Eur Child Adolesc Psychiatry
DOI 10.1007/s00787-017-1008-9
REVIEW
Systematic review of meditation‑based interventions for children
with ADHD
Subhadra Evans1 · Mathew Ling1 · Briony Hill1 · Nicole Rinehart1 · David Austin1 ·
Emma Sciberras1 
Received: 5 January 2017 / Accepted: 17 May 2017
© Springer-Verlag Berlin Heidelberg 2017
Abstract Meditation-based interventions such as mind-
fulness and yoga are commonly practiced in the general
community to improve mental and physical health. Par-
ents, teachers and healthcare providers are also increas-
ingly using such interventions with children. This review
examines the use of meditation-based interventions in the
treatment of children with Attention-Deficit Hyperactivity
Disorder (ADHD). Electronic databases searched included
PsycINFO, Medline, CINAHL, and AMED. Inclusion cri-
teria involved children (aged to 18 years) diagnosed with
ADHD, delivery of a meditation-based intervention to chil-
dren and/or parents, and publication in a peer-reviewed
journal. Studies were identified and coded using stand-
ard criteria, risk of bias was assessed using Risk of Bias
in Non-randomised Studies- of interventions (ROBINS-
I), and effect sizes were calculated. A total of 16 studies
were identified (8 that included children in treatment, and
8 that included combined parent–child treatment). Results
indicated that risk of bias was high across studies. At this
stage, no definitive conclusions can be offered regarding
the utility of meditation-based interventions for children
with ADHD and/or their parents, since the methodological
quality of the studies reviewed is low. Future well designed
research is needed to establish the efficacy of meditation-
based interventions, including commonly used practices
such as mindfulness, before recommendations can be made
for children with ADHD and their families.
Electronic supplementary material  The online version of this
article (doi:10.1007/s00787-017-1008-9) contains supplementary
material, which is available to authorized users.
* Subhadra Evans
subhadra.evans@deakin.edu.au
1
School of Psychology, Deakin University, Geelong, Australia
Keywords  Review · Meditation · Yoga · Mindfulness ·
ADHD · Child
ADHD in childhood
Attention-Deficit Hyperactivity Disorder (ADHD) is a
neurobiological disorder characterised by impairing symp-
toms of inattention and/or hyperactivity/impulsivity. Many
children with ADHD have measurable deficits in executive
functioning (e.g., impaired working memory, sustained
attention, inhibition) and motivation (e.g., altered process-
ing of reinforcement and incentives) compared with peers
without ADHD [1], underpinned by disordered biochemi-
cal function involving multiple brain structures (cortical,
subcortical and white matter) [2]. ADHD is highly preva-
lent, affecting approximately 5% of children worldwide
[3].
Compared with their peers, children with ADHD are
at substantially higher risk for multiple adverse outcomes
including poorer social, educational, and mental health
outcomes, substance abuse and adult psychiatric disorders
than non-ADHD peers [4–6]. Two recent papers reported
an increased adult mortality rate in individuals with ADHD
compared to controls [7, 8]. ADHD also causes consider-
able societal and family burden, particularly impacting
parents who face stressors related to their child’s ADHD
symptoms.
The role of parents
Parents deal with numerous challenges when managing
children’s ADHD symptoms and associated impairments,
often resulting in high levels of parenting stress compared
13

