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Mindful Awareness Practices (MAPs) in Adolescents with ADHD and Cognitive Disengagement Syndrome (CDS): A Pilot Open Trial

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Title: Mindful Awareness Practices (MAPs) in Adolescents with ADHD and Cognitive Disengagement Syndrome (CDS): A Pilot Open Trial
Language: English
Authors: Kelsey K. Wiggs (ORCID 0000-0002-8013-7925), Keely Thornton, Nicholas C. Dunn, John T. Mitchell (ORCID 0000-0002-9586-3823), Joseph W. Fredrick (ORCID 0000-0003-4617-8552), Zoe R. Smith, Stephen P. Becker (ORCID 0000-0001-9046-5183)
Source: Journal of Attention Disorders. 2025 29(2):83-100.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 18
Publication Date: 2025
Sponsoring Agency: Health Resources and Services Administration (HRSA) (DHHS)
National Center for Advancing Translational Sciences (NCATS) (DHHS/NIH)
Contract Number: T32HP10027
5UL1TR00142504
Document Type: Journal Articles
Reports - Research
Descriptors: Metacognition, Adolescents, Attention Deficit Hyperactivity Disorder, Cognitive Processes, Attention Deficit Disorders, Attention Control, Student Characteristics, Outcomes of Treatment, Group Therapy, Individual Development, Program Effectiveness
DOI: 10.1177/10870547241290182
ISSN: 1087-0547
1557-1246
Abstract: Objective: Very few studies have investigated intervention approaches that may be efficacious for youth with ADHD and co-occurring cognitive disengagement syndrome (CDS) symptoms. This study examined the feasibility, acceptability, and preliminary efficacy of a mindfulness-based intervention for adolescents with ADHD and co-occurring CDS symptoms. Methods: Fourteen adolescents ages 13 to 17 years (35.71% female; 64.29% White, 7.14% Black, 28.57% Multiracial) with ADHD and elevated CDS symptoms completed the 8-week group-based Mindful Awareness Practices (MAPs) program developed for individuals with ADHD. We collected measures of CDS, ADHD, mind-wandering, mindfulness, and other difficulties and functioning at baseline, 1-month post-intervention, and 3-month post-intervention to examine preliminary efficacy. We measured participant session attendance, session engagement, at-home practice adherence, and satisfaction of adolescents and caregivers at 1-month post-intervention to examine feasibility and acceptability. We also collected qualitative feedback from adolescents and caregivers at 1-month post-intervention. Results: The intervention was overall feasible to administer, and caregivers and adolescents reported satisfaction with the intervention despite some difficulties with attendance and engagement. We observed improvements to both caregiver- and adolescent-reported CDS symptoms and ADHD-inattentive symptoms from pre-intervention to post-intervention time points, though findings across 1- and 3-month follow-up differed based on informant. We also observed improvements to some indices of adolescent-reported mind-wandering, mindfulness, brooding rumination, and academic functioning. For caregiver report, the only other noted improvement was for executive functioning. No improvements were reported by teachers. Conclusions: Findings support the initial feasibility, acceptability, and preliminary efficacy of MAPs for adolescents with ADHD and co-occurring CDS symptoms on a range of outcomes. Larger trials with a randomized design are warranted to further examine mindfulness-based interventions for adolescents with ADHD and co-occurring CDS symptoms.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1450843
Database: ERIC
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  Value: <anid>AN0181053394;gs015jan.25;2024Nov26.02:25;v2.2.500</anid> <title id="AN0181053394-1">Mindful Awareness Practices (MAPs) in Adolescents With ADHD and Cognitive Disengagement Syndrome (CDS): A Pilot Open Trial </title> <p>Objective: Very few studies have investigated intervention approaches that may be efficacious for youth with ADHD and co-occurring cognitive disengagement syndrome (CDS) symptoms. This study examined the feasibility, acceptability, and preliminary efficacy of a mindfulness-based intervention for adolescents with ADHD and co-occurring CDS symptoms. Methods: Fourteen adolescents ages 13 to 17 years (35.71% female; 64.29% White, 7.14% Black, 28.57% Multiracial) with ADHD and elevated CDS symptoms completed the 8-week group-based Mindful Awareness Practices (MAPs) program developed for individuals with ADHD. We collected measures of CDS, ADHD, mind-wandering, mindfulness, and other difficulties and functioning at baseline, 1-month post-intervention, and 3-month post-intervention to examine preliminary efficacy. We measured participant session attendance, session engagement, at-home practice adherence, and satisfaction of adolescents and caregivers at 1-month post-intervention to examine feasibility and acceptability. We also collected qualitative feedback from adolescents and caregivers at 1-month post-intervention. Results: The intervention was overall feasible to administer, and caregivers and adolescents reported satisfaction with the intervention despite some difficulties with attendance and engagement. We observed improvements to both caregiver- and adolescent-reported CDS symptoms and ADHD-inattentive symptoms from pre-intervention to post-intervention time points, though findings across 1- and 3-month follow-up differed based on informant. We also observed improvements to some indices of adolescent-reported mind-wandering, mindfulness, brooding rumination, and academic functioning. For caregiver report, the only other noted improvement was for executive functioning. No improvements were reported by teachers. Conclusions: Findings support the initial feasibility, acceptability, and preliminary efficacy of MAPs for adolescents with ADHD and co-occurring CDS symptoms on a range of outcomes. Larger trials with a randomized design are warranted to further examine mindfulness-based interventions for adolescents with ADHD and co-occurring CDS symptoms.</p> <p>Keywords: adolescence; ADHD; cognitive disengagement syndrome; mindfulness; sluggish cognitive tempo</p> <hd id="AN0181053394-2">Introduction</hd> <p>About 25% to 40% of youth with ADHD exhibit co-occurring symptoms of cognitive disengagement syndrome (CDS; formerly called sluggish cognitive tempo; [<reflink idref="bib5" id="ref1">5</reflink>]; [<reflink idref="bib10" id="ref2">10</reflink>]; [<reflink idref="bib12" id="ref3">12</reflink>]; [<reflink idref="bib63" id="ref4">63</reflink>]). Youth with CDS may seem to be adrift or in their own world, spacey, or disengaged from others around them, as CDS is characterized by symptoms of internal distraction (e.g., excessive daydreaming and getting lost in thought), mental confusion (e.g., slowed thinking and losing train of thought), and hypoactivity (e.g., excessive sleepiness, fatigue, and slowed behavior; [<reflink idref="bib6" id="ref5">6</reflink>]; [<reflink idref="bib10" id="ref6">10</reflink>]). Although there is overlap, CDS symptoms are distinct from ADHD symptoms ([<reflink idref="bib9" id="ref7">9</reflink>]), with CDS symptoms more characteristic of internal sources of distraction (rather than being distracted by things in the environment) and hypoactivity (rather than hyperactivity; [<reflink idref="bib6" id="ref8">6</reflink>]; [<reflink idref="bib10" id="ref9">10</reflink>]; [<reflink idref="bib7" id="ref10">7</reflink>]). CDS symptoms are also associated with academic, social, and mental health difficulties beyond what is accounted for by ADHD symptoms (for a review, see [<reflink idref="bib10" id="ref11">10</reflink>]). Furthermore, individuals with elevations in both ADHD and CDS symptoms have poorer functioning than individuals with either alone ([<reflink idref="bib5" id="ref12">5</reflink>]; [<reflink idref="bib12" id="ref13">12</reflink>]; [<reflink idref="bib63" id="ref14">63</reflink>]).</p> <p>CDS is also strongly related to internalizing symptoms—especially depression, as approximately 32% to 48% of youth with CDS exhibit elevated depressive symptoms ([<reflink idref="bib63" id="ref15">63</reflink>]). In fact, there is emerging evidence that CDS may be best conceptualized within the internalizing spectrum based on factor analytic work ([<reflink idref="bib9" id="ref16">9</reflink>]), which also supports CDS as a separable construct from both ADHD (as mentioned above) and internalizing disorders. Finally, evidence suggests that difficulties can be long-lasting ([<reflink idref="bib4" id="ref17">4</reflink>]), as CDS is related to lower quality of life, educational and occupational attainment, income, and higher rates of depression and inattention in adulthood ([<reflink idref="bib19" id="ref18">19</reflink>]; [<reflink idref="bib70" id="ref19">70</reflink>]).</p> <p>As research on CDS has grown, there has been growing interest in identifying evidence-based treatments for CDS among individuals with and without ADHD ([<reflink idref="bib6" id="ref20">6</reflink>]; [<reflink idref="bib10" id="ref21">10</reflink>]). Because CDS overlaps and co-occurs with both ADHD and internalizing disorders, researchers have reasoned that interventions for these disorders may also be effective treatment candidates for CDS ([<reflink idref="bib5" id="ref22">5</reflink>], [<reflink idref="bib6" id="ref23">6</reflink>]; [<reflink idref="bib77" id="ref24">77</reflink>]). However, very little research has been conducted to provide evidence-based guidance. Three studies have shown a reduction of CDS symptoms in response to behavioral interventions primarily targeting ADHD symptoms: a randomized control trial (RCT) of a multimodal intervention (i.e., school-based intervention, parent training, and child skills training) of 7- to 10-year-olds resulting in large-sized reduction in CDS symptoms ([<reflink idref="bib57" id="ref25">57</reflink>]), a briefer RCT of a school-based intervention (i.e., organizational skills training, at-home practice completion) of middle-schoolers resulting in small to medium-sized reductions in CDS symptoms ([<reflink idref="bib69" id="ref26">69</reflink>]), and a pre- to post- cognitive-behavioral-based sleep intervention pilot study of 13- to 17-year-olds demonstrating medium to large-sized reductions in symptoms ([<reflink idref="bib8" id="ref27">8</reflink>]). Despite promising findings that interventions targeting ADHD can improve CDS symptoms, there is also preliminary evidence suggesting that the presence of co-occurring CDS symptoms predicts poorer response to both behavioral interventions (e.g., parent-training programs; [<reflink idref="bib55" id="ref28">55</reflink>]) and stimulant treatment for the management of ADHD symptoms ([<reflink idref="bib27" id="ref29">27</reflink>]; [<reflink idref="bib30" id="ref30">30</reflink>]).</p> <p>Although prior treatment studies including adolescents with elevated CDS symptoms demonstrated promise, they were limited in their scope (i.e., improving organizational skills and homework completion and improving sleep) and had a primary focus on improving ADHD symptoms ([<reflink idref="bib8" id="ref31">8</reflink>]; [<reflink idref="bib69" id="ref32">69</reflink>]). Treatments are needed that can broaden the focus and be developed to specifically target CDS symptoms within their scope. There is also a decline in the use of medication treatment for ADHD across adolescence ([<reflink idref="bib47" id="ref33">47</reflink>]), and some early evidence to suggest CDS symptoms may be less responsive to medication treatment ([<reflink idref="bib77" id="ref34">77</reflink>]), making it important to consider other intervention options. Adolescence is a developmental period when CDS symptoms may increase and become more impairing ([<reflink idref="bib46" id="ref35">46</reflink>]), and internalizing symptoms also increase and commonly co-occur with ADHD and CDS symptoms ([<reflink idref="bib10" id="ref36">10</reflink>]; [<reflink idref="bib54" id="ref37">54</reflink>]). These increases in CDS and internalizing symptoms coalesce with expectations for more autonomy and a higher work load in school, which can exacerbate difficulties ([<reflink idref="bib54" id="ref38">54</reflink>]). As such, there is a need to identify evidence-based treatments for adolescents with ADHD who exhibit co-occurring CDS that help adolescents manage their own symptoms and may have broader, transdiagnostic benefit.