppositional defiant and conduct problems, versus waitlist, but not ADHD symptoms by parent or self report.

“A subgroup analysis on participants with co-occurring ADHD indicated improvement on parent-rated externalizing behavior, particularly oppositional defiant problems and conduct problems for the treatment group (n = 14) relative to the waitlist subgroup with co-occurring ADHD (n = 14). ADHD symptom change did not differ between groups according to both parent report and self-report.”

• cites Haydicky, Wiener, Badali, Milligan, & Ducharme, 2012Not checked yet

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In that study, retention was high with 78% completing treatment; participants reported significant practice outside weekly sessions and high satisfaction.

“Retention rates were high with the majority (78%) of participants completing the treatment. Participants reported significant practice outside of weekly sessions and overall high satisfaction with the treatment.”

• cites Zylowska et al., 2008 sourceNot checked yet

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In a feasibility study, adolescents with ADHD (n=8) had good attendance and high satisfaction with mindfulness training, but tended to have poorer at-home practice compliance than adults.

“Although feasibility measures indicated good attendance and high satisfaction with the treatment among the adolescents, there was a tendency for poorer compliance with at-home practice compared to adults.”

• cites Zylowska et al., 2008 sourceNot checked yet

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In that study, these improvements were no longer significant at follow-up, but pre-treatment to follow-up comparisons showed improvement for adolescent-reported depression, anxiety, and internalizing symptoms; parent-reported depression approached significance.

“While these findings were no longer significant at follow-up, pairwise comparisons of pre-treatment and follow-up indicated improvement for adolescent report of depression, anxiety, and internalizing symptoms. Parent report of depression approached statistical significance (p < .10).”

• cites Haydicky et al., in pressNot checked yet

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In an 8-week group MAPs for ADHD program administered to 24 adults and 8 adolescents with ADHD, pre-post assessments showed improvement in self-reported inattentive, hyperactive-impulsive, depressive, and anxious symptoms.

“Pre- and post-treatment assessments revealed improvement in self-reported inattentive, hyperactive-impulsive, depressive, and anxious symptoms.”

• cites Zylowska et al., 2008 sourceNot checked yet

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Five days of meditation training (20 min/day) improved anxiety, depression, anger, and stress-related cortisol compared with an active treatment group.

“a group that received five days of meditation training (20 minutes per day) reported improvement on measures of anxiety, depression, anger, and stress-related cortisol in comparison to an active treatment group (Tang et al., 2007).”

• cites Tang et al., 2007 sourceNot checked yet

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In that study, adolescents improved on a sustained attention task at post-treatment, maintained at 8-week follow-up.

“the adolescents improved in performance on a sustained attention task at post-treatment, which was maintained at eight-week follow-up.”

• cites Bögels et al., 2008 sourceNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

The review's search of PubMed and PsycINFO used terms for ADHD combined with mindfulness and meditation, reviewed references, excluded dissertations, placed no date restrictions, and was conducted on August 10, 2014.

“Treatment studies that included samples diagnosed with ADHD in the English language (including abstract-only) were identified by searches of PubMed and PsycINFO using the following search terms: “attention deficit hyperactivity disorder,” “ADHD,” and “ADD,” in combination with “mindfulness” and “meditation.””

Classified as probably not a substantial claim.

Mindfulness may reduce how much negative cognitions affect adults with ADHD.

“Consequently, mindfulness could help adults with ADHD diminish the impact of negative cognitions.”

May combine two claims.

In that trial, self-reported inattention did not differ at post-treatment but was statistically significant at three-month follow-up; self-reported quality of life was higher for DBT at post-treatment but not at three-month follow-up.

“Self-reported inattention did not significantly differ at post-treatment, but was statistically significant at three-month follow-up. Self-reported quality of life was higher for the DBT group at post-treatment, but did not differ at three-month follow-up.”

• cites Fleming et al., in pressNot checked yet

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A controlled MBCT trial was effective in preventing depressive relapse and enabled patients to lower antidepressant use.

“one controlled study of MBCT has demonstrated effectiveness for preventing depressive episode relapse while allowing patients to reduce their use of antidepressant medication (Kuyken et al., 2008).”