to the general population [9]. Parenting stress has been
defined as an aversive psychological reaction to the chal-
lenges of being a parent [10]. Although a certain amount
of parenting stress is expected, parents who experience
extreme levels of parenting stress are at risk of psycho-
pathology, and are less able to engage in behaviours that
are helpful in addressing their child’s psychopathology
[11]. Such stress also adversely impacts upon parent-
ing efficacy and the quality of parent–child relationships
[12], which further interferes with the child’s function-
ing [13]. Bhide et al. showed, in a large cross-sectional
study of children with and without ADHD (n = 391), that
negative parenting behaviours which may be underpinned
by stress, were associated with poorer child social and
emotional functioning, even when taking into account the
severity of child ADHD symptoms and other comorbid
conditions [14]. Thus, involving parents in treatment of
childhood ADHD is important.
In addition to experiencing parenting-related stress,
many parents of children with ADHD themselves experi-
ence ADHD symptoms, further underscoring the impor-
tance of considering parents in the treatment of child
ADHD. ADHD is highly heritable [15]. The presence of
parent ADHD also signals higher risk for more severe
clinical presentation of ADHD in children [16]. Paren-
tal ADHD has a substantial impact upon the functioning
of the family, with such parents more likely to engage in
poor parental practices, such as low monitoring of the
child’s behaviour, providing more inconsistent discipline
than parents without ADHD, and displaying greater dif-
ficulties remaining calm [17, 18]. Not surprisingly, paren-
tal ADHD symptomology is one of the strongest predic-
tors of parent stress in families coping with a child who
has ADHD [13].
Two other key aspects of parenting that appear to be neg-
atively impacted in the context of child ADHD -and which
have particularly detrimental consequences for children’s
outcomes—are parental reactivity and the parent–child
relationship [12, 19]. Child ADHD may lead parents to be
over-reactive towards the child (which includes behaviours
such as impatience, excessive attention to disruptive behav-
iour and acting impulsively), which is predictive of greater
externalising behaviour in the child [20, 21]. In addition, an
absence of parental warmth has been demonstrated to elicit
internalising symptoms, including depression, in children
with ADHD [20]. Thus, it is imperative when considering
treatment that the broader social system of children with
ADHD is accounted for, since parents are both negatively
impacted by children’s challenging behaviours and may
also contribute to the child’s behaviour [22]. The present
review is focused on child meditation-based interventions,
and parent meditation-based interventions, since involving
parents in treatment is likely to address parent stress, parent
13
Eur Child Adolesc Psychiatry
psychopathology and maladaptive parenting, all of which
contribute to child symptoms.
Treatment
The present mainstay of treatment for ADHD is stimulant
medication, with 1 in 5 children prescribed two or more
psychotropic medications [23]. Although medications can
be effective for reducing ADHD symptoms, children with
ADHD continue to have poorer outcomes than their peers
even if prescribed medication [24]. Some children also
experience adverse side effects such as sleep problems and
loss of appetite [25]. In terms of behavioural interventions,
a number of interventions have been tested, mostly behav-
ioural parent training, which demonstrate good effects
for unblinded outcomes (e.g., ratings provided by parents
who are not blind to treatment status), with less evidence
for blinded outcome measures (e.g., ratings provided by
someone probably blind to intervention status like a class-
room teacher) [26]. Traditional operant behavioural mod-
els of parenting, which largely focus on parents providing
rewards or aversive consequences for children’s behaviour,
are often effective in the short term. However, a number
of concerns have been raised, including that use of reward
and punishment strategies do not typically teach children
socially acceptable replacement behaviours or emotion
regulation in parents or children, and their use by parents
can initiate coercive parent–child interactions [27]. Behav-
ioural treatments may also be limited in their focus on the
child’s behaviour, with little attention paid to reducing the
parent’s psychopathology and parenting stress. Thus, there
is a pressing need to develop evidence-based, psychologi-
cal interventions that involve parents to improve outcomes
for these children.
Meditation‑based interventions
Meditation-based interventions (MI) such as yoga and
mindfulness are popular amongst the general population,
and are increasingly used alongside conventional pharma-
cological and psychological treatments to optimise mental
health [28]. A variety of working definitions of meditation
exist, some describing a method and others a state [29]. For
the purposes of this review, we understand the core, shared
features of MI’s to involve the cultivation of attention pro-
cesses that lead to strengthened awareness, presence and a
more integrated sense of self [30]. In addition to attention
regulation strategies, MI’s also typically tend to develop
emotion regulation skills, with calmness and contentment
commonly co-occurring. This broad definition subsumes a
number of Eastern traditions, including physical practices
Eur Child Adolesc Psychiatry
(such as Tai chi and yoga taught in its many lineages), con-
centrative practices (such as transcendental meditation and
mantra meditation), vipassana (mindfulness), metta (loving
kindness), and a range of modern day descendants, includ-
ing acceptance and commitment therapy (ACT), and mind-
fulness-based stress reduction (MBSR). Inclusion of vari-
ous meditation styles allows for investigation of common
and overlapping elements of MI’s, with a broader range of
potentially therapeutic practices available for analysis.
Meditation-based activities seem particularly suited to
addressing the deficits associated with ADHD. For exam-
ple, mindfulness involves attention and emotion regulation
through focusing one’s awareness on the present moment,
while calmly acknowledging and accepting one’s feelings,
thoughts, and bodily sensations; the very regulatory capaci-
ties that are impaired in ADHD [31]. Two primary symp-
tom groups exist for ADHD: inattention and poor behav-
ioural control, expressed as hyperactivity and impulsivity.
The difficulty sustaining attention is typically due to an
inability to inhibit and control external and internal stimuli
that interfere with the executive functions that assist in self-
regulated persistence [32]. While hyperactivity may dimin-
ish over time, impulsivity/inattention is often stable across
development and has associated problems with a range of
wellbeing outcomes, including physical and mental health
[33]. ADHD and mindfulness clearly appear to involve
the same processes, with ADHD compromising sustained
attention and impulse control, and mindfulness building
upon the capacity to observe impulses without acting upon
them [34]. The emotion and attention regulation benefits of
mindfulness apply to other MI’s as well. For example, yoga
has been associated with improvements in internalising and
externalising behaviours in children with a range of psy-
chopathologies [35, 36].
Involving parents in MI for children with ADHD may
further benefit children. Mindful parenting theory suggests
that through mindful practices, parents who are aware and
accepting their child’s needs and less focused on narratives
around the child doing wrong create a family context that
allows for greater capacity to respond rather than react to
the children’s behaviour, and ultimately allows more endur-
ing satisfaction and enjoyment in the parent–child relation-
ship [37]. Research with healthy families demonstrates that
mindful parenting is associated with increased parent–child
relationship quality [38]. In particular, mindful parent-
ing may improve relationships through reducing parental
negative reactions, over-control, and by increasing positive
parent–child emotions and interactions [39]. Improved par-
enting and a warmer parent–child relationship are in turn
associated with less child externalizing behaviour [19, 40].
Despite the potential benefits of MIs in the manage-
ment of ADHD, there is little empirical evidence avail-
able from large, randomised controlled trials (RCTs). The
benefit of mindfulness for internalising disorders such as
depression and anxiety are well documented [41], but the
role of MI’s in externalising disorders, including ADHD,
has received less empirical attention [42]. A number of
pilot studies have emerged in this area, with a recent meta-
analysis suggesting that mindfulness-based therapies may
improve the core symptoms of ADHD, with improvements
likely in both attention and executive functioning aspects
of the disorder [42]. For example, a recent pilot RCT found
that adults with ADHD who were randomized to receive
mindfulness training (n = 11) had improved clinician and
self-report executive function symptoms, clinician and self-
report ratings of ADHD, and self-reported emotion dysreg-
ulation relative to the waitlist group (n = 9) over time with
large effect sizes [43]. However, as with most research in
this field, the study is small and does not include an active
control group to account for the non-specific benefits of
group membership.
Although a number of pilot studies and reviews of MI
exist concerning adults with ADHD, there has been less
focus on children. A further question that relates to treating
children is whether including additional family members is
beneficial, since providing MIs to parents could conceiv-
ably consolidate or multiply the effects of MIs on the child.
Thus, the present review is focused on meditation-based
interventions for children, and seeks to address the question
of whether multi-system interventions that include parents
are more beneficial than mindfulness interventions admin-
istered to individual children.
Objectives
Two systematic reviews of meditation for ADHD have
been carried out in recent years [42, 44], although thus far
no review has specifically focused on children or covered
a wide range of meditation-based practices for ADHD in
children that include yoga, mindfulness and meditation
practices from other traditions. Additionally, studies that
target only the child, versus those that combine children
and parents, versus the parent alone have not been exam-
ined separately to highlight the effects and issues specific
to each treatment condition. The current review takes a
broad approach to meditation-based interventions and
examines the literature according to whether the child, par-
ents or both children and parents were targeted. We have
used expanded search criteria to include all trial designs,
including single-arm studies and case studies, which we
deemed important given the paucity of empirical studies in
this area.
The primary objective of this review was to address the
question of whether meditation-based practices reduce the
core symptoms of ADHD, increase child wellbeing (e.g.,
13

self-esteem, social functioning, happiness) and reduce
internalising and externalising problems in children with
ADHD.
The secondary objective was to examine whether med-
itation-based practices in parents of children with ADHD
improve parent-related functioning (e.g., parenting stress)
or the quality of parent–child relationships.
The third objective was to determine whether combined
meditation-based interventions for children with ADHD
that involve parents and children to show more prom-
ise than interventions that individually target parents or
children.
It was also our aim to determine the risk of bias of the
included studies.
Method
Inclusion criteria
Eligibility criteria were as follows:
(1) Inclusion of an ADHD sample; ADHD status involved
a clinical diagnosis, which could be based on parent
or practitioner retroactive report of a clinical ADHD
diagnosis, or children could be assessed at the point
of study entry to meet criteria for ADHD using diag-
nostic interviews or scoring above clinical cut points
on diagnostic ADHD scales with confirmation by a
professional (using any DSM-ICD version); inclusion
was limited to those studies that specifically reported
on outcomes for children with ADHD (i.e., if a heter-
ogenous group of disorders was present, the findings
needed to be reported separately for children with
ADHD; and
(2) Delivery of an intervention focusing on mindfulness
and/or yoga techniques with either parents, children,
and/or parents + children as the recipients (includ-
ing single-case studies through to RCTs). Interven-
tions could be delivered in variety of ways, including
through a trained mindfulness teacher, psychologist or
the provision of information without direct instruction.
Interventions could be randomised, pre-post, wait list
controls, or multiple baseline design given the limited
research in this area; and
(3) Empirical article published in a peer-reviewed journal.
Thesis dissertations were excluded, as were conference
proceedings unless they linked to full-text papers. Arti-
cles published need to be published in English; and
(4) Inclusion of a sample of children ≤18 years of age.
We did not apply any exclusions based on child
comorbid conditions or ADHD medication use. We were
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interested in a range of outcomes as they pertained to
child and parent functioning and wellbeing, including core
ADHD symptoms, psychological adjustment as well as
quality of life domains.
Electronic searches
Studies of meditation-based interventions (including mind-
fulness and yoga) for paediatric ADHD were identified by
searching the following databases: PsycINFO, Medline,
CINAHL, and AMED from their inception until March
2017. We also checked reference lists of reviews and
retrieved articles for additional studies.
Search terms for ADHD included (abbreviations and
full text were used): ADHD, ADD, ADHS, hyperactivity,
hyperkinesis, attention deficit and disruptive behaviour dis-
orders, inattention, impulsivity, overactivity, and external-
ising. Search terms for interventions included terms such
as meditation, mindfulness, vipassana, loving kindness,
mindful-self compassion, yoga, zen, sudarshan, chi kung,
qigong, kirtan, pranayama, and ACT (the full search strat-
egy is provided in the supplementary materials).
Two review authors, one an expert in ADHD (ES) and
the other in meditation-based interventions (SE) indepen-
dently screened the titles and abstracts of the studies iden-
tified in Covidence (https://www.covidence.org/), which
sorts screening according to ‘yes’, ‘no’ and ‘maybe’ cate-
gories to eliminate those studies not relevant to this review.
Any discrepancies were then discussed in person and a
consensus was reached, with a record of changes captured
on covidence. When the title and abstract did not have suf-
ficient information for screening purposes, we retrieved the
full-text copy to review.
Data extraction
Following the collection of all eligible studies, the follow-
ing information was extracted by SE: details relating to the
design of the study, the participants, method of treatment,
therapist characteristics, outcome measurement tools used,
and outcome data including follow-up. We completed a
data extraction sheet for every study included in the review,
and a summary of the studies is provided in Tables 1 and 2.
Analysis
Assessment of risk of bias
Risk of bias at the individual study level was assessed using
the ROBINS-I tool (Risk of Bias in Non-randomised Stud-
ies- of interventions) [44]. The ROBINS-I tool is based
on the Cochrane Risk of Bias tool for RCTs [45]. Risk of
bias is assessed within specified bias domains, and review
 Table 1  Meditation-based interventions for children with ADHD
References; Research design Participant Intervention Therapist Child outcomes Parent Findings Post-study Effect size (Hedges’ g) [95%
Country of characteristics characteristics outcomes follow-up CI]
research

