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17

Mindful Awareness and ADHD

L. Zylowska, S.L. Smalley, and J.M. Schwartz

The faculty of voluntarily bringing back a wandering attention over

and over again, is the very root of judgment, character, and will. No

one is compos sui (master of himself) if he have it not. An educa-

tion which should improve this faculty would be the education par

excellence. But it is easier to define this ideal than to give practical

instructions for bringing it about.

William James, 1890

Introduction

One of our most important faculties is attention. It is a doorway into our

experience and a foundational quality of our awareness. Where and how we

place our attention or where and how other things grab our attention deter-

mines our daily experiences, relationships with ourselves and others, and the

quality of our lives. This connection between the ability to regulate attention

and well-being is profoundly exemplified in mindfulness or mindful aware-

ness, and a neuropsychiatric condition called attention-deficit hyperactivity

disorder (ADHD). In both, the role of attention is thought to be crucial to the

self-regulation of cognition, emotion, and behavior, and while ADHD may be

considered a disorder characterized by difficulties in self-regulation, mindful

awareness training maybe considered a tool of enhancing self-regulation. This

chapter outlines the theoretical framework for how mindful awareness train-

ing can be applied to treat different facets of ADHD as informed by cognitive-

affective neuroscience and our own experiences with a mindfulness-based

program for ADHD, appropriate for adults and teens, called mindful aware-

ness practices (MAPs) for ADHD.

Attention Deficit Hyperactivity Disorder

ADHD is a behaviorally defined condition characterized by a clustering of

symptoms of inattention (e.g., “difficulty following tasks,” “forgetful”) and/or

hyperactivity and impulsivity (e.g., “fidgety,” “difficulty remaining seated”)

with onset by seven years of age and impairment in at least two settings
(APA,

1994).
Currently, three subtypes of ADHD are recognized: primarily inattentive (50–75%), primarily hyperactive/impulsive (20–30%), and a combined

subtype (less than 15%)
(Wilens, Biederman, & Spencer, 2002).
Prevalence rates vary from 2 to 16% but with a majority of estimates falling between 5

and 10% of children and adolescents and 4% of adults
(Kessler et al., 2006;

319

320

L. Zylowska, S.L. Smalley, and J.M. Schwartz

Skounti, Philalithis, & Galanakis, 2007).
From early age, diagnosis of ADHD

is associated with a wide variety of comorbid conditions including disrup-

tive behavior disorders (oppositional defiant and conduct disorder), anxiety

and/or mood disorders, and substance abuse/dependence
(Cantwell, 1996;

McGough et al., 2005).
In addition to psychiatric comorbidity, individuals with ADHD often have comorbid disorders of learning and social–emotional

development, including dyslexia, executive function deficits, and social prob-

lems (including elevated rates of autism spectrum disorders) (Biederman

et al.,
2004;
Clark, Feehan, Tinline, & Vostanis, 1999;
Loo et al., 2007).

Etiology of ADHD

The disorder is heterogeneous in presentation and etiology: genetic,

neurobehavioral, psychosocial and environmental influences have all been

identified as influential in the development and variability of ADHD. While

environmental risk factors such as low birth weight, maternal smoking

during pregnancy, lead exposure, and socioeconomic status are important,

a biological predisposition is perhaps most salient
(Nigg, 2003;
Zuddas, Ancilletta, Muglia, & Cianchetti,
2000).
Family, twin, and adoption studies show that ADHD and its component behaviors of inattention, hyperactivity, and impulsivity are highly heritable, with estimates of heritability on

the order of 76%
(Faraone et al., 2005).
Genes involved in brain neuro-

transmission (e.g., dopamine, serotonin, norepinephrine, and cannabinoids)

(Faraone, Biederman, & Mick
,
2006;
Lu et al., 2008) are implicated. Several brain regions (e.g., prefrontal cortex, amygdala, cerebellum, basal ganglia)

show functional and/or structural differences in ADHD individuals as com-

pared to non-ADHD controls
(Bush, Valera, & Seidman, 2005).
Certain brain regions involved in ADHD are also implicated in self-control or self-regulation

(Berger, Kofman, Livneh, & Henik, 2007;
Nigg & Casey, 2005).
Increasingly, ADHD is understood as a disorder with varied genetic, developmental and

environmental underpinnings that results in difficulties in self-regulatory

abilities.

It should be noted that although ADHD is a categorically defined condi-

tion (i.e., either the diagnosis is present or absent), the continuous nature

of the behavioral dimensions of inattention and hyperactivity-impulsivity is

well recognized (Smalley, 2008a;
Swanson et al., 2001).
It may be appropriate to think of ADHD as an extreme along a population continuum of variability along these behavioral dimensions, much in the same way that we now

recognize dyslexia as an extreme along a continuum of reading ability, or

diabetes as an extreme along a continuum of glucose tolerance. Neurobio-

logical research over the last several decades has led to an improved under-

standing of the likely etiological factors that contribute to liability in ADHD.