• cites Kuyken et al., 2008 sourceNot checked yet

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In that trial, except DBT outperforming control on omission errors at three-month follow-up, no group differences emerged on Conners' CPT indices; no group differences emerged for anxiety, depression, or GPA.

“With the exception of the DBT group outperforming the control group on omission errors at three-month follow-up, group differences did not emerge. No group differences emerged when anxiety, depression, or GPA were considered.”

• cites Fleming et al., in pressNot checked yet

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In one DBT study, mindfulness was well-liked and was one of the most useful components of the training.

“mindfulness was well-liked and was as one of the most useful components of the training (Philipsen et al., 2007).”

• cites Philipsen et al., 2007Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The default mode network is a promising target for mindfulness and is implicated in ADHD.

“Another example includes assessment of the default mode network, which is another promising target for mindfulness (Sood & Jones, 2013) and is implicated in ADHD (Castellanos et al., 2008; Fair et al., 2010)”

• cites Sood & Jones, 2013Not checked yet

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• cites Castellanos et al., 2008 sourceNot checked yet

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• cites Fair et al., 2010 sourceNot checked yet

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ADHD is commonly comorbid with mood disorders.

“ADHD is commonly comorbid with mood disorders (Sobanski, 2006)”

• cites Sobanski, 2006 sourceNot checked yet

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Mindfulness-related metacognitive awareness may broaden from thoughts to body, emotions, actions, and environmental feedback, improving self-monitoring and self-regulation.

“Furthermore, this type of metacognitive awareness that mindfulness purportedly elicits may also be expanded beyond cognition to observing one’s own body, emotional reactions, overt behavior, and environmental feedback with greater awareness, which can lead to improved overall self-monitoring and self-regulation (Zylowska et al., 2009).”

• cites Zylowska et al., 2009Not checked yet

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Classified as probably not a substantial claim.

Such improvement remains undemonstrated in ADHD samples.

“this has yet to be demonstrated in an ADHD sample—future ADHD studies should expand sample diversity to inform generalization.”

May combine two claims.

Some controlled studies included mindfulness practice as a component of a treatment that also introduced other modalities, so the contribution of mindfulness training itself is unclear.

“Although some controlled studies included mindfulness practice, it was a component of a treatment that also introduced other modalities (e.g., Hesslinger et al., 2002; Hirvikoski et al., 2011; Philipsen et al., 2007) and the contribution of mindfulness training itself is not clear.”

• cites Hesslinger et al., 2002Not checked yet

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• cites Hirvikoski et al., 2011 sourceNot checked yet

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• cites Philipsen et al., 2007Not checked yet

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In that same comparison, the three groups did not differ significantly on other measures, including self-rated ADHD symptoms, depression, quality of life, or clinician-rated occupational performance.

“No other significant group differences emerged among the three groups for self-reported ADHD symptoms, self-reported depression, self-reported quality of life, and clinician ratings of occupational performance.”

• cites Pettersson, Soderstrom, Edlund-Soderstrom, & Nilsson, in pressNot checked yet

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In major depressive disorder, mindfulness-based treatments have been shown to reduce residual depressive symptoms and protect against relapse.

“mindfulness-based treatments have been shown to have a protective impact on the re-emergence of depressive episodes and reduction of residual depressive symptoms in patients with major depressive disorder (Fjorback et al., 2011).”

• cites Fjorback et al., 2011 sourceNot checked yet

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Alpha-band frontal EEG asymmetry is linked to ADHD symptoms and fits the motivational dysfunction hypothesis of abnormal behavioral approach.

“frontal brain electroencephalogram (EEG) asymmetry in the alpha band is associated with ADHD symptoms and is consistent with the motivational dysfunction hypothesis involving abnormal behavioral approach (Keune, Wiedemann, Schneidt, & Schonenberg, in press).”

• cites Keune, Wiedemann, Schneidt, & Schonenberg, in pressNot checked yet

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The reviewed studies have limitations including small samples, lack of active comparison groups, lack of control for ADHD pharmacotherapy, and long-term follow-up beyond three months for most or all studies.

“Limitations include small sample sizes, a lack of active treatment comparison groups, a lack of control for the effects of pharmacotherapy for ADHD, and long-term follow-up beyond three months for either most or all of the studies reviewed.”

May combine two claims.