Abadi et al. [53] Controlled trial 9–12 yo Yoga group No description ADHD N/A Relative decrease in No FU CSI-4 (ADHD) 1.43
Iran 40 children 45 min twice/ subscale of mean CSI-4, including
(% male not week for the CSI-4 hyperactivity/impulsiv-
specified) 8 weeks (unclear, but ity in the yoga group
Eur Child Adolesc Psychiatry

Yoga n = 20 No-intervention appears to be compared to the control

Control n = 20 controls a combined group
parent/teacher
score)
Carboni et al. Single-arm 8 yo Individual MF Interventionist P/T BASC-2 N/A Graphic analysis No FU P BASC-2
[60] Single-case 4 children adapted from with MF train- of observation: (hyperactivity) 1.12 [−2.25,
USA multiple baseline 100% male MBSR ing and experi- increased  % of 0.02]
30-45 min ence working intervals of on-task P BASC-2
twice/week with children behaviour; general (inattention) 0.39 [−1.39,
for 8 sessions decrease in hyperac- 0.61]
tive behaviours (parent T BASC-2
and teacher ratings), (hyperactivity) 0.53 [−1.54,
no change in attention 0.49]
problems T BASC-2
(inattention) 1.04 [−2.15,
0.07]
Haydicky et al. Controlled trial 12–18 yo Mindfulness Child/family P BRIEF N/A ANCOVA: significantly No FU BRIEF (total) 0.46 [0.18,
[59] (waitlist) 28 children Martial Arts therapists with P CBCL reduced parent-reported 0.75]
Canada 100% male (MMA) black belts and YSR CBCL conduct and CBCL (ADHD) −0.39 [0.1,
MMA = 14 90 min/week MF practitioners social problems and 0.67]
Control = 14 for 20 weeks self-reported social and (Social) 0.44
Waitlist control externalizing problems [−0.73, −0.16]
in the MMA group (Externalizing) 0.63 [0.34,
compared to controls 0.92]
YSR (ADHD) 0.1 [−0.18,
0.38]
(Social) 0 [−0.28, 0.28]
(Externalizing) −0.43 [0.15,
0.72]

13


Table 1  continued
References; Research design Participant Intervention Therapist Child outcomes Parent Findings Post-study Effect size (Hedges’ g) [95%
Country of characteristics characteristics outcomes follow-up CI]

13
research
Jensen and RCT 8–13 yo Yoga: 60 min/ No description P CPRS N/A Yoga improved Oppo- No FU CPRS (ADHD) 0.71 [−1.16,
Kenny [54] 19 children week for T CTRS sitional and ADHD −0.26]
Australia 100% male 20 weeks TOVA; Acti- Index. Controls (Anxious) −0.29 [−0.72,
Yoga n = 11 Control: graph improved Anxious and 0.14]
Control n = 8 60 min/month Social Problems. Both (Social) −0.24 [−0.67, 0.19]
of groups improved on (oppositional) 0.55 [−0.99,
cooperative DSM–IV Hyperactive/ −0.11]
activities Impulsive, DSM–IV CTRS (ADHD) −0.38
total [−0.05, 0.81]
(Anxious) 0.32 [−0.11, 0.74]
(Social) 0.15 [−0.58, 0.27]
(Oppositional) 0.41 [−0.02,
0.84]
Mehta et al. [55] Single-arm 6–11 yo Climb Up Trained high T/P Vanderbilt: N/A 91% of children FU below Vanderbilt
India 76 children (yoga, medi- school volun- improvement in school (ADHD)− 2.2 [−2.29,
63% male tation BT) teers performance (no −2.11]]
60 min/twice threshold set); 40% of
week for children improved into
6 weeks a normative range
Mehta et al. [56] (one year follow- 69 children As above once/ As above As above As above Above improvements Study is N/A (data not presented in a
India up) week for one were sustained through FU to manner to calculated ESs)
year 12 months above
Murrell et al. Single-arm 11–15 yo ACT for Kids Recognized ACT C BASC-2 N/A Single-case analysis: No FU C BASC-2 (Emotional
[57] 9 children Group format trainer (Emotional 2 BASC-2 scores Symptoms) −0.44 [0, 0.89]
USA 44% male 60 min/week Symptoms) changed in unexpected
for 8 weeks Bulls-Eye direction; Interview
Values data noted positive
experiences of children
Singh et al. [58] Single-arm 10–12 yo Samatha medi- Meditation Observational N/A Significant increase in No FU Engagement 4.38 [1.05, 7.71]
USA Single-case 4 children tation instructor with data dur- maths engagement and Problem solving 9.11 [−2.04,
Multiple baseline 100% male Individual (dur- 40 years per- ing maths significant increase 20.26]
ing school) sonal experience instruction; in correct answers to
10-30 min daily meditating maths quiz maths problems
for 8 weeks

yo years old, MF Mindfulness, FU Follow-up, T Teacher report, P Parent report, C Child report, ACT Acceptance and Commitment Therapy, BASC-2 Behaviour Assessment System for Chil-
dren-Second edition, BRIEF Behaviour Rating Inventory of Executive Functioning (consists of behaviour regulation and monitoring), CBCL Child Behaviour Checklist, CPRS Conners’ Parent
Rating Scale—Revised: Long, CTRS Conners’ Teacher Rating Scale–Revised: Long, CSI-4 Child Symptom Inventory—4th edition, MBSR Mindfulness-Based Stress Reduction, TOVA Test Of
Variables Of Attention, YSR Youth Self Report
Eur Child Adolesc Psychiatry
 Table 2  Combined meditation-based interventions for children with ADHD and their parents
References; Research design Participant Intervention Therapist Child outcomes Parent Findings Follow-up Effect size
Country of characteristics characteristics outcomes (Hedges’ g)
research [95% CI]