</p> <hd id="AN0181053394-3">Mindfulness as a Possible Treatment for Adolescents With ADHD and CDS</hd> <p>Mindfulness meditation practices involve training one's ability to maintain intentional focus and acceptance of one's present experience ([<reflink idref="bib2" id="ref39">2</reflink>]; [<reflink idref="bib11" id="ref40">11</reflink>]; [<reflink idref="bib37" id="ref41">37</reflink>]). Mindfulness was originally developed for management of chronic pain ([<reflink idref="bib36" id="ref42">36</reflink>], [<reflink idref="bib37" id="ref43">37</reflink>]), though it has been established as an evidence-based intervention for many mental health outcomes, including internalizing disorders ([<reflink idref="bib41" id="ref44">41</reflink>]; [<reflink idref="bib83" id="ref45">83</reflink>]). Mindfulness-based interventions (MBIs) have theoretical and empirical grounding in the transdiagnostic construct of self-regulation ([<reflink idref="bib83" id="ref46">83</reflink>]). The benefit of mindfulness to the regulation of emotions ([<reflink idref="bib35" id="ref47">35</reflink>]; [<reflink idref="bib83" id="ref48">83</reflink>]), attention and awareness ([<reflink idref="bib83" id="ref49">83</reflink>]), and executive functions ([<reflink idref="bib65" id="ref50">65</reflink>]; [<reflink idref="bib73" id="ref51">73</reflink>]; [<reflink idref="bib74" id="ref52">74</reflink>]; [<reflink idref="bib83" id="ref53">83</reflink>]) has sparked research investigation on the efficacy of mindfulness for ADHD ([<reflink idref="bib17" id="ref54">17</reflink>]; [<reflink idref="bib34" id="ref55">34</reflink>]; [<reflink idref="bib40" id="ref56">40</reflink>]; [<reflink idref="bib49" id="ref57">49</reflink>]).</p> <p>Mindfulness interventions have shown promising effects for adults and youth with ADHD ([<reflink idref="bib49" id="ref58">49</reflink>]). For example, meta-analytic findings indicate medium to large effect sizes for inattentive symptoms among child and adult samples with ADHD (respectively), and small to medium effect sizes for hyperactive-impulsive symptoms among child and adult samples with ADHD (respectively; [<reflink idref="bib15" id="ref59">15</reflink>]). However, there is far less research that has examined mindfulness-based interventions for adolescents with ADHD ([<reflink idref="bib49" id="ref60">49</reflink>]). Adolescence is an important period of development in establishing self-management strategies, including mindfulness ([<reflink idref="bib23" id="ref61">23</reflink>]), given findings suggesting higher capacity for meta- and self-awareness as children transition into adolescence ([<reflink idref="bib21" id="ref62">21</reflink>]; [<reflink idref="bib22" id="ref63">22</reflink>]). However, early evidence suggests that adolescents with ADHD may have more barriers to treatment (e.g., scheduling restrictions) and may be harder to engage (e.g., significantly less at-home practice) in mindfulness-based treatment compared with adults with ADHD ([<reflink idref="bib84" id="ref64">84</reflink>]). As such, more research is needed to establish feasibility, acceptability, and efficacy of mindfulness-based interventions in adolescents with ADHD.</p> <p>One additional aspect of self-regulation that MBIs have demonstrated benefit to is maladaptive and excessive mind-wandering ([<reflink idref="bib26" id="ref65">26</reflink>])—a construct theorized to be central to the CDS phenotype ([<reflink idref="bib7" id="ref66">7</reflink>]; [<reflink idref="bib77" id="ref67">77</reflink>]). As such, MBIs have been suggested as a candidate treatment for CDS symptoms ([<reflink idref="bib7" id="ref68">7</reflink>]; [<reflink idref="bib10" id="ref69">10</reflink>]), though no research to date has examined this directly. However, preliminary evidence suggests that mind-wandering may be more strongly related to CDS than to ADHD-IN or internalizing symptoms ([<reflink idref="bib28" id="ref70">28</reflink>]; [<reflink idref="bib29" id="ref71">29</reflink>]; [<reflink idref="bib76" id="ref72">76</reflink>]), which is perhaps unsurprising in the context of prior work that has differentiated CDS from both ADHD and internalizing symptoms ([<reflink idref="bib9" id="ref73">9</reflink>]). Youth with elevated CDS symptoms may be of unique fit for mindfulness-based interventions, consistent with calls from a recent meta-analysis to consider distinct subgroups that may be most likely to benefit from mindfulness ([<reflink idref="bib23" id="ref74">23</reflink>]).</p> <hd id="AN0181053394-4">Current Study</hd> <p>We conducted an open trial pilot study of the group-based Mindful Awareness Practices (MAPs) for ADHD intervention in a sample of adolescents with ADHD and co-occurring CDS. The primary goals of the current study were to test the (<reflink idref="bib1" id="ref75">1</reflink>) initial feasibility and acceptability of MAPs for adolescents with ADHD and co-occurring CDS and (<reflink idref="bib2" id="ref76">2</reflink>) preliminary efficacy of MAPs for improving CDS and ADHD symptoms and associated difficulties. We expected reduction in ADHD and CDS symptoms and explored changes to emotional and affective symptoms and difficulties with sleep, academic achievement, and executive functioning. This study extends prior literature that has examined MBIs in the treatment of youth with ADHD, and it is the first study that we are aware of to examine a MBI in the treatment of CDS.</p> <hd id="AN0181053394-5">Methods</hd> <p></p> <hd id="AN0181053394-6">Participants and Procedures</hd> <p>Participants were 14 adolescents aged 13 to 17 years with ADHD and elevated CDS symptoms (see Table 1 for participant characteristics). The Cincinnati Children's Hospital Medical Center Institutional Review Board approved all study procedures. We recruited participants through advertisements, a newsletter received by families who have previously received ADHD-related services, and by contacting previous research participants who agreed to be contacted for future research opportunities. Following a phone screen to determine initial eligibility, a pre-intervention study visit was conducted to confirm eligibility. Our inclusion criteria were as follows: ages of 13 to 17 years; meeting full DSM-5 diagnostic criteria for ADHD per caregiver report on the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; [<reflink idref="bib39" id="ref77">39</reflink>]); ≥85th percentile on CDS symptoms measured by caregiver report on the Child and Adolescent Behavior Inventory (CABI) CDS Module ([<reflink idref="bib14" id="ref78">14</reflink>]; [<reflink idref="bib60" id="ref79">60</reflink>]); and estimated full scale IQ ≥80 assessed by the Kaufman Brief Intelligence Test, Second Edition ([<reflink idref="bib38" id="ref80">38</reflink>]). We did <emph>not</emph> exclude participants on the basis of comorbid internalizing disorders, as we believed this would limit the external validity of our study given the high rates of comorbidity and CDS is distinct from anxiety and depression ([<reflink idref="bib68" id="ref81">68</reflink>]). Caregivers and adolescents also had to have sufficient English language necessary to complete study measures and the intervention. If adolescents were taking any medication for ADHD or another psychiatric disorder, caregivers were instructed to maintain medication dose and schedule until completing 3-month follow-up. Additional exclusions were the receipt of behavioral therapy treatment in the past 6 months; adolescent history of autism spectrum disorder, bipolar disorder, obsessive-compulsive disorder, or psychosis per caregiver report; significant visual, hearing, or speech impairment not helped by corrective or assistive devices; and the enrollment in any other ongoing ADHD-related research studies.</p> <p>Table 1. Participant Characteristics for N = 14 Who Completed MAPs Intervention.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /></colgroup><thead><tr><th /><th align="center"><italic>M</italic> (<italic>SD</italic>)</th></tr></thead><tbody><tr><td>Age</td><td>15.07 (1.49)</td></tr><tr><td>IQ</td><td>102.79 (16.48)</td></tr><tr><th /><th align="center"><italic>n</italic> (%)</th></tr><tr><td colspan="2">Sex</td></tr><tr><td> Female</td><td>5 (35.71)</td></tr><tr><td> Male</td><td>9 (64.29)</td></tr><tr><td colspan="2">Race</td></tr><tr><td> Black</td><td>1 (7.14)</td></tr><tr><td> White</td><td>9 (64.29)</td></tr><tr><td> Multiracial</td><td>4 (28.57)</td></tr><tr><td colspan="2">Ethnicity</td></tr><tr><td> Hispanic/Latiné</td><td>1 (7.14)</td></tr><tr><td> Non-Hispanic/Latiné</td><td>13 (92.89)</td></tr><tr><td colspan="2">Family Income</td></tr><tr><td> Missing income</td><td>1 (7.14)</td></tr><tr><td> $30,000 or less</td><td>0 (0)</td></tr><tr><td> $30,001–$60,000</td><td>2 (14.29)</td></tr><tr><td> $60,001–$90,000</td><td>0 (0)</td></tr><tr><td> $90,001–$120,000</td><td>6 (42.86)</td></tr><tr><td> Over $120,000</td><td>5 (35.71)</td></tr><tr><td colspan="2">ADHD presentation</td></tr><tr><td> Inattentive</td><td>13 (92.86)</td></tr><tr><td> Combined</td><td>1 (7.14)</td></tr><tr><td> Medications</td><td>5 (35.71)</td></tr><tr><td> Stimulant</td><td>4 (28.57)</td></tr><tr><td> Non-stimulant ADHD medication</td><td>0 (0)</td></tr><tr><td> Antidepressants</td><td>3 (21.43)</td></tr><tr><td> Anxiolytics</td><td>1 (7.14)</td></tr><tr><td colspan="2">Comorbid diagnoses</td></tr><tr><td> Social anxiety disorder</td><td>2 (14.29)</td></tr><tr><td> Generalized anxiety disorder</td><td>2 (14.29)</td></tr><tr><td> Past depressive episode</td><td>3 (21.43)</td></tr><tr><td colspan="2">Prior behavioral treatment</td></tr><tr><td> Community health/private practice</td><td>12 (85.71)</td></tr><tr><td> Inpatient hospitalization</td><td>1 (7.14)</td></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note.</emph> MAPs = mindful awareness practices; <emph>M</emph> = mean; <emph>SD</emph> = standard deviation; IQ = intelligence quotient.</p> <p>After confirming eligibility, pre-intervention data were collected, and participants were assigned to one of two MAPs groups based on participant availability and balance in group numbers. We obtained permission to contact up to three teachers during the pre-intervention visit, and teachers were emailed a link to complete surveys regarding the adolescent's functioning in the school setting. We administered post-intervention measures during in-person study visits within 1 and 3 months of intervention completion.</p> <hd id="AN0181053394-7">Intervention</hd> <p>MAPs is an eight-session weekly group-based intervention developed primarily for adults with ADHD ([<reflink idref="bib85" id="ref82">85</reflink>]), though it has also been used in a study of older adolescents (<emph>n</emph> = 8 adolescents 15–18 years old) and adults ([<reflink idref="bib84" id="ref83">84</reflink>]). Each session is approximately 90 to 120 min in length. A postdoctoral fellow led two MAPs groups (with eight and six participants each) under the supervision of a licensed clinical psychologist. The intervention includes approaches to make mindfulness more gradual and accessible to individuals with ADHD (e.g., shorter meditations, ADHD-specific psychoeducation and application, use of visual aids and handouts, and discussion of use of calendars and reminders to facilitate practice). In addition to traditional MAPs, some flexibility around missed sessions was employed, both in an effort to normalize forgetfulness to some extent in working with adolescents and families with ADHD, and because hospital policies at the time the study was conducted did not allow participants on-site if they were ill. Abbreviated (i.e., 15–30 min) individual check-ins via phone or video call were offered to participants when sessions were missed.</p> <p>Supplemental Table 1 provides a summary of the content covered in each intervention session. MBIs, including MAPs, are commonly delivered in group settings because this setting allows for (<reflink idref="bib1" id="ref84">1</reflink>) sharing between participants to enhance learning and understanding of common and unique experiences, and thus (<reflink idref="bib2" id="ref85">2</reflink>) de-stigmatization of the treated condition, and (<reflink idref="bib3" id="ref86">3</reflink>) delivery and practice of longer guided meditation with the support of the group leader ([<reflink idref="bib85" id="ref87">85</reflink>]). For these reasons, and the lack of available evidence on MAPs delivered individually, we also adopted the group format. Before considering possible adaptations that may be relevant for adolescents with ADHD and co-occurring CDS symptoms in future iterations of this intervention, we first wanted to test it without modification and gather feedback from adolescents and caregivers with lived experience. To participate in the intervention, caregivers were required to be on the premises per hospital requirement for treatment of a minor. However, they were provided a separate room to wait in with other caregivers and were not included in any part of the intervention sessions. Following sessions, caregivers were emailed session content summaries, session handouts, and any other materials (e.g., audio recordings of meditations) relevant for adolescents' at-home practice, as recommended in the MAPs intervention guide for clinicians ([<reflink idref="bib85" id="ref88">85</reflink>]).