Breathing techniques, anxiety, and ADHD

Q: Hi Dr. Nowell, 

I’m working on the PESI ADHD certification, and am enjoying your presentation a lot.

I did want to reach out regarding the breathing technique you mentioned that involved breath holding. My colleague and I have recently been undergoing an extensive lit review to try to find support for these techniques, which are popular these days, but have come up without much on the empirical front. (We were more looking at it due to people recommending it for panic attacks and anxiety, but then I saw you mention it in your presentation as well). We have found ample support for diaphragmatic breathing techniques, but not for those involving breath holding. We’ve read people’s explanations that it stimulates the vagal response, but haven’t found any actual studies supporting this.

Do you know of any empirical studies supporting this technique?

A: Thanks for your email!
I’m not aware of studies of the efficacy of breathing techniques on core ADHD symptoms (and maybe wouldn’t predict such?) but do find an abundance of research on “breathing interventions” on indices such as self-reported mood and anxiety. Some studies make use of HRV as a dependent variable.
What I do not see is a clear manualized intervention. I.e, what specific breathing strategies are evidence-based? One study used an intervention vaguely defined as “Taking deep breaths before a timed math test.
I don’t see research on “holding” versus “not holding” strategies but I have met with some resistance in workshops to holding strategies due to concern that holding the breath is ill-advised (?) unless maybe one is swimming (?)
So in the workshop I offer several breathing techniques, two of which do not involve holding the breath. Would love to be able to point to a detailed manualized breathing intervention for anxiety/self regulation.
Re: vagal nerve stimulation, I offer the following (with a box of aspirin tablets, as Blanche Dubois says):

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