Bogels et al. [31] Clinical case 10- yo MYMind Experienced Quantitative: not Quant: not Quant: less inatten- No FU N/A
Netherlands study 1 child MF for children MF teacher specified specified tion, stress and
100% male and parents who is also a Qualitative Inter- Qualitative OR in mother; less
1 mother 90 min/week child therapist view Inter- inattention and
Eur Child Adolesc Psychiatry

for 8 weeks (second support views opposition in child.

teacher) Qual: C: sleep,
coping, relation-
ship with mother.
M: less stress,
better structure
Hariprasad et al. Single-arm 5–16 yo Daily 60 min Certified yoga Research staff: None pro- Significant improve- Effects not ADHD-RS 1.02
[47] 9 children yoga inpatient instructor ADHD-RS; vided ment on all maintained at [−1.52, −0.53]
India 90% male stay (8 ses- with > CARS; outcomes 1st, 2nd or 3rd CARS 1.27 [−1.8,
Parent data not sions) 2 years yoga CGI Severity month post- −0.75]
reported (n, % Child-parent teaching expe- study FU CGI 1.44 [−1.99,
mothers) rience −0.89]
Harrison et al. Single-arm 4–12 yo Sahaja Yoga No description P Conners’; CPRS; Quant benefits: No FU Child Outcomes
[48] Mixed-methods 26 children Meditation P/C Indicators of interview ADHD symptoms, P ADHD 1.3 [−1.48,
Australia Quasi control 85% male 90 min twice/ Self-Esteem; self-esteem, rela- −1.12]
using waitlist Parent data not week for CPRS tionship quality. P Self-esteem 0.75
reported (n,  % 6 weeks Qual benefits: [0.58, 0.91]
mothers) Parallel/joint par- sleep, less anxiety, C Self-esteem 0.07
ent group concentration, less [−0.22, 0.08]
conflict. PR: hap- Parent/child relation-
pier, less stressed, ship 0.66 [0.5, 0.82]
manage child’s
behaviour

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Table 2  continued
References; Research design Participant Intervention Therapist Child outcomes Parent Findings Follow-up Effect size
Country of characteristics characteristics outcomes (Hedges’ g)

13
research [95% CI]
Haydicky et al. Single-arm 13–18 yo MYmind groups Clinical psych P/C Conners-3P; SIPA; Reduced child inat- 6 weeks: Child Outcomes
[49] 18 teens, based on students RCADS; FAD IM-P tention, conduct improvement P Inattentive 0.78
Canada 72% male MBCT attended AAQ problems, peer maintained; [−1.03, −0.53]
17 mothers and 1.5 h/week for 12 week MF problems and child SR P H/I 0.42 [−0.66,
4 fathers (data 8 weeks course and parent stress, reductions in −0.18]
used from 16 Parallel parent meditate regu- increased parent internalizing C Inattentive −0.15
mothers and 1 group larly mindfulness; no problems [−0.07, 0.37]
father) child SR changes C H/I 0.11 [−0.33,
0.1]
P CD 0.68 [−0.93,
−0.44]
C CD −0.07 [−0.15,
0.29]
P Internalizing 0.11
[−0.34, 0.13]
C Internalizing 0.11
[−0.33, 0.11]
Impairment in:
P Learning 0.54
[−0.78, −0.3]
P EF 0.34 [−0.58,
−0.11]
Peer relations 0.48
[−0.71, −0.26]
C family −0.15
[−0.07, 0.37]
Parent stress 0.33
[−0.56, −0.1]
Singh et al. [58] Single-arm 10–12 yo 12 MF sessions Experienced MF Mother-reported SSIMC; Child compliance Mothers’ Child Compliance
USA Single-case 2 children with mothers; trainer child compli- SUHMC; increased after satisfaction Mother MF 0.49
Multiple Base- 100% male followed by 12 ance inter- MF in mothers; continued [−1.53, 2.5]
line 2 mothers MF with child views increased further to increase Child MF 1.65
(unspecified after child MF; across [−0.98, 4.28]
duration) Mothers’ satisfac- 24 weeks FU M satisfaction
tion with self and Mother MF 0.92
happiness with [−1.25, 3.09]
child increased Child MF 1.59
[−0.99, 4.17]
M Happiness
Mother MF 1.18
[−1.12, 3.48]
Child MF 8.77
[−12.02, 29.55]
Eur Child Adolesc Psychiatry
 Table 2  continued
References; Research design Participant Intervention Therapist Child outcomes Parent Findings Follow-up Effect size
Country of characteristics characteristics outcomes (Hedges’ g)
research [95% CI]
Van de Weijer- Single-arm 11–15 yo MF groups with Cognitive-behav- YSR, CBCL, MAAS, Paired t-tests: 8-week FU: Child Outcomes
Bergma et al. 10 teens homework iour therapists TRF, BRIEF, PSI, PS less teen atten- stronger C Attention 0.46
[50] 67% male 1.5 h/week for who were MF MAAS, FFS, tion and behav- effects [−0.86, −0.06]
Netherlands 11 parents (6 8 weeks practitioners SHS, ANT iour problems, 16-week FU: M Attention 0.08
mothers; 5 Parallel parent improved executive effects waned [−0.74, 0.57]
Eur Child Adolesc Psychiatry

fathers:- one group functioning (SR, F Attention 0.55

child had both Homework father and teacher [−1.36, 0.26]
parents under- report); attention C Internalizing 0.09
take MF) test improve- [−0.48, 0.3]
ment; Fathers, not M Internalizing 0.1
mothers reported [−0.75, 0.56]
reduced parenting F Internalizing 0.4
stress; reduced [−1.2, 0.4]
mother over- C Externalizing
reactive parenting −0.11 [−0.29, 0.5]
while fathers’ M Externalizing
increased −0.17 [−0.49, 0.82]
F Externalizing 0.18
[−0.97, 0.6]
C Happiness −0.43
[−0.83, −0.03]
M BRIEF 0.23
[−0.42, 0.89]
F BRIEF 0.86
[−1.72, −0.01]
M Par Stress −0.44
[−0.23, 1.1]
F Par Stress 0.63
[−1.45, 0.19]
M Overreact 0.96
[−1.69, −0.23]
F Overreact −0.78
[−0.07, 1.62]
Van der Oord Single-arm 8–12 yo MF based on Cognitive behav- P/T DBDRS PSI, PS, Paired t-tests: 8 week FU: Child outcomes
et al. [51] 22 children MBSR and iour therapists ARS-D, reduced parent- child/par- P Inattention 0.80a
Belgium 72% male MBCT with MF expe- MAAS rated ADHD ent ADHD P H/I 0.56a
22 parents (21 1.5 h/week for rience behaviour (self and improved, Parent outcomes
mothers) 8 weeks child); increase parent stress Inattention 0.36a
Parallel parent parent mindful and OR main- H/I 0.48a
group awareness and tained Parent stress 0.57a
Homework reduced parental OR 0.85a
stress and over-
reactivity

13


Table 2  continued
References; Research design Participant Intervention Therapist Child outcomes Parent Findings Follow-up Effect size
Country of characteristics characteristics outcomes (Hedges’ g)