Three inter-related broad areas—attention/cognition, affect, and stress reac-

tivity show differences in ADHD and likely play a role in its etiology. These

areas are likely to underlie many of the observed self-regulatory difficulties in

ADHD and are discussed as mechanisms by which mindful awareness train-

ing may be helpful in this condition (reviewed subsequently).

Chapter 17 Mindful Awareness and ADHD

321

Current Treatment Modalities in ADHD

A variety

of treatments have been investigated

in ADHD includ-

ing: psychotropic medications (stimulants and non-stimulants), psychoso-

cial treatments (behavioral therapy, cognitive-behavioral therapy, fam-

ily therapy, social skills training), individual psychotherapy, coaching,

and complementary and alternative approaches (neurofeedback, dietary

changes, supplements, and mind-body interventions)
(Arnold, 2001).
The

standard treatment for ADHD, involves medications, behavioral therapy or

both
(Jensen et al., 2007).
Stimulant medications are considered “best practice” in the treatment of ADHD across the lifespan
(Dodson, 2005).
While clearly helpful for many ADHD individuals, as many as 20–30% of children

and adolescents and perhaps 50% of adults are considered non-responders

because of insufficient reduction in symptoms or intolerable side effects

(Shekim, Asarnow, Hess, Zaucha, & Wheeler, 1990;
Wender, 1998).
Importantly, many parents or adults with ADHD dislike the use of medication for

various reasons, and desire alternative forms of treatment.

Novel Self-Regulatory Approaches

Novel non-pharmacological treatment strategies that target neurocognition

and/or build self- awareness and self-regulatory capacities are of increasing

interest in ADHD. Although still limited, recent studies of such treatments

support the utility of such approaches. In children and adults, examples of

such studies include a working memory training program
(Klingberg et al.,

2005),
and attention training programs including ones using neurofeedback

(Beauregard & Levesque, 2006).
In adults, additional approaches that build greater “self-awareness” capacities include individual psychotherapy (Rostain & Ramsay,
2006),
cognitive-behavioral therapy
(Safren et al., 2005),

metacognitive training (using metaphors to describe ADHD brain and behav-

ior patterns)
(Wasserstein & Lynn, 2001),
Cognitive Remediation Program (remediation of skill deficits in planning and organization) (Stevenson, Whitmont, Bornholt, Livesey, & Stevenson,
2002)
and coaching
(ADDA, 2002).

Meditation has been proposed as a promising complementary/alternative

treatment for ADHD
(Arnold, 2001)
and a few early studies investigated its effectiveness in this population. Two unpublished pilot studies (
n
= 23–24)

looked at the use of meditation in children 12 years of age and younger

(type of meditation unspecified). Both studies supported the utility of medi-

tation for improving behavior in ADHD
(Kratter, 1983;
Moretti-Altuna, 1987).

Another pilot study (
n
= 8) with ADHD adults investigated effects of a

structured skills training program based on the principles of dialectical

behavioral therapy
(Hesslinger et al., 2002)
which includes teaching in mindfulness skills (done without a formal meditation training). Improvements in

ADHD and depression symptoms as well as attentional tests were found in

the treatment group compared to a wait list control; however, interpretation

of findings is limited due to small sample size and high drop out rate. Lit-

tle is yet know regarding how meditation or mindfulness practices can be

used in the ADHD population across the lifespan. Our group recently com-

pleted a feasibility study of a mindfulness-based training in a group of ADHD

322

L. Zylowska, S.L. Smalley, and J.M. Schwartz

adults (
n
= 25) and adolescents (
n
= 8). An 8-week training called mindful

awareness practices for ADHD (MAPs for ADHD; see description in section to

follow) was tested in an open label study with pre- and post-assessments of

ADHD symptoms, symptoms of mood and anxiety, perceived stress, mind-

fulness and measures of neurocognition (attention, inhibition, and work-

ing memory). Several of the self-report scales (ADHD, anxiety, depression,

stress and mindfulness measures) were also collected at 3 months after the

training. The study and its initial results are described in detail elsewhere

(Zylowska et al., 2008). Overall, the study found good program adherence

rate and high satisfaction among the participants. Pre-post training compar-

isons showed significant (
p <
0. 01) reductions in self-reported ADHD, anx-

iety, and depressive symptoms as well as measures of conflict attention and

attentional set-shifting. In addition, (unpublished data) significant (
p <
0. 01)

improvements were found in measures of perceived stress and mindful-

ness. At a 3-month follow-up, additional improvements were reported in

ADHD symptoms with no changes (e.g., no additional improvement or loss

of improvement) in anxiety, depression, mindfulness, or stress. The study

demonstrated that mindfulness-based training is a feasible intervention in a

subset of ADHD adults and adolescents and may improve behavioral and neu-

rocognitive impairments.

Mindful Awareness: Overview

The term
mindful awareness
or
mindfulness
has been used in different

contexts and can denote different things: a quality of awareness or atten-

tion, a mental mode or process, a psychological trait, a specific meditative

technique, a collection of techniques, or an outcome of the practice itself