</p> <hd id="AN0181053394-8">Measures</hd> <p>We provide a brief overview of the measures included in the present study, with a more comprehensive summary of our measures, including measure reliabilities, presented in Supplemental Table 2. We (<reflink idref="bib1" id="ref89">1</reflink>) administered all measures at pre-intervention, 1-month post-intervention, and 3-month post-intervention and (<reflink idref="bib2" id="ref90">2</reflink>) computed mean scores for all measures, except where indicated below. For all measures, higher scores indicate greater presence of the construct being assessed.</p> <hd id="AN0181053394-9">Participant Characteristics</hd> <p>At the pre-intervention study visit, caregivers reported on caregiver and adolescent demographics. We administered the K-SADS to assess <emph>DSM-5</emph> diagnoses and establish ADHD diagnostic status (i.e., inclusion criteria) and presentation, as well as to appropriately characterize common comorbidities in our sample. We interviewed caregivers regarding ADHD and disruptive behavior, and adolescents regarding anxiety (i.e., generalized anxiety, social anxiety, and panic disorder) and mood disorders (i.e., major depressive disorder, persistent depressive disorder, and mania/hypomania; see Table 1), based on gold standard assessment practices for externalizing ([<reflink idref="bib56" id="ref91">56</reflink>]) and internalizing disorders ([<reflink idref="bib42" id="ref92">42</reflink>]; [<reflink idref="bib66" id="ref93">66</reflink>]), respectively, and to minimize overall time burden to families. Caregivers reported on previous services obtained for the adolescent, including medication, via the Service Assessment for Children and Adolescents (SACA; [<reflink idref="bib71" id="ref94">71</reflink>]).</p> <hd id="AN0181053394-10">Primary Outcomes</hd> <p></p> <hd id="AN0181053394-11">Feasibility and Acceptability</hd> <p>The clinician reported on levels of adherence to and feasibility of the study for each participant and for each intervention session. The form included information on attendance, level of engagement and participation in the session (1 = <emph>not at all</emph>, 2 = <emph>somewhat</emph>, 3 = <emph>moderate</emph>, 4 = <emph>strong</emph>, and 5 = <emph>extremely</emph>), and level of at-home practice of skills and adherence (1 = <emph>not at all</emph>, 2 = <emph>somewhat</emph>, 3 = <emph>moderate</emph>, 4 = <emph>strong</emph>, and 5 = <emph>extremely</emph>).</p> <p>We administered a 9-item study-created adolescent and caregiver satisfaction measure at the 1-month post-intervention visit (7-point scale; see Table 2 for list of questions). Finally, we created an exit interview that was administered at the 1-month post-intervention visit to caregivers and adolescents to obtain qualitative feedback from adolescents and their caregivers (e.g., most beneficial aspects, least beneficial aspects, suggestions for improvement, and how they felt the intervention addressed CDS), as well as information on degree of adolescent use of strategies (i.e., adherence) and degree of caregiver involvement/support in adolescent strategy use (see Supplemental Table 3 for complete list of questions). Importantly, although caregivers were not present for any MAPs sessions, we believed it would still be important to obtain satisfaction and feedback data from caregivers since they did receive email summaries of sessions and were potentially able to observe adolescents' at-home practice and daily life at home.</p> <p>Table 2. Satisfaction Survey Means and Standard Deviations for Adolescents and Caregivers.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" rowspan="2">Question</th><th align="center" rowspan="2">Scale</th><th align="center">Adolescent</th><th align="center">Caregiver</th></tr><tr><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>M</italic> (<italic>SD)</italic></th></tr></thead><tbody><tr><td>1. Now that it's over, did you find the intervention as helpful as you expected before starting?</td><td>1 = Much less helpful; 4 = Neutral; 7 = Much more helpful</td><td>5.00 (0.96)</td><td>5.36 (0.93)</td></tr><tr><td>2. I found the information taught in the intervention easy to understand/for my child to understand.</td><td>1 = Very untrue; 4 = Neutral; 7 = Very true</td><td>5.86 (0.77)</td><td>5.79 (1.25)</td></tr><tr><td>3. I found the information taught in the intervention easy to use in my/my child's life.</td><td>1 = Very untrue; 4 = Neutral; 7 = Very true</td><td>5.07 (1.00)</td><td>5.86 (1.17)</td></tr><tr><td>4. The attentional difficulties I/my child was experiencing before starting the intervention are...</td><td>1 = Much worse; 4 = No change; 7 = Much better</td><td>4.64 (1.78)</td><td>5.14 (0.77)</td></tr><tr><td>5. If you/your child were to seek help for your attentional difficulties later in life, how likely would you/your child be to participate in this intervention again?</td><td>1 = Unlikely; 4 = Neutral; 7 = Very likely</td><td>5.00 (1.47)</td><td>5.64 (1.45)</td></tr><tr><td>6. If a friend or family member is experiencing attentional problems, how likely are you to recommend this intervention to them?</td><td>1 = Unlikely; 4 = Neutral; 7 = Very likely</td><td>5.78 (1.05)</td><td>6.29 (0.83)</td></tr><tr><td>7. How would you rate the quality of service you/your child received from the study therapist?</td><td>1 = Very low; 4 = Neutral; 7 = Very high</td><td>6.07 (0.73)</td><td>6.21 (0.89)</td></tr><tr><td>8. I found the group approach used in the intervention to be...</td><td>1 = Very inappropriate; 4 = Neutral; 7 = Very appropriate</td><td>5.71 (1.14)</td><td>5.79 (1.42)</td></tr><tr><td>9. In an overall, general sense, how satisfied are you with receiving this intervention?</td><td>1 = Very unsatisfied; 4 = Neutral; 7 = Very satisfied</td><td>5.71 (0.83)</td><td>6.14 (0.86)</td></tr></tbody></table> </ephtml> </p> <p>2 <emph>Note. M</emph> = mean; <emph>SD</emph> = standard deviation.</p> <hd id="AN0181053394-12">CDS Symptoms</hd> <p>We collected caregiver- and teacher-report on the CABI ([<reflink idref="bib13" id="ref95">13</reflink>]; [<reflink idref="bib14" id="ref96">14</reflink>]; [<reflink idref="bib60" id="ref97">60</reflink>]), and self-report on the Child Concentration Inventory, Second Edition (CCI-2; [<reflink idref="bib9" id="ref98">9</reflink>]; [<reflink idref="bib61" id="ref99">61</reflink>]).</p> <hd id="AN0181053394-13">ADHD Symptoms</hd> <p>We used caregiver- and teacher-report of inattention and hyperactivity/impulsivity on the Vanderbilt ADHD Diagnostic Rating Scales (VADRS; [<reflink idref="bib82" id="ref100">82</reflink>], [<reflink idref="bib80" id="ref101">80</reflink>]). <emph>T</emph>-scores of ADHD sub-dimensions on the self-report Conners-3 (short-version; [<reflink idref="bib20" id="ref102">20</reflink>]) were used.</p> <hd id="AN0181053394-14">Mind-Wandering Surveys</hd> <p>Adolescent report on the (<reflink idref="bib1" id="ref103">1</reflink>) Mind-wandering Questionnaire (MWQ) was used because it has good internal consistency and convergent validity with other mind-wandering measures ([<reflink idref="bib50" id="ref104">50</reflink>]) and (<reflink idref="bib2" id="ref105">2</reflink>) Mind-Wandering Deliberate and Spontaneous Scales were used because these two scales were developed to capture distinct types of mind-wandering—deliberate and spontaneous (i.e., unintentional)—that may function differently and be differentially associated with ADHD symptoms ([<reflink idref="bib16" id="ref106">16</reflink>]) and aspects of a mindfulness ([<reflink idref="bib1" id="ref107">1</reflink>]).</p> <hd id="AN0181053394-15">Probe-Caught Mind-Wandering on Sustained Attention to Response Task (SART)</hd> <p>Participants completed a SART, during which probe-caught mind-wandering was measured ([<reflink idref="bib75" id="ref108">75</reflink>]). The SART is a go/no go task adapted from [<reflink idref="bib58" id="ref109">58</reflink>] in which a digit (1–9) is displayed upon a computer screen, and participants are instructed to respond by hitting the space bar for all digits (go trials) except for one (e.g., 3) no-go trial (less than 10% of trials). Following a practice block, participants completed 5 blocks (60s breaks between blocks) of 200 trials. Twenty thought probes were distributed in equal intervals, approximately once every 1.5 min and 5 times per block. During the probes, participants responded to the following <emph>Yes/No</emph> prompt: "Were you attending to the task?". See Supplement for additional details. Research staff noted validity concerns for three participants' SART data, resulting in removal of these data from analysis (see Supplemental Material).</p> <hd id="AN0181053394-16">Mindfulness</hd> <p>Adolescents completed the global Child and Adolescent Mindfulness Measure (CAMM; [<reflink idref="bib32" id="ref110">32</reflink>]) and the multi-dimensional Five Facet Mindfulness Questionnaire (FFMQ; [<reflink idref="bib1" id="ref111">1</reflink>]).</p> <hd id="AN0181053394-17">Secondary Outcomes</hd> <p></p> <hd id="AN0181053394-18">Emotional and Affective Functioning</hd> <p>Caregivers and adolescents completed the depression and anxiety subscales of the Revised Child Anxiety and Depression Scales (RCADS; [<reflink idref="bib18" id="ref112">18</reflink>]; [<reflink idref="bib24" id="ref113">24</reflink>]) and the Difficulties in Emotion Regulation Scale (DERS; [<reflink idref="bib31" id="ref114">31</reflink>]). Adolescents also completed the brooding and reflection subscales of the Ruminative Response Scale (RRS; [<reflink idref="bib72" id="ref115">72</reflink>]) and the Penn State Worry Questionnaire (PSWQ; [<reflink idref="bib48" id="ref116">48</reflink>]).</p> <hd id="AN0181053394-19">Social Functioning</hd> <p>Self-reported loneliness was measured with the 9-item version of the UCLA Loneliness Scale ([<reflink idref="bib25" id="ref117">25</reflink>]).</p> <hd id="AN0181053394-20">Sleep Functioning</hd> <p>Self-reported sleep hygiene was measured with the Adolescent Sleep Hygiene Scale (ASHS; [<reflink idref="bib44" id="ref118">44</reflink>]).</p> <hd id="AN0181053394-21">Academic and Executive Functioning</hd> <p>Adolescents, caregivers, and teachers completed the Adolescent Academic Problems Checklist (AAPC; [<reflink idref="bib64" id="ref119">64</reflink>]) and caregivers completed the Barkley Deficits in Executive Functioning Scale, Children and Adolescents (BDEFS-CA; [<reflink idref="bib3" id="ref120">3</reflink>]).</p> <hd id="AN0181053394-22">Analytic Plan</hd> <p>All analyses were performed using SPSS Statistics, Version 26. We first examined whether our outcome data met the assumptions of parametric testing (i.e., check for outliers, Shapiro-Wilk test for normality). We then used either paired sample <emph>t</emph>-tests or Wilcoxon Signed-Rank tests (i.e., the non-parametric alternative to paired sample <emph>t</emph>-tests for measures that did not meet parametric testing assumptions) to examine changes from pre-intervention measures for both 1- and 3-month post-intervention. We computed Hedge's <emph>g</emph> and matched-pairs rank biserial correlation coefficients for <emph>t</emph>-tests and Wilcoxon Signed Ran tests, respectively ([<reflink idref="bib59" id="ref121">59</reflink>]). Similar to prior work (e.g., [<reflink idref="bib8" id="ref122">8</reflink>]), we emphasize effects size (i.e., 0.2 = small, 0.5 = medium/moderate, and 0.8 = large effect) over statistical significance given our small sample size, and do not correct for multiple comparisons for similar reasons ([<reflink idref="bib52" id="ref123">52</reflink>]). For two participants, different teachers provided ratings at one of the timepoints. Finally, we conducted a post-hoc analysis comparing mean changes in CDS symptoms with the exclusion of hypoactivity items (see Supplemental Material for rationale, results, and interpretation).