13
research [95% CI]
Zhang et al. [52] Single-arm 8–12 yo MYmind MF Therapists with Conners, reaction PSI, PS, Piared t-tests: No FU Child outcomes
China 11 children groups MF training time, TEA-Ch, IM-P improved Conners Conners-d 0.73a
72% male 1.5 h/week for ECBI (detectability), Conners-o 2.29a
11 parents (7 8 weeks omissions), TEA- Reaction time 0.05a
mothers) Parallel parent Ch, Sky Search, TEA-ch-sky 0.76
group ECBI TEA-ch-creature 0.81
Homework Worse PSI TEA-ch-Walk −1.35
TEA-opp world
−0.16
ECBI intensity 0.36
Parent outcomes
PSI −0.18
PS lax 0.28
PS overreact −0.12
PS verbose 0.07
a
  Effect sizes as reported in text
yo years old, MF Mindfulness, FU Follow-up, T Teacher report, P Parent Report, C Child report, AAQ Acceptance and Action Questionnaire, ACT Acceptance and Commitment Therapy,
ADHD-RS ADHD Rating Scale IV, ANT Amsterdam Neuropsychological Tasks, ARS-D ADHD Rating Scale-Dutch, BRIEF Behaviour Rating Inventory of Executive Functioning (consists of
behaviour regulation and monitoring), CARS Conners’ Abbreviated Rating Scale, CBCL Child Behaviour Checklist, Conners’ Conners Parent-Teacher Questionnaire; Conners 3P Conners 3rd
edition, CGI Clinical Global Impression, CPRS Child-Parent Relationship Scale, DBDRS Disruptive behaviour Disorder Rating Scale, ECBI Eyberg Child Behaviour Inventory, FAD Family
Assessment Device, FFS Flinders Fatigue Scale, IM-P Interpersonal Mindfulness in Parenting Scale, MAAS Mindful Awareness Attention Scale, MBCT Mindfulness-Based Cognitive Therapy,
MBSR Mindfulness-Based Stress Reductuion, OR Over reactivity, PS Parenting Scale, PSI Parenting Stress Index, RCADS Revised Manifest Child Anxiety and Depression Scale, SIPA Stress
index for Parents of Adolescents, SHS Subjective Happiness Scale, SR self report, SSIMC Satisfaction with Self in Interactions with My Child, SUHMC Subjective Units of Happiness with My
Child, TEA-ch Test of Everyday Attention for Children, TOVA Test of Variables of Attention, TRF Teacher Report Form, YSR Youth Self Report
Eur Child Adolesc Psychiatry
Eur Child Adolesc Psychiatry

Fig. 1  Literature search study

flow diagram 1103 records retrieved
from electronic
databases

162 duplicates
discharged

804 excluded: tle and abstract

830 tles and abstracts indicated ineligibility based on
screened aims, sample composion, and
intervenon

19 Records selected for

full text screening

3 Records excluded
No confirmed ADHD diagnosis

16 Studies included

authors are asked to document the information on which
judgements are based. In this context, bias focuses on stud-
ies’ internal validity and is defined as a tendency for study
results to differ systematically from the results expected
from a randomised trial, conducted on the same participant
group that had no flaws in its conduct. Seven domains were
assessed: confounding, selection, departures from intended
interventions, missing data, outcome measurement, selec-
tive reporting and overall bias. Given that most of the stud-
ies identified were single-arm design, bias specific to this
review included the likelihood that the findings would dif-
fer from a welldesigned RCT. Funnel plots were not used
since only a small number of studies were available for
each outcome, and most did not use comparison groups.
Effect sizes
Hedges’ g was used to calculate effect sizes for each of the
studies. Hedges’ g is a standardised mean difference and
can be interpreted using the same criteria as Cohen’s d;
however, it corrects for biases that arise from smaller sam-
ple sizes [46]. An ES of 0.2 represents a ‘small’ effect size,
0.5 represents a ‘medium’ effect size and 0.8 represents
a ‘large’ effect size. Positive effect sizes indicated an
improvement in functioning following a MI, while a nega-
tive effect size indicated poorer functioning following a MI.
Results
Results of the search
The searching and screening process is summarized in
Fig. 1. The literature search yielded 1103 records, of which
162 were duplicates. Titles and abstracts of 830 records
were screened, resulting in 19 records for full-text screen-
ing. Independent screening and cross-checking identified
16 eligible studies for inclusion; 3 did not meet with inclu-
sion criteria and thus were excluded. Reasons for exclusion
are listed in Fig. 1.
Included studies
Details on participants and interventions are summarized
in Tables 1 and 2. Table 1 includes studies that focused on
MI’s for children only, while Table 2 includes combined

13

studies that provided MI’s to children and parents. Eight
of the 16 studies targeted children, and 8 of the 16 studies
included a parallel intervention for parents [31] [47] [48]
[49] [27] [50] [51, 52]. No studies focused on MIs for par-
ents alone.
Treatments comprised three yoga interventions [47,
53, 54], one combined yoga and behavioural therapy pro-
gram with a follow-up study [55, 56], one ACT program
[57], one sahaja meditation [48], one samatha meditation
[58], one mindful martial arts [59], and seven mindfulness
meditation interventions [27, 31, 50–52, 60], of which six
included parents along with children. Four studies used sin-
gle cases, and the findings from these should be regarded as
preliminary and proof of concept [27, 31, 58, 60].
The curriculum of each intervention varied according
to the intervention tradition. For example, yoga interven-
tions included some physical poses and some meditation
material, while mindfulness-based interventions generally
focused on meditation and breathing practices. Most com-
monly, mindfulness-based interventions included 8 mod-
ules which covered concepts such as: psychoeducation
about mindfulness and ADHD; introduction to the body
scan and emotional awareness; using the breath; dealing
with distractors; strategies for when the child is out of con-
trol; recap and mindfulness using all the senses; practicing
through difficulty; being on one’s own [31].
Studies spanned a number of countries, including the
USA, Canada, Australia, the Netherlands, Belgium, India,
China, and Iran. Participating children were aged between
4–18 years, and the majority of participants were male. Par-
ticipant numbers ranged from a single case [31], to the larg-
est study of 76 children [55]. The majority of study designs
were single-arm, comparing functioning before versus after
the intervention. Three studies used a control group; in one
case the control comprised a waitlist condition [59], while
in another, the control condition did not receive an inter-
vention [53]; however, neither of these studies randomised
participants to the intervention and control groups. A RCT
design was used in only one study, although no information
regarding the randomisation procedure was offered [54].
Length of individual sessions range from 45 to 90 min,
with most sessions comprising either 54 or 90 min. Length
of the entire intervention ranged from 8 consecutive days
to 20 weeks, with most interventions spanning 8 weeks.
The most common total dose was 12 h, but one study was
as high as 30 h [59]. Both the intervention with the low-
est dose [47] and the highest dose [59] reported favourable
outcomes following MIs.
Various child and parent outcomes were assessed in
the 16 studies. The primary outcome for most studies was
child ADHD symptoms, which was typically measured via
parent and/or teacher report scales such as the Behaviour
Assessment System for Children (BASC-2). Additional
13
Eur Child Adolesc Psychiatry
quantitative child outcomes included other externalising
behaviours, internalising behaviours, executive functioning,
objective measurement of academic engagement and child
compliance. Quantitative outcomes for parents included
parenting stress, mindfulness, subjective happiness with
child and parent–child relationship. A number of stud-
ies also included qualitative data; themes centred around
coping, parenting and parent–child relationship qual-
ity. Although results across the outcomes were generally
reported, at least one study did not report mean and stand-
ard deviations for all measures recorded, and effect sizes
could not be calculated for teacher-reports [50].
Risk of bias
Risk of bias for each study across each of the seven risk
of bias domains are presented in Table 3. Overall, studies
reported either serious (i.e., the study has some important
problems) [48, 49, 52–54, 57, 59] or critical risk of bias
(i.e., the study is too problematic to provide any useful evi-
dence on the effects of intervention) [27, 31, 47, 50, 55, 56,
58, 60]. When using the ROBINS-I assessment, it is rec-
ommended to exclude papers with critical risk of bias from
analyses; however, given the overall high risk of bias, all
papers have been retained for the purposes of this review.
Most commonly, biases arose due to the use of uncon-
trolled, single-arm studies, use of self-report or non-vali-
dated measures, small sample sizes, and choice of analy-
ses that did not allow controlling for covariates or missing
data. Risk of bias for all outcome measures was serious,
except for child academic performance, where the risk of
bias was deemed moderate. Of note, adverse events were
not reported in any study, and it is not clear whether this is
because there were no adverse events, or a protocol did not
exist to measure them.
Effects of interventions
Do meditation‑based practices reduce the core
symptoms of ADHD, increase child wellbeing and reduce
externalising/internalising symptoms in children
with ADHD?
ADHD symptoms  Measures of ADHD symptoms gener-
ally involved parent ratings of symptoms, with some studies
including teacher ratings and child self-reported symptoms.
Eight of the twelve studies that reported ADHD symptoms
as an outcome demonstrated large effect sizes for a reduc-
tion in ADHD symptoms after the intervention, with the
highest reported ES (2.2) in a combined intervention for
children involving yoga, meditation and behavioural ther-
apy [55]. Effect sizes were large across child yoga [53], par-
ent–child yoga [47], parent–child mindfulness [49, 51], and
 Table 3  Risk of Bias Assessment using ROBINS-I
References; Country Bias due to con- Bias in selection of Bias in measurement Bias due to depar- Bias due to missing Bias in measurement Bias in selection of Overall bias
of research founding participants into the of interventions tures from intended data of ­outcomesa reported result
study interventions

