Clinical Handbook of Mindfulness (92 page)

tation, starting with an imagery of a loved person is used to practice cultiva-

tion of positive emotional states. The participants are asked to pay attention

to positive and negative emotions throughout their week.

Session VII: Open awareness of all present-moment experiences is prac-

ticed. Parallels are drawn to different attentional aspects (e.g., alerting, ori-

enting, conflict attention) and participants are asked to notice the quality of

330

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

their attention frequently throughout the day (fostering “meta-attention”). As

difficulties in social interactions and social awareness are frequently found

in ADHD including not listening, interrupting, talking too much, blurting

out answers, or being distracted in a conversation, this session also teaches

mindful listening and mindful speech. In one exercise, one partner is the

sole speaker while the other one is the sole listener bringing awareness to

one’s automatic responses or impulsive urges to interrupt. The participants

are asked to practice mindful listening with a friend or a spouse.

Session VIII: The mindful awareness concepts and practices are reviewed

and resources for a continuous mindful awareness practice are provided. Par-

ticipants comment on what they learned in the process of the class during

a “speaking council” exercise in which everyone has a chance to comment

about their experience. Learning mindfulness is framed as life-long process

of checking in with one’s attention, renewing the intention to return to

the present moment, and applying the acceptance-change dialectic in each

day. Environmental modifications derived from ADHD coaching and CBT

approaches are reviewed to help remember to be mindful or practice loving-

kindness such as visual reminders, using a habitual activity as a reminder to

be mindful (e.g., associating the act of turning on a computer with becom-

ing mindful), e-mail reminders to be mindful, using electronic organizers as

reminders, having a friend or a spouse as a mindfulness-coach, and attending

an on-going meditation group or periodic workshops/retreats. We encourage

practice by highlighting “how long it takes to develop a new skill” in general

(e.g., it takes 50 h to learn harmonica or 1,200 h to learn play a violin) (Stray-

horn,
2002).

Case Studies of Participants in the MAPs for ADHD

Program

Mrs. X is a writer in her forties. Diagnosed with ADHD as a young child,

she was briefly treated with the stimulant medication Ritalin but her par-

ents, weary of using medications, discontinued the stimulant after several

months. Since then, she coped without treatment and was able to finish

college (although she took a two extra years to do so). She worked from

home and was able to pursue a writing career, but frequently doubted her

abilities as a writer and suffered from intermittent depression and anxiety.

She complained of difficulties with concentration, had problems organizing

her day, was forgetful, and frequently did not follow-through on projects.

She reported having many exciting ideas but not being able to organize

her thoughts enough to produce a screenplay. She frequently felt over-

whelmed by attention requiring tasks. When unable to accomplish what

she set out to do in a day, she often berated herself for being lazy or inept.

She was re-motivated for treatment after her 10-year-old son was diagnosed

with ADHD. She was diagnosed with generalized anxiety disorder, major

depression and likely ADHD-inattentive subtype. The initial treatment with

an anti-depressant helped with depression and anxiety but she continued to

complain of disorganization and inattentiveness. Several ADHD medications

were tried but they either exacerbated Mrs. X’s anxiety or were ineffective.

Consequently, Mrs. X decided to pursue non-medication approaches to help

Chapter 17 Mindful Awareness and ADHD

331

with her ADHD symptoms and she enrolled in the MAPs for ADHD program.

During the training she was relieved to learn that he could start with 5 min

of sitting practice and bring mindful awareness to any experience includ-

ing distractions or impatience. She found loving-kindness exercises particu-

larly helpful and when reactive self-criticisms arose during her ADHD-related

difficulties she was able to distance herself from the criticisms. She found

that when she did not over-react, she could problem-solve and organize her

work more effectively. After the training, she also reported a better ability to

concentrate and to accomplish tasks. She stated “the idea that you can see

yourself getting distracted and then you can bring yourself back was prob-

ably the most pivotal thing, just like the experience of practicing it in the

meditation—going off and then coming back. So, when I’m aware now that

I’m distracting myself from a task, I’m able to see it better and get back to it

sooner.”

Mr. Y is a 16-year-old teenager diagnosed with ADHD-Combined Type

(i.e., both inattentive and hyperactive symptoms) at age 10 y/o. He has been

taking stimulants such as amphetamine or methylphenidate since the diagno-

sis, which he reported as helpful for paying attention in school and doing his

homework. However, even when taking his medications, he still endorsed

having periods inattention and restlessness, and frequently needed to get up

out of his seat. He also described “freaking out” when he forgot to take his

medication because he couldn’t seem to focus at all and felt especially irri-

table and moody as a side effect of discontinuing the medication. During

the MAP training sessions, he found himself needing to get up even during

5-min meditations but learned to use walking meditation as a way to con-

tinue the formal practice for the required duration. He attended most MAPs

for ADHD sessions and reported that while his formal practice at home was

irregular (5–10 min twice per week) he had been frequently applying mind-

ful awareness throughout his day. He gave examples of being mindful of his

body moving during a soccer practice and being more aware of his emotions

and thoughts during an argument with his friend. He was noticing his hyper-

critical thoughts more readily and found that without berating himself, he

was more motivated to “try again.” He kept a post-it note at his computer

reminding him to “breathe” and used a cell phone reminder at lunchtime

to “eat more mindfully.” Overall, he felt more empowered to be able “to do

something for my ADHD.” He found that it was easier to regulate his mood

and his attention when he forgot his medication. She stated: “whenever I

get distracted
. . .
I can put myself back in the thing
. . .
whenever I can feel my

mind wandering, I am able to realize that it’s wandering and let go of the

feeling.”

Future Directions

ADHD is a complex trait that arises in childhood but continues throughout

the lifespan in a majority of individuals. It is highly heritable but the likely

interactions of genes and environmental influences that shape its develop-

ment are only now beginning to be understood. ADHD may be thought of as

an extreme along continua of variability of affect and cognitive processes

in the population that alone, or in combination, result in self-regulation

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

impairment associated with ADHD. We believe mindful awareness training

(such as our MAPs for ADHD) can strengthen self-regulatory capacities and

potentially alter the neurobiological impairments of individuals affected with

ADHD as well as those “at risk” for it (based on familial loading of ADHD or

in the future, detectable risk genes). Overall, mindful awareness training can

be a valuable approach in a comprehensive treatment of ADHD across the

lifespan by balancing medication treatment of biological vulnerability with

tools to enhance individual ability for self-regulation.

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