</p> <hd id="AN0181053394-23">Results</hd> <p></p> <hd id="AN0181053394-24">Feasibility</hd> <p>We present the study flow diagram in Figure 1 and participant attendance, session engagement ratings, and at-home practice completion ratings side by side with session content in Supplemental Table 1. Sixteen eligible participants were allocated to two MAPs groups. Attendance ranged from six to eight sessions attended (<emph>M</emph> = 6.86, <emph>SD</emph> = 0.84) over the course of the 8 sessions of the 14 participants who completed the intervention, with an average of 1.5 abbreviated individual sessions attended by participants across the six sessions that had absences. Two participants (both 17-year-old White females in group 2) withdrew. The primary reason provided for withdrawal related to scheduling conflicts, though one participant's caregiver also noted teen discomfort with how much younger most of the other teens in her group were (group 1 age <emph>M</emph> = 15.12; group 2 age <emph>M</emph> = 14.67 when excluding 2 participants who withdrew).</p> <p>Graph: Figure 1. MAPs open trial consort. Note. CDS = cognitive disengagement syndrome; ASD = autism spectrum disorder; BPD = bipolar disorder; OCD = obsessive compulsive disorder; IQ = intelligence quotient.</p> <p>Participants were moderately engaged in sessions on average (<emph>M</emph> = 3.25, <emph>SD</emph> = 1.03), with engagement lowest for the first session (<emph>M</emph> = 2.93, <emph>SD</emph> = 1.21) and highest for session 7 (<emph>M</emph> = 3.73, <emph>SD</emph> = 0.79). Based on behavioral observations recorded by research staff and the clinician, engagement was most often impacted by participants' arriving late or leaving early, lack of volunteering or sharing with others, and difficulties with attention (e.g., staring off and needing questions/content repeated) and alertness (e.g., falling asleep) in session. This may have been made more challenging by the time sessions were held and/or the length of sessions (i.e., group 1 sessions scheduled from 6:00 to 7:30 PM.; group 2 sessions scheduled from 6:30 to 8:00 PM on weekdays; see participant feedback below). Average participant at home practice completion across sessions was rated as "somewhat" (<emph>M</emph> = 2.83, <emph>SD</emph> = 1.03) and ranged from an average of 2.36 (<emph>SD</emph> = 0.92; session 6) to 3.43 (<emph>SD</emph> = 1.22; session 5).</p> <hd id="AN0181053394-25">Acceptability and Satisfaction</hd> <p></p> <hd id="AN0181053394-26">Satisfaction Survey</hd> <p>We present the questions used along with the means and standard deviation for the satisfaction survey in Table 2 and the proportion of participants who endorsed each specific response option in Supplemental Table 4. A majority of adolescents (64.3%) and caregivers (71.4%) rated the intervention as "slightly more helpful" to "much more helpful" than they expected, easy for the adolescent to understand (92.9% of adolescents and 78.6% of caregivers rated "slightly true" to "very true"), and useful in daily life (64.3% of adolescents and 85.7% of caregivers rated "slightly true" to "very true"). More than half (64.3%) of adolescents reported that their attentional difficulties had improved at least "slightly" with the intervention and that they would be "slightly likely" to participate in the same intervention in the future if need be, and a larger proportion of caregivers (78.6%) responded the same way. Most adolescents (85.7%) and caregivers (92.8%) reported that they would be "slightly likely" or "likely" to recommend the intervention to a loved one. All adolescents and caregivers rated the quality of the services received from the study therapist to be at least "slightly high," with 78.6% of adolescents and 85.7% of caregivers rating services received by therapist to be "high" or "very high." The group approach was also rated by most (85.7% of adolescents and 71.4% of caregivers) to be "slightly appropriate" to "very appropriate." Finally, no informants rated dissatisfaction overall with participating in the study, and 85.7% of adolescents and 100% of caregivers rated themselves as "slightly satisfied" to "very satisfied."</p> <hd id="AN0181053394-27">Exit Interview</hd> <p>We present summaries of all open-ended feedback in Supplemental Table 3, and below we discuss the most salient feedback provided by adolescents and caregivers.</p> <hd id="AN0181053394-28">Perceived Positive Aspects of Treatment</hd> <p>Patterns for adolescents in response to what they most liked about treatment included reports of (<reflink idref="bib1" id="ref124">1</reflink>) skill-building and learning to manage ADHD, CDS, and other symptoms or difficulties (e.g., "I think it gave me an alternative to how to deal with the ADHD overall. I think the entire [intervention] was helpful to me for concentrating"), (<reflink idref="bib2" id="ref125">2</reflink>) enjoying group sessions because it helped them relate to and learn from others (e.g., "[It was] nice to be doing [the intervention] with other people who understand"), (<reflink idref="bib3" id="ref126">3</reflink>) certain activities (e.g., meditations that allowed movement: "Walking was good because we weren't just sitting there trying not to fidget, and it helped with [my] tiredness to be walking"), and (<reflink idref="bib4" id="ref127">4</reflink>) activities or meditations that emphasized a practical component for easier application (see Supplemental Table 3). Caregivers also emphasized their adolescent's use of skills to manage difficulties (e.g., "He learned how to calm his body down," "The other day he had an exam, and he was really stressed out. I told him that he should go breathe in a quiet corner of the house, and it calmed him down! He was playing violin the other day and got frustrated, and I suggested that he breathe and it calmed him down again"), as well as the importance of the group component for their adolescents (e.g., "It felt good to be in a room with other kids that knew how he was feeling," "There was a diversity of kids and ages with [different] perspectives. [She] knew her struggles are everywhere").</p> <hd id="AN0181053394-29">Perceived Negative Aspects of Treatment and Suggestions for Improvement</hd> <p>Some adolescents listed specific skills or activities that they liked least about treatment, though there was no pattern to the skills or activities listed (Supplemental Table 3). Fifty percent of adolescents also noted that they did not like when the sessions were scheduled, how long sessions were overall, or how long the meditations in session were. When asked for feedback about what could be cut from the intervention to make sessions shorter, adolescents varied in their suggestions (e.g., no need for a break in the middle of session, fewer meditations, having shorter sessions with more frequent meetings [e.g., twice per week or once per week for 16 weeks], and eliminating review of at home practice and trouble-shooting at the beginning of sessions given the length of time this activity took, particularly in the context of late arrivals). Caregivers agreed with the challenges of scheduling or travel to sessions, though many also noted that there may not be better options to ensure that participants could attend. Most caregivers also reported that sessions were appropriate in length, and a few adolescents and caregivers noted that they would have liked either more sessions or more emphasis on certain topics (e.g., more on internal distraction, more on group discussion and getting to know other teens). Finally, caregivers emphasized the need for more therapist involvement (e.g., check-ins throughout the week, occasional individual sessions) and broader availability of the intervention so that more adolescents could receive treatment.</p> <p>Caregivers who provided feedback regarding defining a clear role for caregiver involvement also endorsed wanting more caregiver involvement, expressing that they wanted to know how to help their adolescent apply what was being learned in the intervention. However, they also acknowledged the need for their adolescent to build independence with symptom management, the respect for their adolescent's privacy, or that their adolescent would be less likely to engage if they were more involved. In fact, most adolescents reported that they thought the amount of caregiver involvement was appropriate, noting that they wouldn't have wanted any more (e.g., "It would be awkward if they were involved," "[They] still knew what we were doing, but more for us learning [the intervention] and learning to do [the skills] on our own"). Suggestions by caregivers for enhancing caregiver involvement included providing copies of materials to caregivers in session (as opposed to being emailed following each session), direct instruction from another therapist or a group facilitator in parallel to the adolescent's session that either provided complimentary information (e.g., what to talk to adolescents about, how to get adolescents to practice at home, how to reinforce practice) or functioned as a support group (e.g., caregivers able to discuss challenges with parenting child with ADHD or balancing autonomy and accountability for adolescent in at-home practice), or a caregiver-focused version of the intervention for caregivers to work on the skills themselves.</p> <p>Aside from those already mentioned, suggestions for improvement that were made by adolescents included (<reflink idref="bib1" id="ref128">1</reflink>) improvement to group dynamics (e.g., wishing they knew the others in the group better: "Lots of the kids were quiet. Anytime [therapist] asked a question everyone was quiet. If we were more comfortable with each other maybe would've answered more"; suggestions that adolescents be closer in age to each other: "...because people would relate even more, and also the content would be easier to tailor"), and (<reflink idref="bib2" id="ref129">2</reflink>) adaptations to session content (e.g., more walking meditations, the inclusion of a sleep treatment component). Caregivers' feedback was largely consistent with adolescent suggestions.</p> <hd id="AN0181053394-30">Perceived Intervention Impact on CDS-Specific Symptoms</hd> <p>In response to whether CDS symptoms were specifically addressed, most adolescents reported symptom improvements to daydreaming, getting lost in one's thoughts, and spacing or zoning out, whereas only a few noted improvements to symptoms of lethargy, sleepiness, and being easily fatigued. One adolescent stated, "Practicing mindfulness helped me get it together from inside my brain," and another stated, "With daydreaming and getting lost in my thoughts, [mindfulness] helped me not to judge myself and get me off track even more. When I stopped judging, it didn't make it worse, and I paid attention faster." Another adolescent also noted the ability to refocus quicker, stating, "I noticed more when I lost my train of thought, and I could more easily get back on track." Suggestions for adaptations to address lethargy, sleepiness, and fatigue included more mindful movement, practicing mindfulness before bed or as part of bedtime routine, and discussion of sleep education and strategies (e.g., sleep schedule and healthy sleep habits). A few caregivers provided similar suggestions, and one stated, "Exercise helps her with this, so adding physical movement component would help. But what's interesting is that she's also quite slow and doesn't always break a sweat there without help. She kind of goes through motions, so mindfulness during would be helpful."</p> <hd id="AN0181053394-31">Perceived Intervention Impact on Internal and External Sources of Distraction</hd> <p>Most adolescents and caregivers also reported that the intervention helped more with internal distraction than external distraction. For example, one adolescent said, "My thoughts and emotions were overwhelming me, and this helped me process them," and another said, "[The meditations] helped me learn how to concentrate on one thing while the meditation was happening, and I saw how I can use it outside of the treatment and concentrate on at-home practice or a test. It would help me not think of something else." A few adolescents and caregivers noted improvements to both types of distraction equally, and one caregiver said, "He was more focused on trying to find a job. He was more focused when his managers would text him. He would text back right away where it would previously take 2 or 3 hours."