Abadi et al. [53] Critical Serious Low No information No information Serious Moderate Serious
Iran
Bogels et al. [31] Critical Critical Moderate No information Serious Serious Critical Critical
Netherlands
Eur Child Adolesc Psychiatry

Carboni et al. [60] Critical Serious Serious Moderate No information Serious Moderate Critical
USA
Hariprasad et al. Critical Low Moderate Low Low Moderate Moderate Critical
[47]
India
Harrison et al. [48] Serious Serious Moderate Low Moderate Moderate Moderate Serious
Australia
Haydicky et al. [59] Serious Serious Moderate Moderate Low Serious Serious Serious
Canada
Haydicky et al. [49] Critical Moderate Moderate Moderate Low Serious Moderate Serious
Canada
Jensen and Kenny Serious Moderate Moderate Moderate Low Serious Moderate Serious
[54]
Australia
Mehta et al. [55] Critical Moderate Moderate Moderate Moderate Serious Moderate Critical
India
Mehta et al. [7] Critical Moderate Moderate Moderate Moderate Serious Moderate Critical
India
Murrell et al. [57] Serious Moderate Moderate Moderate Serious Serious Serious Serious
USA
Singh et al. [27] Critical Moderate Moderate Moderate Low Serious Moderate Critical
USA
Singh et al. [58] Critical Moderate Moderate Moderate Low Moderate Moderate Critical
USA
Van de Weijer et al. Critical Moderate Moderate Moderate Serious Moderate Serious Critical
[50]
Netherlands
Van der Oord et al. Serious Moderate Moderate Moderate Low Moderate Moderate Serious
[51]
Belgium
Zhang et al. [52] Critical Moderate Moderate Moderate Moderate Moderate Moderate Serious

Confounders changes to medication; lack of control group (can’t account for non-specific benefits); lack of randomization
a
  When multiple outcomes were reported for a study, the highest level of bias at the outcome level is reported in the table