In a pilot randomized trial of modified DBT skills for college students with ADHD versus a skills handout, self-reported executive functioning and trait mindfulness improved for DBT at post-treatment and three-month follow-up.

“Self-reported executive functioning and trait mindfulness improved for the DBT group relative to the control group at both post-treatment and three-month follow-up.”

• cites Fleming, McMahon, Moran, Peterson, & Dreessen, in pressNot checked yet

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Existing studies support the acceptability, feasibility, and preliminary effectiveness of mindfulness meditation training for ADHD in adulthood.

“In sum, existing studies support the acceptability and feasibility, and preliminary effectiveness use of this approach in the treatment of ADHD in adulthood.”

Probably not a substantial claim: may not pass S3 (load-bearing).

ADHD symptoms can be considered dimensionally rather than only categorically.

“although ADHD is typically discussed as a categorical diagnosis, symptoms of ADHD can be considered from a dimensional perspective (Frazier, Youngstrom, & Naugle, 2007; Levy, Hay, McStephen, Wood, & Waldman, 1997).”

• cites Frazier, Youngstrom, & Naugle, 2007Not checked yet

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• cites Levy, Hay, McStephen, Wood, & Waldman, 1997 sourceNot checked yet

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Probably not a substantial claim: may not pass S4 (based).

Mindfulness can be integrated with CBT for adults diagnosed with ADHD.

“In addition to being a standalone treatment, mindfulness can be integrated with CBT for adults diagnosed with ADHD, which is an area that warrants future treatment development.”

• AssumptionRests on an assumption: The difference in cognitive approach between mindfulness and CBT can be resolved for integration.

Probably not a substantial claim: may not pass S3 (load-bearing).

MBCT is an example of a behaviorally-based therapy that adopted a mindfulness perspective for targeting cognitions.

“MBCT (Segal et al., 2002) is an example of a behaviorally-based therapy that adopted a mindfulness perspective for targeting cognitions.”

• cites Segal et al., 2002Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Mindfulness meditation training may give extra benefits to adults with ADHD who do respond to CBT.

“In addition, mindfulness meditation training may confer additional benefits among those who are responsive.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The MAPs Program includes material that explicitly targets emotional functioning in ADHD, which sets it apart from most CBT-based treatments for this population.

“Further, the MAPs Program introduces material explicitly focusing on emotional functioning in ADHD, which is a unique contribution relative to most CBT-based treatments for this population.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Top-down emotion regulation effects have been proposed for short-term mindfulness practitioners, and bottom-up effects for more experienced practitioners.

“Of note, top-down effects (e.g., cognitive reappraisal involving active reinterpretation of emotional stimuli which results in modifying emotional impact) have been proposed early on in treatment for short-term mindfulness practitioners and bottom-up effects (e.g., regulation of emotions without cognitive reappraisal in the presence of emotionally provocative stimuli) have been proposed among more”

• cites Chiesa, Serretti, & Jakobsen, 2013 sourceNot checked yet

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Because mindfulness training is effective for other disorders such as mood and anxiety disorders, it may be especially beneficial for adults with ADHD and a comorbid psychiatric disorder.

“Relatedly, given the effectiveness of mindfulness training for other disorders (e.g., mood and anxiety disorders), mindfulness training may be especially beneficial for adults diagnosed with ADHD and a comorbid psychiatric disorder.”

• AssumptionRests on an assumption: Mindfulness training is effective for mood and anxiety disorders.

Probably not a substantial claim: may not pass S3 (load-bearing).

Mindfulness training focuses less on changing thought content and more on observing cognitions and changing one's relationship to them.

“Mindfulness, however, focuses less on changing the content of thinking and places greater emphasis on observing cognitions and changing one’s relationship with those cognitions.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Mindfulness may improve patients' learning of CBT strategies in session by helping them manage stress, focus, cope with distractions, and manage negative affect.

“Mindfulness may also enhance patient learning of CBT strategies in session by providing techniques that help patients manage stress, focus in the session, cope with distractions, and manage overall negative affect.”

• AssumptionRests on an assumption: Adults with ADHD often experience stress, distraction, and negative affect that interfere with learning CBT strategies in session.

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Combining mindfulness with CBT may be clinically meaningful in ADHD and allow for greater treatment options.

“Such a combination may be clinically meaningful in ADHD as well and allow for greater treatment options.”