</p> <hd id="AN0181053394-32">Feedback on Providing the Intervention via Telehealth in the Future</hd> <p>Finally, most adolescents and caregivers reported that for future patients and participants, in person sessions would be better than telehealth, though many acknowledged the importance of flexibility or hybrid options as needed (e.g., illness, convenience at times). Adolescents reasoned that in person sessions are better for skill practice (e.g., "Some of the walking around or meditation would've been harder [over telehealth]"), and many specifically stated that they would find it harder not to get distracted via telehealth. Several adolescents noted the added benefit of being around peers (e.g., "It was fun being around other people. You get to meet new people and it was way more fun"). Caregivers emphasized the likelihood that their teen might become distracted or space out if they had received the intervention via telehealth (e.g., "For some people I think it would've been good. For others like [child's name], I think not. He did not do well with online school, so no. If he was in his home environment, he would get more distracted by the things around him and would pay less attention to the screen").</p> <hd id="AN0181053394-33">ADHD and CDS Symptoms</hd> <p>Changes to ADHD and CDS symptoms from pre- to post-intervention are presented in Table 3. For ADHD-IN symptoms, adolescents reported a medium-sized decrease in symptoms from pre- to 1-month post-intervention (<emph>g</emph> = 0.57, <emph>p</emph> =.04) and a large decrease in symptoms from pre- to 3-month post-intervention (<emph>g</emph> = 0.87, <emph>p</emph> =.004). Caregiver-reported ADHD-IN changes were more modest, with a moderate improvement to symptoms from pre- to 3-month post-intervention (<emph>r</emph> =.68, <emph>p</emph> =.01). Although no other informant noted substantive changes to ADHD-HI symptoms, adolescents reported a moderate decrease in ADHD-HI symptoms from pre-intervention to 3-month follow-up (<emph>g</emph> = 0.57, <emph>p</emph> =.04). Importantly, it should be noted that mean scores rated by caregivers (<emph>M</emph> = 0.87, <emph>SD</emph> = 0.64) and teachers (<emph>M</emph> = 0.19, <emph>SD</emph> = 0.41) were low to begin with, which may be indicative of a floor effect. In contrast, this may not have been true for self-reported HI symptoms given our use of <emph>T</emph>-scores and/or the different rating scale used.</p> <p>Table 3. Paired Sample T -Test and Wilcoxon Signed-Rank Test Results for ADHD and CDS Symptoms.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" rowspan="2">Primary outcomes</th><th align="center">Pre-treatment</th><th align="center">Post-treatment</th><th align="center">3-Month Follow-Up</th><th align="center" colspan="3">Effect from pre- to post-treatment</th><th align="center" colspan="3">Effect from pre-treatment to follow-up</th></tr><tr><th align="center"><italic>M</italic> (SD)</th><th align="center"><italic>M</italic> (SD)</th><th align="center"><italic>M</italic> (SD)</th><th align="center"><italic>t</italic>/<italic>z</italic></th><th align="center"><italic>p</italic></th><th align="center"><italic>g/r</italic></th><th align="center"><italic>t/z</italic></th><th align="center"><italic>p</italic></th><th align="center"><italic>g/r</italic></th></tr></thead><tbody><tr><td>CR ADHD-IN</td><td>1.91 (0.54)</td><td>1.68 (0.55)</td><td>1.52 (0.49)</td><td>−1.66</td><td>.10</td><td>−0.44<xref ref-type="table-fn" rid="tfn5">b</xref></td><td><bold>−2.56</bold></td><td><bold>.01</bold></td><td><bold>−0.68</bold><xref ref-type="table-fn" rid="tfn5">b</xref></td></tr><tr><td>CR ADHD-HI</td><td>0.87 (0.64)</td><td>0.83 (0.77)</td><td>0.77 (0.66)</td><td>0.57</td><td>.58</td><td>0.15<xref ref-type="table-fn" rid="tfn4">a</xref></td><td>1.56</td><td>.14</td><td>0.39<xref ref-type="table-fn" rid="tfn4">a</xref></td></tr><tr><td>CR CDS</td><td>3.08 (0.54)</td><td>2.21 (1.16)</td><td>2.22 (1.27)</td><td><bold>3.40</bold></td><td><bold>.004</bold></td><td><bold>0.87</bold><xref ref-type="table-fn" rid="tfn4">a</xref></td><td><bold>2.86</bold></td><td><bold>.01</bold></td><td><bold>0.72</bold><xref ref-type="table-fn" rid="tfn4">a</xref></td></tr><tr><td>TR ADHD-IN</td><td>0.95 (0.74)</td><td>0.94 (0.81)</td><td>0.96 (0.86)</td><td>−0.20</td><td>.84</td><td>−0.05<xref ref-type="table-fn" rid="tfn5">b</xref></td><td>−0.46</td><td>.65</td><td>−0.12<xref ref-type="table-fn" rid="tfn5">b</xref></td></tr><tr><td>TR ADHD-HI</td><td>0.19 (0.41)</td><td>0.18 (0.32)</td><td>0.20 (0.44)</td><td>−0.21</td><td>.83</td><td>−0.06<xref ref-type="table-fn" rid="tfn5">b</xref></td><td>−0.69</td><td>.49</td><td>−0.18<xref ref-type="table-fn" rid="tfn5">b</xref></td></tr><tr><td>TR CDS</td><td>0.93 (1.08)</td><td>0.82 (1.16)</td><td>0.98 (1.33)</td><td>−0.71</td><td>.48</td><td>−0.19<xref ref-type="table-fn" rid="tfn5">b</xref></td><td>−0.95</td><td>.34</td><td>−0.25<xref ref-type="table-fn" rid="tfn5">b</xref></td></tr><tr><td>SR ADHD-IN</td><td>74 (13.40)</td><td>65.79 (10.37)</td><td>61.57 (8.51)</td><td><bold>2.26</bold></td><td><bold>.04</bold></td><td><bold>0.57</bold><xref ref-type="table-fn" rid="tfn4">a</xref></td><td><bold>3.48</bold></td><td><bold>.004</bold></td><td><bold>0.87</bold><xref ref-type="table-fn" rid="tfn4">a</xref></td></tr><tr><td>SR ADHD-HI</td><td>63.86 (10.79)</td><td>59.79 (9.77)</td><td>57.79 (10.29)</td><td>1.79</td><td>.10</td><td>0.45<xref ref-type="table-fn" rid="tfn4">a</xref></td><td><bold>2.27</bold></td><td><bold>.04</bold></td><td><bold>0.57</bold><xref ref-type="table-fn" rid="tfn4">a</xref></td></tr><tr><td>SR CDS</td><td>1.41 (0.63)</td><td>1.27 (0.47)</td><td>0.98 (0.45)</td><td>0.94</td><td>.37</td><td>0.24<xref ref-type="table-fn" rid="tfn5">b</xref></td><td><bold>2.06</bold></td><td><bold>.06</bold></td><td><bold>0.52</bold><xref ref-type="table-fn" rid="tfn4">a</xref></td></tr></tbody></table> </ephtml> </p> <ulist> <item>3 <emph>Note.</emph> Medium-sized (>0.50) effects are bolded. Self-reported ADHD-IN and HI symptoms reflect <emph>T-</emph>scores. CDS = cognitive disengagement syndrome; <emph>M</emph> = mean; <emph>SD</emph> = standard deviation; CR = caregiver-report; ADHD-IN = ADHD inattentive symptoms; ADHD-HI = ADHD hyperactive/impulsive symptoms; TR = teacher-report; SR = self-report.</item> <item>4 Paired Sample <emph>T</emph>-Test used, Hedge's <emph>g</emph> coefficient reported.</item> <item>5 Paired Sample Wilcoxon Signed-Rank Test used, biserial correlation coefficient (<emph>r</emph>) reported.</item> </ulist> <p>For CDS symptoms, caregivers reported a large decrease in symptoms from pre- to 1-month post-intervention (<emph>g</emph> = 0.87, <emph>p</emph> =.004) and moderate improvement from pre- to 3-month follow-up (<emph>g</emph> = 0.72, <emph>p</emph> =.01). Adolescents did not report a substantive improvement to CDS symptoms at 1-month post-intervention, but they reported moderate improvement from pre-intervention to the 3-month follow-up (<emph>g</emph> = 0.52, <emph>p</emph> =.06). Teachers did not report any medium-to-large symptom changes.[<reflink idref="bib5" id="ref130">5</reflink>]</p> <hd id="AN0181053394-34">Mind-Wandering and Mindfulness</hd> <p>Changes on the mind-wandering and mindfulness measures, as well as SART accuracy and reaction time variability for each trial type, are reported in Table 4. Although mind-wandering decreased from pre- to post-intervention as measured on the SART, MWQ, and deliberate mind-wandering scale, all effects were small in magnitude. However, adolescents reported medium-sized decreases to spontaneous mind-wandering specifically, suggesting that mind-wandering was more under adolescent control at 1-month (<emph>g</emph> = 0.69, <emph>p</emph> =.02) and 3-month (<emph>g</emph> = 0.65, <emph>p</emph> =.02) post-intervention compared with before the intervention.</p> <p>Table 4. Paired Sample T-Test and Wilcoxon Signed-Rank Test Results for Mind-Wandering and Mindfulness.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" rowspan="2">Mind-wandering outcomes</th><th align="center">Pre-treatment</th><th align="center">Post-treatment</th><th align="center">3 month follow up</th><th align="center" colspan="3">Effect from pre- to post-treatment</th><th align="center" colspan="3">Effect from pre-treatment to follow-up</th></tr><tr><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>t/z</italic></th><th align="center"><italic>p</italic></th><th align="center"><italic>g/r</italic></th><th align="center"><italic>t/z</italic></th><th align="center"><italic>p</italic></th><th align="center"><italic>g/r</italic></th></tr></thead><tbody><tr><td>Percent time mind-wandering</td><td>36.82 (26.82)</td><td>34.47 (34.06)</td><td>30.00 (31.36</td><td>0.08</td><td>.94</td><td>0.02</td><td>1.59</td><td>.14</td><td>0.41</td></tr><tr><td>Thought probe RTV</td><td>3.82 (9.68)</td><td>1.57 (3.40)</td><td>1.14 (1.87)</td><td>1.16</td><td>.27</td><td>0.31</td><td>1.48</td><td>.17</td><td>0.38</td></tr><tr><td>Go accuracy</td><td>95.9 (6.45)</td><td>95.44 (5.42)</td><td>95.58 (5.20)</td><td>1.57</td><td>.15</td><td>0.42</td><td>−0.57</td><td>.58</td><td>0.15</td></tr><tr><td>Go RTV</td><td>0.15 (0.09)</td><td>0.17 (0.11)</td><td>0.15 (0.09)</td><td>−1.79</td><td>.1</td><td>−0.48</td><td>0.28</td><td>.78</td><td>0.07</td></tr><tr><td>No go accuracy</td><td>43.67 (23.10)</td><td>44.92 (25.44)</td><td>47.62 (25.52)</td><td>−0.5</td><td>.63</td><td>−0.13</td><td>−0.76</td><td>.46</td><td>−0.2</td></tr><tr><td>No go RTV</td><td>0.15 (0.11)</td><td>0.15 (0.12)</td><td>0.15 (0.12)</td><td>−0.13</td><td>.9</td><td>−0.04</td><td>0.27</td><td>.8</td><td>0.07</td></tr><tr><td>Mind-wandering Questionnaire</td><td>3.90 (1.19)</td><td>3.73 (0.95)</td><td>3.49 (1.11)</td><td>0.75</td><td>.47</td><td>0.19<xref ref-type="table-fn" rid="tfn7">a</xref></td><td>1.2</td><td>.24</td><td>0.31<xref ref-type="table-fn" rid="tfn7">a</xref></td></tr><tr><td>Deliberate Mind-wandering Scale</td><td>3.29 (1.47)</td><td>3.41 (1.31)</td><td>3.25 (1.21)</td><td>−0.46</td><td>.65</td><td>−0.12<xref ref-type="table-fn" rid="tfn7">a</xref></td><td>0.08</td><td>.94</td><td>0.02<xref ref-type="table-fn" rid="tfn7">a</xref></td></tr><tr><td>Spontaneous Mind-wandering Scale</td><td>4.43 (1.65)</td><td>3.18 (1.37)</td><td>2.96 (1.29)</td><td><bold>2.75</bold></td><td><bold>.02</bold></td><td><bold>0.69</bold><xref ref-type="table-fn" rid="tfn7">a</xref></td><td><bold>2.59</bold></td><td><bold>.02</bold></td><td><bold>0.65</bold><xref ref-type="table-fn" rid="tfn7">a</xref></td></tr><tr><td colspan="10">Mindfulness outcomes</td></tr><tr><td>Child and adolescent mindfulness measure</td><td>2.16 (0.76)</td><td>2.47 (0.78)</td><td>2.70 (0.81)</td><td>−1.7</td><td>.11</td><td>−0.43<xref ref-type="table-fn" rid="tfn7">a</xref></td><td><bold>−2.2</bold></td><td><bold>.046</bold></td><td><bold>−0.55</bold><xref ref-type="table-fn" rid="tfn7">a</xref></td></tr><tr><td>FFMQ nonreactivity</td><td>3.12 (0.64)</td><td>2.93 (0.52)</td><td>3.05 (0.73)</td><td>1.4</td><td>.19</td><td>0.35<xref ref-type="table-fn" rid="tfn7">a</xref></td><td>0.65</td><td>.53</td><td>0.16<xref ref-type="table-fn" rid="tfn7">a</xref></td></tr><tr><td>FFMQ observing</td><td>3.14 (0.73)</td><td>3.04 (0.81)</td><td>3.01 (0.61)</td><td>0.58</td><td>.57</td><td>0.15<xref ref-type="table-fn" rid="tfn7">a</xref></td><td>0.95</td><td>.36</td><td>0.24<xref ref-type="table-fn" rid="tfn7">a</xref></td></tr><tr><td>FFMQ describing</td><td>2.91 (0.80)</td><td>2.78 (0.74)</td><td>2.99 (0.67)</td><td>0.98</td><td>.34</td><td>0.25<xref ref-type="table-fn" rid="tfn7">a</xref></td><td>−0.37</td><td>.72</td><td>−0.09<xref ref-type="table-fn" rid="tfn7">a</xref></td></tr><tr><td>FFMQ nonjudging</td><td>3.49 (0.84)</td><td>3.91 (0.79)</td><td>3.87 (0.99)</td><td><bold>−1.97</bold></td><td><bold>.07</bold></td><td><bold>−0.50</bold><xref ref-type="table-fn" rid="tfn7">a</xref></td><td>−1.56</td><td>.14</td><td>−0.39<xref ref-type="table-fn" rid="tfn7">a</xref></td></tr><tr><td>FFMQ acting with awareness</td><td>2.63 (0.84)</td><td>3.09 (0.84)</td><td>3.29 (0.76)</td><td>−1.4</td><td>.16</td><td>−0.37<xref ref-type="table-fn" rid="tfn8">b</xref></td><td><bold>−2.14</bold></td><td><bold>.03</bold></td><td><bold>−0.57</bold><xref ref-type="table-fn" rid="tfn8">b</xref></td></tr></tbody></table> </ephtml> </p> <ulist> <item>6 <emph>Note.</emph> Medium-sized (>0.50) effects are bolded. <emph>M</emph> = mean; <emph>SD</emph> = standard deviation; RTV = reaction time variability; FFMQ = Five Facet Mindfulness Questionnaire.</item> <item>7 Paired Sample <emph>T</emph>-Test used, Hedge's <emph>g</emph> coefficient reported.</item> <item>8 Paired Sample Wilcoxon Signed-Rank Test used, biserial correlation coefficient (r) reported.