13

other traditions of meditation [48]. However, an increase in
ADHD symptoms compared to controls was reported in two
studies of MI’s for children, with small effect sizes favour-
ing a waitlist control group [59] and a cooperative activities
control group [54]. The third controlled study found a large
effect size of 1.43 in favour of yoga compared to a no-inter-
vention control group [53]. Although overall the majority of
studies reported that MIs reduce ADHD symptoms, these
results are tempered by our findings of bias (stated above),
and the fact that two of the three controlled studies did not
find effects favouring the MI.
Child wellbeing  Following a yoga intervention, parent-
reported child self-esteem improved with a medium to large
effect size, but there was no evidence for improvement in
child-reported self-esteem [48]. Mixed evidence was found
for social functioning. While parent-reported social func-
tioning improved following parent–child MF in one study
[49], studies including child-report tended to find no effect
for social functioning [54, 59]. One study examined child-
reported happiness as an outcome, finding a medium sized
size for reduced happiness in a combined parent–child MF
intervention [50]. These findings suggest limited evidence
in improving a broad range of children’s wellbeing indices
using MIs and underscore the importance of including mul-
tiple informants to assess outcomes.
Although not strictly as an aspect of wellbeing, chil-
dren’s academic functioning was examined in a number of
studies. Given the importance of learning and school func-
tioning in the child’s overall sense of self and wellbeing,
these outcomes are examined here. Two studies reported
medium to large effect sizes in learning outcomes fol-
lowing MIs. The largest effect size was seen in a study
of Samatha meditation administered to children daily for
8 weeks; however, this study is limited to 4 individual cases
[58]. Observational data during maths instructions revealed
improvements in engagement of the problem and prob-
lem solving. In a parent–child MF study, parent-reported
children’s improvement in functional learning impairment
increased moderately [49]. One study of a parent–child MF
intervention also found significantly improved scores on
objective attention tests [52].
Internalising and externalising symptoms  Four MI stud-
ies examined internalising symptoms as an outcome. In an
RCT of yoga, teacher-reported child internalising symp-
toms improved following yoga compared to a coopera-
tive activities control group; however, for parent-reported
internalising symptoms, there was a small improvement
in the cooperative activities control group compared to
yoga [54]. A study of parent–child MF found little effect
on mother or child-reported child internalising symptoms
[49]. In another parent–child MF study, mothers and chil-
13
Eur Child Adolesc Psychiatry
dren similarly reported little effect on child internalising
symptoms, although fathers reported a small improvement
in their child’s internalising symptoms [50]. In a study of
ACT, child self-reported emotional symptoms (comprising
social stress, anxiety, depression, inadequacy, self-esteem
and self-reliance) moderately increased following the inter-
vention [57]. In this study, children’s qualitative responses
were favourable towards the intervention, and it is unclear
whether the children understood the quantitative items, or
if the intervention actually resulted in a deterioration of
symptoms. Overall, there appears to be limited support for a
reduction in internalising symptoms associated with ADHD
following MIs, with only one study showing an effect size
favouring the MI intervention, and this was only for teacher-
(and not parent) reported child internalising symptoms [54].
Five studies included child externalising behaviours as
an outcome. One study examining mindful martial arts
for teens reported moderate reduction in parent-reported
externalising symptoms, but a moderate increase in teen-
reported externalising symptoms [59]. This study also dem-
onstrated a small increase in parent-reported ADHD symp-
toms compared to the control group, questioning whether
martial arts is conducive for children with ADHD. An RCT
of yoga demonstrated a moderate reduction in parent and
teacher-reported oppositional behaviour compared to the
cooperative activities control group [54]. Similarly, in two
studies of parent–child MF, parents reported small to mod-
erate reductions in disruptive behaviour [52] and conduct
disorder [49], respectively. In another parent–child MF
study, fathers, mothers and children reported little to no
effect on child externalising symptoms [50]. In contrast,
a parent–child MF intervention with 2 children examined
child compliance as the primary outcome [27], finding that
maternal-reported child compliance increased substantially,
and even further after the child received 12 weeks of MF.
Although this study is limited to 2 cases, it highlights the
possible utility of including measures of child compliance.
Do meditation‑based interventions in parents of children
with ADHD improve parent‑related functioning or the
quality of parent–child relationships?
Parent functioning  No study that focused on MIs for chil-
dren included parent outcomes, whereas 7 of the 8 combined
parent–child MIs included outcomes for parents as well as
children. Outcomes included stress, overreactivity, parent
ADHD symptoms and increased satisfaction and happiness.
Three of the four studies that examined parent stress after a
parent–child MF intervention found small to medium effect
sizes of reduced parental stress [50–51]; however, in one
of these studies, there was a moderate increase in moth-
ers’ stress with a corresponding decrease in fathers’ stress
following the intervention [50]. In the fourth study with a
Eur Child Adolesc Psychiatry
mixed sample of mothers and fathers, increased parent stress
was reported [52]. Parental overreactivity reduced following
combined parent–child MF training, with large effect sizes
for mothers in two studies [50, 51], but increased in fathers
in one study [50], and failed to change in another [52]. Par-
ent ADHD symptoms improved, with a small-medium effect
size [51]. In a parent–child MF intervention in which moth-
ers first received the intervention followed by their child,
maternal satisfaction and happiness increased after MF in
the mother, and even further after the child received MF;
although this study was limited to 2 cases, it highlights that
future research should explore the potential additive benefit
of including parents in treatment [27].
Parent–child relationships  The parent–child relationship
was examined as a quantitative outcome in one parent–child
MI, with a medium sized improvement in the quality of the
parent–child relationship, measured with a parent-reported
relationship scale following yoga [48]. A number of the
combined parent–child MIs also included qualitative data
that referenced the parent–child relationship in addition to
the parent’s functioning. For example, in a single-case study
by Bogels and colleagues of a combined parent–child MF
intervention, children reported an improved relationship
with their mothers, while mothers reported less stress and
greater resources to implement structure within the family,
which had positive effects on the child’s functioning [31]. In
a similar vein, interviews with mothers revealed improved
stress, mood and the capacity to handle the child’s behav-
iour following sahaja yoga meditation [48].
Are combined interventions for children with ADHD
that involve both parents and children more effective
than interventions that individually target parents or
children?
As discussed, involving parents in treatment may address a
number of parent issues that flow on to children, ultimately
improving child outcomes beyond just treating the child.
Such issues include addressing parent stress, parent psy-
chopathology and adaptive parenting (including reduced
overreactivity and improving parent–child relationships).
No study focused solely on parents of children with
ADHD. Studies either targeted children with ADHD or
included parents and children. Parent–child MIs gener-
ally reported beneficial effects, ranging from small to large
effect sizes. The most consistent large effect sizes were
for improvement in child ADHD symptoms with 4 stud-
ies reporting effect sizes of at least 0.8 in inattention [47,
49, 51] or ADHD summary scores [47, 48]. Next in mag-
nitude were improvements in parent factors, of medium to
large effect sizes including parental stress and overreactiv-
ity [50, 51], although findings for stress and overreactivity
were mixed [50, 52]. The parent–child relationship also
improved moderately [48]. In contrast, little improvement
was observed in children’s wellbeing indices such as self-
esteem, social functioning and happiness or internalising/
externalising symptoms [49–50]. Three studies reported
poorer outcomes following MIs [49, 50, 52], and children’s
self-reported improvements following MIs were less robust
than parental reports of child symptoms.
Interventions that included the child-only reported a
number of benefits for children, including a decrease in
ADHD symptoms. Three of the eight studies reported large
effect sizes in ADHD symptom improvement [53, 55, 60],
although one of these studies is limited by the use of single
cases [60], and two of the controlled trials reported small
effect sizes demonstrating an increase in ADHD symp-
toms following yoga and mindful martial arts compared
to controls [54, 59]. Child social functioning did not seem
to improve in these studies and child-reported external-
ising symptoms were reported to be moderately worse in
the mindful martial arts group [59]. Child-reported inter-
nalising symptoms were moderately worse after ACT [57],
while in the RCT of yoga, parent-reported internalising
symptoms were slightly worse and child-reported internal-
ising symptoms were slightly improved [54].
Overall, combined interventions that include parents in
treatment may prove to be more beneficial than treatments
that only target children, since parent–child interventions
resulted in more consistently large effect sizes in child
outcomes, less incidence of poorer outcomes following
the intervention, and more favourable outcomes for par-
ents, which may have further beneficial effects on children.
However, all three of the controlled trials were child-only
interventions and as such the risk of bias was higher in the
combined parent–child intervention studies. The lack of
interventions focused on parents only precludes compari-
son to this group.
Discussion
In this paper, literature on the potential impact of MIs on
children’s ADHD symptoms, wellbeing and internalising/
externalising behaviour, as well as on parent’s functioning
and the quality of parent–child relationships was reviewed.
We also attempted to determine whether combined MIs for
children with ADHD that involve parents and children are
more beneficial than interventions individually targeting
parents or children. Altogether, the findings were limited by
serious or critical risk of bias, and only one RCT of MIs for
children with ADHD exists. Thus, although existing studies
may at first glance suggest the utility of MIs, particularly
those involving yoga and/or mindfulness and when parents
and children are targeted in the intervention, our findings
13