</item> </ulist> <p>Adolescents reported moderately higher mindfulness in global mindfulness from pre- to 3-month post-intervention (<emph>r</emph> =.55, <emph>p</emph> =.046). Adolescents also reported medium-sized increases in two facets of mindfulness measured by the FFMQ; at 1-month post-intervention, adolescents reported that they engaged in more nonjudgment of their experience (<emph>r</emph> =.50, <emph>p</emph> =.07), and at 3-month post-intervention, they reported that they acted with awareness more often than they had prior to the intervention (<emph>r</emph> =.57, <emph>p</emph> =.03).</p> <hd id="AN0181053394-35">Rumination, Academic Achievement, and Executive Functioning Improvement</hd> <p>Of the secondary outcomes, we only observed improvements in brooding rumination, academic problems, and executive functioning, though results were not consistent across follow-up interval (i.e., 1- or 3-month post-intervention) or informant (e.g., caregiver, teacher, and self-report) (Supplemental Table 5). Specifically, adolescents reported a moderate reduction in brooding rumination at the 3-month post-intervention visit compared with their pre-intervention ratings (<emph>g</emph> = 0.51, <emph>p</emph> =.07), as well as a moderate reduction in academic problems at their 1-month post-intervention visit (<emph>g</emph> = 0.52, <emph>p</emph> =.06); there were no changes from baseline to academic problems reported at the 3-month follow-up, nor by caregivers or teachers at either post-intervention time point. However, caregivers did report improvements to adolescent executive functioning at the 3-month (<emph>g</emph> = 0.57, <emph>p</emph> =.04), but not 1-month, post-intervention visit; no changes to executive functioning were reported by other informants.</p> <hd id="AN0181053394-36">Discussion</hd> <p>There is a dearth of literature on MBIs in the management of ADHD among adolescents, particularly MBIs that do not have a heavy reliance on parental participation, and on evidence-based treatment for individuals who exhibit CDS symptoms. To our knowledge, this open trial pilot study is the first to examine mindfulness as a treatment for ADHD and co-occurring CDS symptoms. Our findings provide preliminary support for the feasibility, acceptability, and efficacy of a MBI—MAPs—to manage symptoms, especially ADHD-IN and CDS, based on caregiver- and adolescent-report. Our findings also provide guidance for future adaptations of MAPs for adolescents with ADHD and CDS to enhance treatment engagement.</p> <hd id="AN0181053394-37">Feasibility and Acceptability</hd> <p>Although many studies require a minimum number of sessions (e.g., 6) to be attended in order to be included in completer-based analyses ([<reflink idref="bib49" id="ref131">49</reflink>]), we sought to examine MAPs using a more standard clinical practice context that considered flexibility around lateness and missed sessions. This is especially important when working with individuals with ADHD, as accommodating lateness and missed sessions may be perceived to be more inclusive and de-stigmatizing of ADHD symptoms. Such flexibility may be specifically important for adolescents, who (<reflink idref="bib1" id="ref132">1</reflink>) have less control over their own schedules and transportation ([<reflink idref="bib84" id="ref133">84</reflink>]), and (<reflink idref="bib2" id="ref134">2</reflink>) are likely to have caregivers with ADHD-related difficulties ([<reflink idref="bib54" id="ref135">54</reflink>]).</p> <p>Adolescent and caregiver feedback also provided insight for further adaptation of MAPs to enhance treatment engagement. One central piece of feedback related to scheduling options. Both groups that participated in the intervention had start times of 6:00 PM or later on weekdays based on caregiver and adolescent schedules, highlighting a need for innovative solutions to enhance feasibility (e.g., MBIs delivered in schools or on weekends, shorter or more frequent sessions). Interestingly, one potential adaptation that was overwhelmingly disliked by caregivers and adolescents was intervention-delivery via telehealth. It was agreed that telehealth delivery would inhibit treatment engagement for this population, who already exhibit more difficulties with staying alert/awake, focused, and engaged ([<reflink idref="bib10" id="ref136">10</reflink>]). This is important for providers to consider against the backdrop of the changing healthcare landscape and increasing availability of telehealth services. Additionally, although most adolescents reported preferring a group format because they were able to relate and connect with others ([<reflink idref="bib85" id="ref137">85</reflink>]), feasibility regarding scheduling may be improved by offering the intervention in an individual format. In fact, much of the feedback we received regarding perceived benefits of our intervention could be applied within the context of individualized therapy for those who might prefer it, including psychoeducation of ADHD, self-monitoring, modification of self-criticisms, and greater acceptance of ADHD symptoms, emotions, and experiences. Thus, future research should compare group vs. individual-delivery format—or a hybrid—to understand potential trade-offs to each. Finally, a few participants also suggested decreasing the length of sessions.</p> <p>Additional suggestions to enhance treatment engagement included built-in activities for adolescents to get to know each other better to allow for greater comfort in sharing in a group setting. This may be especially relevant to adolescents with ADHD who experience co-occurring CDS, as youth with CDS frequently experience social withdrawal (above and beyond both ADHD and internalizing symptoms) which likely reduce engagements ([<reflink idref="bib10" id="ref138">10</reflink>]). Relatedly, a few older adolescents suggested creating groups for younger and older adolescents to tailor content and alleviate their own discomfort being among much younger adolescents. This was also one cited reason alongside busy schedules given by one caregiver whose adolescent withdrew from the study.</p> <p>Most adolescents and caregivers agreed that more caregiver involvement would potentially produce negative outcomes (e.g., conflict and less engagement), though at least a few adolescents perceived caregiver involvement to mean that caregivers would be in sessions with them (e.g., noting it would be awkward to have caregiver more involved, stating that adolescents would not be as honest in group if caregivers were present). If caregiver engagement were increased in future iterations of MAPs for adolescents with ADHD and CDS, it should balance the importance of external scaffolding caregivers can provide with developing adolescent autonomy, which may abate adolescents concerns regarding over-involvement by caregivers. One possibility is to have a separate group where caregivers learned the skills, which was suggested by several caregivers.</p> <hd id="AN0181053394-38">Changes to ADHD and CDS Symptoms</hd> <p>We found larger and more consistent changes to CDS symptoms than to ADHD symptoms based on caregiver report, with the inverse evident for adolescent report. This pattern for CDS symptoms was also observed in one of the only other behavioral intervention studies examining change in CDS symptoms, which was a school-based intervention for ADHD ([<reflink idref="bib69" id="ref139">69</reflink>]). Emerging evidence has suggested that CDS may be best conceptualized within an internalizing framework ([<reflink idref="bib9" id="ref140">9</reflink>]), such that adolescents may be especially important in the multi-informant assessment of CDS and differentiation between certain symptom dimensions (i.e., CDS vs. ADHD inattention), though more research is needed to clarify informant discrepancies. Finally, it is also possible that any relative benefit to CDS symptoms over ADHD symptoms (or vice versa) may be more about perception of what a person struggles with most often, as several adolescents and caregivers stated that they perceived more benefit to internal distraction for this reason.</p> <p>Although our post-hoc analyses did not find compelling evidence for differential effects across potential CDS sub-dimensions, this remains an important for future research as CDS sub-dimensions may reflect different intervention targets ([<reflink idref="bib67" id="ref141">67</reflink>]). Our qualitative findings pointed toward the possible benefit to mindful movement and/or more vigorous physical exercise for hypoactive symptoms specifically, which is consistent with emerging evidence suggesting the physical inactivity seen in adolescents with ADHD may be more strongly related to CDS symptoms than to ADHD symptoms ([<reflink idref="bib5" id="ref142">5</reflink>]; [<reflink idref="bib78" id="ref143">78</reflink>]).</p> <p>Adolescents were also the only informant to report any improvement to ADHD-HI symptoms, reporting medium sized improvement to symptoms. Whereas we computed <emph>T</emph>-scores for adolescent-reported ADHD symptoms, we computed mean scores for caregiver and teacher ratings, and means scores were rated as low to begin with which may be unsurprising given 92% of our sample met criteria for ADHD-inattentive presentation. Furthermore, impulsivity via hyperactive motor movements tends to decline as children enter adolescents, though symptoms may be reflected in adolescents' internal experience (e.g., feeling of restlessness) or by more subtle (e.g., verbal impulsiveness rather than hyperactive movement; [<reflink idref="bib51" id="ref144">51</reflink>]; [<reflink idref="bib79" id="ref145">79</reflink>]) behaviors, which may also explain our findings by informant.</p> <hd id="AN0181053394-39">Changes to Mind-Wandering and Mindfulness</hd> <p>Although we included several indices of mind-wandering, we only observed substantive reductions to self-reported spontaneous mind-wandering measured with the Deliberate and Spontaneous Mind-wandering Scales both at 1- and 3-month post-intervention. This finding is promising, as it suggests that adolescents learned to control mind-wandering to some extent. Given that mind-wandering may be beneficial with respect to certain situations or outcomes ([<reflink idref="bib62" id="ref146">62</reflink>]), skills to manage any excessive or maladaptive mind-wandering might be specifically important in situations in which mind-wandering would impede functioning (e.g., during teacher instruction). As such, the distinction between deliberate and spontaneous mind-wandering may be important, as spontaneous mind-wandering may be more indicative of excessive, maladaptive mind-wandering ([<reflink idref="bib16" id="ref147">16</reflink>]).</p> <p>We also observed moderate improvements to trait mindfulness, though there was inconsistency across measures regarding when findings were observed. First, consistent with our global measure of mindfulness, adolescents reported improvements in a facet of mindfulness that emphasizes acting with awareness, concentration, and non-distraction in the present moment, rather than acting while on "automatic pilot," at 3-month post-intervention. This facet, as well as many of the items included (e.g., "I find it difficult to stay focused on what's happening in the present," "It seems I am running on automatic without much awareness of what I am doing") appear to reflect the aspects of attentional control and regulation also captured by ADHD and CDS symptoms, providing additional evidence to symptom improvements.</p> <p>Second, adolescents reported moderate-sized increases to non-judgment of themselves and their experiences at 1-month post-intervention. As with all mindfulness-based interventions, MAPs emphasizes acceptance and non-judgment balanced with behavior change ([<reflink idref="bib49" id="ref148">49</reflink>]). The acceptance-change framework is important for individuals with a range of chronic conditions who may not reasonably anticipate complete symptom remission ([<reflink idref="bib36" id="ref149">36</reflink>]), including individuals with ADHD, which is conceptualized as a lifespan disorder ([<reflink idref="bib54" id="ref150">54</reflink>]). However, there are still persistent stigmatizing views and misinformation about ADHD (e.g., individuals with ADHD are weak-willed, intentionally act out, or are lazy) that individuals with ADHD face and often internalize ([<reflink idref="bib33" id="ref151">33</reflink>]; [<reflink idref="bib45" id="ref152">45</reflink>]; [<reflink idref="bib53" id="ref153">53</reflink>]), and most interventions focus on behavior change through management of behavior by caregivers and teachers without (<reflink idref="bib1" id="ref154">1</reflink>) consideration of internalized or lived experience of the disorder ([<reflink idref="bib81" id="ref155">81</reflink>]) or (<reflink idref="bib2" id="ref156">2</reflink>) prioritizing ADHD psychoeducation ([<reflink idref="bib43" id="ref157">43</reflink>]). Thus, in conjunction with psychoeducation and reframing of ADHD included in the MAPs intervention, the use of the acceptance-change framework may be particularly helpful for adolescents with ADHD to combat any internalized stigma and low self-efficacy, and simultaneously learn to self-regulate and build independence in symptom management over time.</p> <p>The benefit of the MAPs intervention with regard to better understanding of ADHD and the non-judgment of experiences is also echoed in the qualitative feedback we received from adolescents, who emphasized learning to think about their ADHD in a new way and being able to "refocus" attention following distraction, especially when they were able to suspend judgment of themselves from losing focus to begin with. Furthermore, the rationale for the use of a group format is to promote de-stigmatization of ADHD and related difficulties through connection with others, which was also reported by several adolescents and caregivers (see Supplemental Material; [<reflink idref="bib85" id="ref158">85</reflink>]). As such, one possible trade off that should be examined in any adaptations to individual format may be less self-acceptance and/or non-judgment. It is also important to note that measured changes to non-judgment of oneself and experiences were smaller by the 3-month follow-up. Though replication with larger samples and stronger internal validity is needed, our findings might suggest that any benefit to non-judgment may have diminished over time and that booster sessions may be needed to maintain gains.</p> <hd id="AN0181053394-40">Rumination, Academic Achievement, and Executive Functioning Improvement</hd> <p>The only improvements we observed related to other aspects of functioning were for self-reported academic problems 1-month post-intervention, as well as for self-reported brooding rumination and caregiver-reported executive functioning at 3-months post-intervention. Given our lack of consistent findings across follow-up periods and our many null findings, we again emphasize the need for replication. However, these findings provide preliminary evidence of mindfulness impacting downstream academic and internalizing outcomes related to ADHD and CDS symptoms. Additionally, our findings related to brooding rumination—but not reflective rumination—may provide further context to some previously discussed findings. In parallel to our suggestion regarding the differences between deliberate and spontaneous mind-wandering, some research has indicated that reflective rumination may be more adaptive—or at least less maladaptive—compared with brooding rumination ([<reflink idref="bib72" id="ref159">72</reflink>]).</p> <hd id="AN0181053394-41">Consideration of Broader Pattern of Finding</hd> <p>More broadly, there is a noteworthy pattern to our findings that may reflect more substantive improvements to symptoms at the 3-month follow-up compared with just following completion of the MAPs intervention. Specifically, medium effects at 1-month post-intervention for adolescent-reported ADHD-IN symptoms were large by the 3-month follow-up, and there were delayed effects for caregiver-reported ADHD-IN symptoms and executive functioning, as well as for adolescent-reported ADHD-HI and CDS symptoms, our global measure of mindfulness, and the FFMQ <emph>Acting with Awareness</emph> subscale. This pattern may suggest that, at least for some outcomes (e.g., attentional awareness, self-regulation), treatment effects may not fully take hold for several months. Given the outcomes that displayed this pattern (i.e., most are for adolescents-report, all involve attentional awareness or mindfulness), findings may more specifically reflect a hierarchal pattern suggestive of improvements to core symptoms prior to improvements to mindfulness and meta-awareness skills that provide better insight into treatment gains. Results may also be evidence of continued honing and use of skills, resulting in additional gains for these outcomes. Although we did not measure frequency of mindfulness use at 3-month post-intervention, such investigation is warranted in future investigations.</p> <p>Finally, we did not observe any substantive pre- to post-intervention changes based on teacher-report, nor for many other outcome measures across caregiver- and adolescent-report. Given the limited power, these findings, like our findings in which changes were observed, should be considered preliminary. Relatedly, our use of two teachers' data to examine pre- to post-intervention changes for two of our participants may have impacted our ability to detect changes overall, especially given how small our sample was.</p> <hd id="AN0181053394-42">Limitations and Future Directions</hd> <p>As our study did not use a randomized design or treatment-control condition, we cannot rule out that any changes observed from pre- to post-intervention are due to regression to the mean, maturation, or placebo/expectation effects. Replication with larger samples using methods that prioritize internal validity (e.g., randomized control trial) and rigor (e.g., mixed models, examination of relevant interactions), examination of predictors of study-withdrawal and attendance, and predictors of treatment outcomes (e.g., quantity and quality of at-home practice, or engagement in sessions needed for improvement) are all needed before stronger conclusions can be drawn. Future research should also examine possible group differences or heterogeneity regarding ADHD, CDS, and internalizing symptoms to more directly examine the extent to which mindfulness-based interventions may each symptom domain. Finally, more research is needed on other treatment options for CDS in particular, including the investigation of cognitive behavioral therapies ([<reflink idref="bib6" id="ref160">6</reflink>]; [<reflink idref="bib7" id="ref161">7</reflink>]).</p> <hd id="AN0181053394-43">Conclusions</hd> <p>The present study examined the feasibility, acceptability, and preliminary efficacy of a mindfulness-based intervention for adolescents with ADHD and CDS symptoms. Our findings are promising, as they suggest that (<reflink idref="bib1" id="ref162">1</reflink>) mindfulness may be feasible to implement despite difficulties in scheduling and attendance for adolescents and for individuals with ADHD, (<reflink idref="bib2" id="ref163">2</reflink>) adolescents with ADHD and their caregivers view mindfulness as an important and applicable intervention for the management of ADHD, and (<reflink idref="bib3" id="ref164">3</reflink>) mindfulness may improve adolescent ADHD and CDS symptoms and rumination, executive functioning, and academic difficulties. Finally, our qualitative analysis of adolescent and caregiver perspectives provide direction for MAPs adaptation for adolescents with ADHD and CDS to make treatment more engaging and feasible for families.</p> <hd id="AN0181053394-44">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-jad-10.1177_10870547241290182 for Mindful Awareness Practices (MAPs) in Adolescents With ADHD and Cognitive Disengagement Syndrome (CDS): A Pilot Open Trial by Kelsey K. Wiggs, Keely Thornton, Nicholas C. Dunn, John T. Mitchell, Joseph W. Fredrick, Zoe R. Smith and Stephen P. Becker in Journal of Attention Disorders</p> <ref id="AN0181053394-45"> <title> References </title> <blist> <bibl id="bib1" idref="ref75" type="bt">1</bibl> <bibtext> Baer R. A., Smith G. T., Hopkins J., Krietemeyer J., Toney L. (2006). Using self-report assessment methods to explore facets of mindfulness. 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Pediatrics, 144(4), e20192528.</bibtext> </blist> <blist> <bibtext> Wolraich M. L., Lambert W., Doffing M. A., Bickman L., Simmons T., Worley K. (2003). Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of Pediatric Psychology, 28(8), 559–568.</bibtext> </blist> <blist> <bibtext> Zhang D., Lee E. K., Mak E. C., Ho C., Wong S. Y. (2021). Mindfulness-based interventions: An overall review. British Medical Bulletin, 138(1), 41–57.</bibtext> </blist> <blist> <bibtext> Zylowska L., Ackerman D. L., Yang M. H., Futrell J. L., Horton N. L., Hale T. S., Pataki C., Smalley S. L. (2008). Mindfulness meditation training in adults and adolescents with ADHD: A feasibility study. Journal of Attention Disorders, 11(6), 737–746.</bibtext> </blist> <blist> <bibtext> Zylowska L., Mitchell J. T. (2020). Mindfulness for adult ADHD: A clinician's guide. Guilford Publications.</bibtext> </blist> </ref> <ref id="AN0181053394-46"> <title> Footnotes </title> <blist> <bibtext> The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JTM acknowledges research support, consulting, and/or royalties over the past 2 years from Guilford Press, Lumos Labs, Akili Interactive, MindFit, and Keller Postman LLC. SPB acknowledges editorial honorarium from the Association of Child and Adolescent Mental Health (ACAMH), royalties from Guilford Press, and educational seminar speaking fees and continuing education course royalties from J&K Seminars and from PESI, Inc. The remaining authors have no conflicts of interest to report.</bibtext> </blist> <blist> <bibtext> The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research, and Dr. Wiggs' effort while preparing this manuscript, was supported by the National Research Service Award in Primary Medical Care, T32HP10027, through the Health Resources and Services Administration. This research was also supported by a Cincinnati Children's Research Foundation Endowed Scholar Award to Dr. Becker. The use of REDCap in this project was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH), under Award Number 5UL1TR001425-04.</bibtext> </blist> <blist> <bibtext> Kelsey K. Wiggs</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-8013-7925 John T. Mitchell</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-9586-3823 Joseph W. Fredrick</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0003-4617-8552 Stephen P. Becker</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0001-9046-5183</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> <blist> <bibtext> We conducted a post-hoc analysis in consideration of our qualitative findings suggesting minimal benefit to CDS hypoactive symptoms compared to CDS daydreaming/mental confusion symptoms. The overall pattern of findings was the same, though the magnitude of effects for adolescent-reported CDS was slightly larger once hypoactive symptoms were excluded (though still medium in size; see https://journals.sagepub.com/doi/suppl/10.1177/10870547241290182).</bibtext> </blist> </ref> <aug> <p>By Kelsey K. Wiggs; Keely Thornton; Nicholas C. Dunn; John T. Mitchell; Joseph W. Fredrick; Zoe R. Smith and Stephen P. Becker</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author</p> <p></p> <p>Kelsey K. Wiggs, Ph.D., recently transitioned from a Post-Doctoral T32 Research Fellow in the Divisions of General and Community Pediatrics and Behavioral Medicine and Clinical Psychology at Cincinnati Children's Hospital Medical Center to an Assistant Professor in the Department of Psychiatry at Indiana University School of Medicine. Her research broadly focuses on the predictors, correlates, and treatment of attention-deficit/hyperactivity disorder and cognitive disengagement syndrome.</p> <p>Keely Thornton is a Clinical Research Coordinator at the Center for ADHD at Cincinnati Children's Hospital. Her research interests include the heterogeneity of ADHD and its unique associations with internalizing psychopathology.</p> <p>Nicholas C. Dunn is a Clinical Research Coordinator at the Center for ADHD at Cincinnati Children's Hospital. His research interests focuses on the relationship between individual differences in self-regulation and outcomes among individuals with attention-deficit/hyperactivity disorder.</p> <p>John T. Mitchell is an Associate Professor of Psychiatry and Behavioral Sciences at Duke University School of Medicine and the Duke ADHD Program. His research interests include ADHD across the lifespan and treatment development, including the application of mindfulness-based interventions for ADHD.