regarding risk of bias indicate that further welldesigned
studies are required to address questions of efficacy. Key
findings are discussed below.
Child ADHD symptoms, wellbeing and internalising/
externalising problems
The majority of studies that assessed ADHD symptoms
reported improvements; however, two of the three con-
trolled trials did not find effects favouring the MI they
examined (martial arts and yoga). In terms of child wellbe-
ing, there was mixed evidence for self-esteem, social func-
tioning, and academic performance with favourable find-
ings for parent-reports of child functioning, but either no
to a limited effect for child self-report outcomes. In addi-
tion, child self-reported happiness appeared to decrease
following the combined parent–child mindfulness (MF).
Overall, there was limited support for a reduction in inter-
nalising/externalising symptoms associated with ADHD
following MIs, especially for child-reports. Parent and/or
teacher-reports were more favourable for child internalis-
ing/externalising behaviour. Larger parent- as opposed to
child-reported effects is consistent with previous research,
as parents tend to have higher expectancies toward treat-
ment that may influence their perceptions of the therapeutic
response [61]. These findings point to the need to improve
the rigour of such studies to deal with expectancy effects,
and to include multiple informants where possible.
Parent‑related functioning and quality of parent–child
relationships
Studies that targeted both parents and children in the MI
generally reported outcomes for children and parents, in
contrast to studies that only targeted children, which only
reported outcomes for children. Reported parent outcomes
in parent–child MIs included reduced stress, overreactiv-
ity, parent ADHD symptoms and increased satisfaction and
happiness, although findings for stress and overreactivity
were mixed. Parent–child relationships, assessed via quan-
titative and qualitative data were also reported as improving
following MIs.
Combined parent–child MIs compared to child‑only
MIs
It is likely that involving parents in treatment of child
ADHD addresses a number of parental issues that impact
not only parent wellbeing, but also child outcomes. These
include parent stress, parent psychopathology and adaptive
parenting strategies. Parent–child interventions resulted in
more consistently improved ADHD symptoms and well-
being, less incidence of poorer outcomes following the
13
Eur Child Adolesc Psychiatry
intervention, and more favourable outcomes for parents
compared to interventions that targeted children only. How-
ever, the comparison between combined and child-only
interventions is compromised by the fact that all three of
the controlled trials were child-only interventions and as
such the risk of bias was higher in the combined parent–
child intervention studies. In addition, since none of the
child-only interventions included parent outcomes, com-
parisons cannot be made between the designs in terms of
parent symptoms and wellbeing. Future well designed stud-
ies are required to address the question of whether MIs that
include parents are of additional value. It is also unknown
whether targeting parents has equal or additional value to
child-only or combined interventions, since no studies
to date have included a parent-only MI for children with
ADHD.
Different meditation‑based traditions
In this review we took a broad definition of MI interven-
tions, as any treatment that involved the cultivation of
attention with the goals of increased awareness, pres-
ence and an integrated sense of self [30]. Important dif-
ferences may exist between the various meditation-based
traditions, and as the field moves forward and more stud-
ies are available to examine, systematic reviews of each
tradition are warranted. For example, yoga and martial
arts involve physical activity and can be considered as a
mindful movement, whereas other meditation traditions
are more stationary and focus on attention to sounds, the
breath and bodily sensations. The mechanisms and out-
comes of each practice may consequently vary. However,
even within traditions a great deal of overlap exists. For
example, mindful walking and yoga-like movements are
commonly practiced within mindfulness meditation. As
such, the overarching goal of directing attention towards
moment-to-moment experience along with a sense of
acceptance is a thread that runs through each meditation-
based practice.
The interventions covered within this review included
mindfulness, yoga, mindful martial arts, ACT and other
meditation traditions (including samatha and sahaja). The
strongest effect sizes were noted for yoga and meditation
(including mindfulness), with minimal positive evidence
for martial arts or ACT. In fact, a small increase in ADHD
symptoms and child-reported externalising symptoms
was observed in the martial arts intervention compared to
a waitlist control group, suggesting that martial arts may
not be conducive for children with ADHD, perhaps even
increasing aggression. Given the high risk of bias across
studies, we are unable to suggest which MIs have the high-
est degree of efficacy; however, yoga and mindfulness
Eur Child Adolesc Psychiatry
appear ripe for testing with methodologically sound
studies.
Methodological considerations
The studies included in this review have multiple limita-
tions. Only three studies used a control group, and only
one of those studies randomised participants to either the
intervention or control group [54]. It is unclear whether
the studies included were adequately powered. Almost
all studies are limited in the areas of bias due to con-
founding variables, selection of participants into the
study, measurement of interventions, departures from
intended interventions, missing data, outcome meas-
urement and selection of reported results. Eight stud-
ies received a critical rating of risk of bias [27, 31, 47,
50, 55, 56, 58, 60], indicating that the study is so prob-
lematic that any useful evidence on the effects of the
intervention is questionable. Other limitations include
missing information, including a lack of clarity around
participant information including parent characteristics
[47], lack of post-intervention follow-up data to exam-
ine maintenance of effects and inconsistent reporting of
medication status or co-morbidities, and failure to pro-
vide information about adverse events.
Future research
Additional studies are needed to better understand the
efficacy and effectiveness of MIs for children with
ADHD and their parents. In particular, adequately pow-
ered RCTs are needed to establish whether such interven-
tions work. Appropriate control groups are also required,
that sufficiently control for the non-specific benefits of
attention, expectation and group membership. Research
should also directly compare child-only, parent-only and
combined parent–child interventions to determine which
family members produce the greatest benefits relative to
the cost of delivering the intervention. Future research
should also compare whether interventions that combine
practices (for example, physical yoga poses along with
mindfulness meditation) add value over singular tech-
niques, since the greatest benefits may be seen when bod-
ily and mental states are targeted. In addition, the age and
developmental maturation of the child is an important
consideration for future research. Cognitively demand-
ing content, such as some of the core concepts of ACT,
may be beyond the comprehension of many younger
children, and consideration should be given to matching
content with the developmental skills and challenges of
particular age-groups. A further consideration relates to
the heterogeneity of ADHD symptoms, and it is impera-
tive that studies attract children with a range of sub-types
and symptom severity to increase the generalizability of
results.
Clinical implications
At this stage, no definitive conclusions can be offered
regarding the utility of MIs for children with ADHD and/or
their parents, since the methodological quality of the stud-
ies reviewed is low. However, yoga and/or mindfulness may
be particularly promising to explore in future methodologi-
cally sound studies, given their large effect sizes in these
small pilot studies. If found to be efficacious and effec-
tive, MIs could conceivably be delivered alongside exist-
ing treatment, including pharmacotherapy and behavioural
treatments. In fact, MIs may prove to complement existing
behavioural treatments and vice versa. For example, quan-
titative data from the Zhang study found that although par-
ents reported MF to be useful and enjoyable, they felt that
behavioural strategies were important for those situations
that can be changed (i.e., some behaviours need more from
parents than simply ‘acceptance’) [52]. The next wave of
parent MF interventions may be well served to combine
elements of existing parenting interventions that include
behavioural strategies, particularly around offering behav-
iourbehavioural strategies in an open, accepting and warm
manner to address previous criticisms regarding operant-
based behavioural models (e.g., [27].
It is important to comment upon the intervention devel-
opment of the reviewed studies. None of the interven-
tions were developed alongside parents or families. Lack
of inclusion of consumers in development may lead to
poor acceptance, adherence and ultimately low up-take of
the intervention. In particular, issues such as homework
expectations, and face validity of the meditation materi-
als is important when targeting consumers from diverse
religious, socioeconomic and educational backgrounds.
Indeed, the same MY mind protocol resulted in less favour-
able outcomes for parents in China [52], versus those in
Western and European countries [31, 49], indicating that
cultural factors should be considered when designing and
implementing such interventions. It is important that future
work address this issue by including parents, children and
families in the design of meditation-based treatments.
Method of delivery is another concern across studies. All
of the interventions that described the therapist character-
istics involved training for therapists, ranging from brief
training for high school volunteers [55] to a meditation
instructor with 40 years of personal mediation experience
[58]. Many MIs require instructors to receive training in
the tradition being taught, as well as maintaining a personal
practice; however, it is unclear whether expertise in the MI
being taught has any realistic impact upon outcomes, and
guidelines regarding training of therapists have not been
13

established. If teachers require extensive training and per-
sonal practice in the meditative tradition being taught, then
this limits the translational appeal of such interventions
since it is questionable whether professionals with a suf-
ficiently advanced level of meditation/yoga expertise are
consistently available outside major cities, and a broad roll-
out of the intervention is unlikely. Further work is needed
to understand the minimal meditation-based qualifications
required for a medical or mental health professional to pos-
sess to deliver the intervention. Alternatively, the possibility
of delivering such interventions online should be explored.
Conclusion
This review provides evidence that the methodological
quality of research in the area of MIs for children with
ADHD and their families is low and adequately powered
RCTs of MIs for children and their parents are required
before such practices become commonplace. Despite
this lack of evidence, mindfulness appears to be a grow-
ing component of psychological treatment for people with
ADHD [31], yet more research is needed to understand the
therapeutic benefits, possible adverse events, and best-prac-
tice delivery mechanisms for such interventions.
Author contribution Authors Evans and Sciberras designed the
study. Authors Evans, Ling and Hill conducted literature searches
and undertook the analyses. Author Evans wrote the first draft of the
manuscript and all authors contributed to and have approved the final
manuscript.
Compliance with ethical standards  19. Katzmann J, et al. (2016) Behavioral and nondirective guided
Conflict of interest  All authors declare that they have no conflicts of
interest.
Funding sources  Funding for this study was provided by a Deakin
University Central Research Grants Scheme.
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