</p> <p>Joseph W. Fredrick is an Assistant Professor of Pediatrics in the Division of Behavioral Medicine and Clinical Psychology at Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine. His research interests focus on assessment and intervention of cognitive disengagement syndrome in children and adolescents with ADHD.</p> <p>Zoe R. Smith is an Assistant Professor of Psychology at Loyola University Chicago. Her research focuses on creating culturally responsive assessments for Black and/or Latiné adolescents with ADHD. She also focuses on how to develop interventions for youth with ADHD and/or CDS. Her research is funded by the Robert Wood Johnson Foundation.</p> <p>Stephen P. Becker is Professor of Pediatrics, Endowed Chair, Director of Research, and Co-Director of the Center for ADHD in the Division of Behavioral Medicine and Clinical Psychology at Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine. His research, funded by the National Institute of Mental Health (NIMH) and the Institute of Education Sciences (IES), focuses on cognitive disengagement syndrome and sleep in youth with and without ADHD.</p> </aug> <nolink nlid="nl1" bibid="bib10" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib12" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib63" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib19" firstref="ref18"></nolink> <nolink nlid="nl5" bibid="bib70" firstref="ref19"></nolink> <nolink nlid="nl6" bibid="bib77" firstref="ref24"></nolink> <nolink nlid="nl7" bibid="bib57" firstref="ref25"></nolink> <nolink nlid="nl8" bibid="bib69" firstref="ref26"></nolink> <nolink nlid="nl9" bibid="bib55" firstref="ref28"></nolink> <nolink nlid="nl10" bibid="bib27" firstref="ref29"></nolink> <nolink nlid="nl11" bibid="bib30" firstref="ref30"></nolink> <nolink nlid="nl12" bibid="bib47" firstref="ref33"></nolink> <nolink nlid="nl13" bibid="bib46" firstref="ref35"></nolink> <nolink nlid="nl14" bibid="bib54" firstref="ref37"></nolink> <nolink nlid="nl15" bibid="bib11" firstref="ref40"></nolink> <nolink nlid="nl16" bibid="bib37" firstref="ref41"></nolink> <nolink nlid="nl17" bibid="bib36" firstref="ref42"></nolink> <nolink nlid="nl18" bibid="bib41" firstref="ref44"></nolink> <nolink nlid="nl19" bibid="bib83" firstref="ref45"></nolink> <nolink nlid="nl20" bibid="bib35" firstref="ref47"></nolink> <nolink nlid="nl21" bibid="bib65" firstref="ref50"></nolink> <nolink nlid="nl22" bibid="bib73" firstref="ref51"></nolink> <nolink nlid="nl23" bibid="bib74" firstref="ref52"></nolink> <nolink nlid="nl24" bibid="bib17" firstref="ref54"></nolink> <nolink nlid="nl25" bibid="bib34" firstref="ref55"></nolink> <nolink nlid="nl26" bibid="bib40" firstref="ref56"></nolink> <nolink nlid="nl27" bibid="bib49" firstref="ref57"></nolink> <nolink nlid="nl28" bibid="bib15" firstref="ref59"></nolink> <nolink nlid="nl29" bibid="bib23" firstref="ref61"></nolink> <nolink nlid="nl30" bibid="bib21" firstref="ref62"></nolink> <nolink nlid="nl31" bibid="bib22" firstref="ref63"></nolink> <nolink nlid="nl32" bibid="bib84" firstref="ref64"></nolink> <nolink nlid="nl33" bibid="bib26" firstref="ref65"></nolink> <nolink nlid="nl34" bibid="bib28" firstref="ref70"></nolink> <nolink nlid="nl35" bibid="bib29" firstref="ref71"></nolink> <nolink nlid="nl36" bibid="bib76" firstref="ref72"></nolink> <nolink nlid="nl37" bibid="bib39" firstref="ref77"></nolink> <nolink nlid="nl38" bibid="bib14" firstref="ref78"></nolink> <nolink nlid="nl39" bibid="bib60" firstref="ref79"></nolink> <nolink nlid="nl40" bibid="bib38" firstref="ref80"></nolink> <nolink nlid="nl41" bibid="bib68" firstref="ref81"></nolink> <nolink nlid="nl42" bibid="bib85" firstref="ref82"></nolink> <nolink nlid="nl43" bibid="bib56" firstref="ref91"></nolink> <nolink nlid="nl44" bibid="bib42" firstref="ref92"></nolink> <nolink nlid="nl45" bibid="bib66" firstref="ref93"></nolink> <nolink nlid="nl46" bibid="bib71" firstref="ref94"></nolink> <nolink nlid="nl47" bibid="bib13" firstref="ref95"></nolink> <nolink nlid="nl48" bibid="bib61" firstref="ref99"></nolink> <nolink nlid="nl49" bibid="bib82" firstref="ref100"></nolink> <nolink nlid="nl50" bibid="bib80" firstref="ref101"></nolink> <nolink nlid="nl51" bibid="bib20" firstref="ref102"></nolink> <nolink nlid="nl52" bibid="bib50" firstref="ref104"></nolink> <nolink nlid="nl53" bibid="bib16" firstref="ref106"></nolink> <nolink nlid="nl54" bibid="bib75" firstref="ref108"></nolink> <nolink nlid="nl55" bibid="bib58" firstref="ref109"></nolink> <nolink nlid="nl56" bibid="bib32" firstref="ref110"></nolink> <nolink nlid="nl57" bibid="bib18" firstref="ref112"></nolink> <nolink nlid="nl58" bibid="bib24" firstref="ref113"></nolink> <nolink nlid="nl59" bibid="bib31" firstref="ref114"></nolink> <nolink nlid="nl60" bibid="bib72" firstref="ref115"></nolink> <nolink nlid="nl61" bibid="bib48" firstref="ref116"></nolink> <nolink nlid="nl62" bibid="bib25" firstref="ref117"></nolink> <nolink nlid="nl63" bibid="bib44" firstref="ref118"></nolink> <nolink nlid="nl64" bibid="bib64" firstref="ref119"></nolink> <nolink nlid="nl65" bibid="bib59" firstref="ref121"></nolink> <nolink nlid="nl66" bibid="bib52" firstref="ref123"></nolink> <nolink nlid="nl67" bibid="bib67" firstref="ref141"></nolink> <nolink nlid="nl68" bibid="bib78" firstref="ref143"></nolink> <nolink nlid="nl69" bibid="bib51" firstref="ref144"></nolink> <nolink nlid="nl70" bibid="bib79" firstref="ref145"></nolink> <nolink nlid="nl71" bibid="bib62" firstref="ref146"></nolink> <nolink nlid="nl72" bibid="bib33" firstref="ref151"></nolink> <nolink nlid="nl73" bibid="bib45" firstref="ref152"></nolink> <nolink nlid="nl74" bibid="bib53" firstref="ref153"></nolink> <nolink nlid="nl75" bibid="bib81" firstref="ref155"></nolink> <nolink nlid="nl76" bibid="bib43" firstref="ref157"></nolink>
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  Group: Ti
  Data: Mindful Awareness Practices (MAPs) in Adolescents with ADHD and Cognitive Disengagement Syndrome (CDS): A Pilot Open Trial
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  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Kelsey+K%2E+Wiggs%22">Kelsey K. Wiggs</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-8013-7925">0000-0002-8013-7925</externalLink>)<br /><searchLink fieldCode="AR" term="%22Keely+Thornton%22">Keely Thornton</searchLink><br /><searchLink fieldCode="AR" term="%22Nicholas+C%2E+Dunn%22">Nicholas C. Dunn</searchLink><br /><searchLink fieldCode="AR" term="%22John+T%2E+Mitchell%22">John T. Mitchell</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-9586-3823">0000-0002-9586-3823</externalLink>)<br /><searchLink fieldCode="AR" term="%22Joseph+W%2E+Fredrick%22">Joseph W. Fredrick</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-4617-8552">0000-0003-4617-8552</externalLink>)<br /><searchLink fieldCode="AR" term="%22Zoe+R%2E+Smith%22">Zoe R. Smith</searchLink><br /><searchLink fieldCode="AR" term="%22Stephen+P%2E+Becker%22">Stephen P. Becker</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-9046-5183">0000-0001-9046-5183</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Attention+Disorders%22"><i>Journal of Attention Disorders</i></searchLink>. 2025 29(2):83-100.
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  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
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  Data: Y
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  Group: Src
  Data: 18
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  Label: Publication Date
  Group: Date
  Data: 2025
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  Group: SrcSuprt
  Data: Health Resources and Services Administration (HRSA) (DHHS)<br />National Center for Advancing Translational Sciences (NCATS) (DHHS/NIH)
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  Label: Contract Number
  Group: NumCntrct
  Data: T32HP10027<br />5UL1TR00142504
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  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Metacognition%22">Metacognition</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Attention+Deficit+Hyperactivity+Disorder%22">Attention Deficit Hyperactivity Disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Cognitive+Processes%22">Cognitive Processes</searchLink><br /><searchLink fieldCode="DE" term="%22Attention+Deficit+Disorders%22">Attention Deficit Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Attention+Control%22">Attention Control</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Characteristics%22">Student Characteristics</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink><br /><searchLink fieldCode="DE" term="%22Group+Therapy%22">Group Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Individual+Development%22">Individual Development</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/10870547241290182
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1087-0547<br />1557-1246
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: Very few studies have investigated intervention approaches that may be efficacious for youth with ADHD and co-occurring cognitive disengagement syndrome (CDS) symptoms. This study examined the feasibility, acceptability, and preliminary efficacy of a mindfulness-based intervention for adolescents with ADHD and co-occurring CDS symptoms. Methods: Fourteen adolescents ages 13 to 17 years (35.71% female; 64.29% White, 7.14% Black, 28.57% Multiracial) with ADHD and elevated CDS symptoms completed the 8-week group-based Mindful Awareness Practices (MAPs) program developed for individuals with ADHD. We collected measures of CDS, ADHD, mind-wandering, mindfulness, and other difficulties and functioning at baseline, 1-month post-intervention, and 3-month post-intervention to examine preliminary efficacy. We measured participant session attendance, session engagement, at-home practice adherence, and satisfaction of adolescents and caregivers at 1-month post-intervention to examine feasibility and acceptability. We also collected qualitative feedback from adolescents and caregivers at 1-month post-intervention. Results: The intervention was overall feasible to administer, and caregivers and adolescents reported satisfaction with the intervention despite some difficulties with attendance and engagement. We observed improvements to both caregiver- and adolescent-reported CDS symptoms and ADHD-inattentive symptoms from pre-intervention to post-intervention time points, though findings across 1- and 3-month follow-up differed based on informant. We also observed improvements to some indices of adolescent-reported mind-wandering, mindfulness, brooding rumination, and academic functioning. For caregiver report, the only other noted improvement was for executive functioning. No improvements were reported by teachers. Conclusions: Findings support the initial feasibility, acceptability, and preliminary efficacy of MAPs for adolescents with ADHD and co-occurring CDS symptoms on a range of outcomes. Larger trials with a randomized design are warranted to further examine mindfulness-based interventions for adolescents with ADHD and co-occurring CDS symptoms.
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  Label: Entry Date
  Group: Date
  Data: 2024
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  Label: Accession Number
  Group: ID
  Data: EJ1450843
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        Value: 10.1177/10870547241290182
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      – Text: English
    PhysicalDescription:
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        PageCount: 18
        StartPage: 83
    Subjects:
      – SubjectFull: Metacognition
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Attention Deficit Hyperactivity Disorder
        Type: general
      – SubjectFull: Cognitive Processes
        Type: general
      – SubjectFull: Attention Deficit Disorders
        Type: general
      – SubjectFull: Attention Control
        Type: general
      – SubjectFull: Student Characteristics
        Type: general
      – SubjectFull: Outcomes of Treatment
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      – SubjectFull: Group Therapy
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      – SubjectFull: Individual Development
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      – SubjectFull: Program Effectiveness
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      – TitleFull: Mindful Awareness Practices (MAPs) in Adolescents with ADHD and Cognitive Disengagement Syndrome (CDS): A Pilot Open Trial
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              Y: 2025
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