Clinical Handbook of Mindfulness (90 page)

(Bishop et al., 2004;
Brown & Ryan, 2003;
Hayes & Shenk, 2004;
Schwartz

& Begley,
2002; Segal, Williams, & Teasdale, 2002).
In discussing the application of mindfulness to ADHD, we focus on “mindful awareness” as meta-

awareness,
(Teasdale et al., 2000)
a quality of consciousness that has a regulatory (observing and correcting) function on the rest of the one’s experience

and leads to improved cognitive-emotional and behavioral self-regulation

(Brown & Ryan, 2003;
Brown, Ryan, & Creswell, 2007). We believe that mindful awareness can be fostered in diverse ways (meditation or non-meditation

tools) and in our program we use psychoeducation and formal (sitting and

walking meditation) and informal (mindfulness in daily life) practices as ways

to train mindful awareness.

There are many definitions of self-regulation, either as a unitary con-

cept, or as its components of emotional regulation, cognitive regulation

or behavioral regulation. Terms such as impulse control, inhibition, self-

control, self-management, self-correction or independence have been used

to describe aspects of self-regulation. It can be said that self-regulation is cen-

tral to being a human being, a mark of one’s ability to execute a choice,

self-correct and over-ride pre-potent responses that can come from genet-

ics/biology, intrauterine environmental influences, and/or or early learning.

While self-regulation capacities are a result of a combination of tempera-

ment, cognitive processing styles, parenting, and environment, humans can

learn to self-regulate through active (or effortful) engagement of higher cor-

Chapter 17 Mindful Awareness and ADHD

323

tical functions involved in cognitive and emotional regulation (Ochsner &

Gross,
2005; Schwartz, Gullifor, Stier, & Thienemann, 2005a).
In this context, mindful awareness could be seen as a specific quality of attention and

intention
(Bishop et al., 2004;
Brown & Ryan, 2003;
Shapiro, 1982)
that leads to monitoring and modulation of cognition, emotion and behavior

resulting in improved awareness and flexibility in responding. The processes

involved in this regulatory function have been diversely described including

de-centering, de-automatization
(Teasdale, Segal, & Williams, 2003),
exposure
(Baer, 2003),
attention regulation to the present moment and adop-

tion of open and accepting attitude
(Bishop et al., 2004;
Hayes, Follette,

& Linehan,
2004;
Kabat-Zinn, 1990),
and an impartial spectator stance

(Schwartz & Beyette, 1997).

Below we outline how training in mindful awareness may impact aspects

of self-regulation in ADHD namely attention/cognition, emotion, and stress

management and potentially lead to functional/structural brain changes.

While we recognize that 1) emotional regulation involves conflict or exec-

utive attention or cognitive control
(Hariri, Bookheimer, & Mazziotta, 2000;

Ochsner & Gross, 2005);
2) affective states or stress can influence attention
(Davidson, Amso, Anderson, & Diamond, 2006);
and 3) stress response is likely related to one’s cognitive-emotional regulation capacities (Urry

et al.,
2006),
we discuss these domains separately to emphasize affect and stress as the so far under-emphasized dimensions in ADHD and targets for

mindfulness-based approaches.

Mindful Awareness as an Attention/Cognition Regulation

Tool in ADHD

In ADHD, impairments in four cognitive processes are fairly consistently

found to show deficits: language processing (e.g., verbal fluency, reading,

spelling), working memory, inhibition (the ability to inhibit a response), and

attention
(Barkley
,
1997;
Nigg, Blaskey, Stawicki, & Sachek, 2004;
Seidman,

2006;
Verte, Geurts, Roeyers, Oosterlaan, & Sergeant, 2006).
Several of these cognitive processes are known to work together in forming executive function, defined as the ability to plan ahead, set goals, and execute upon such

goals. Executive function (a concept closely related to the idea of cognitive

control) is frequently compromised in ADHD and it also a key component

in development of self-regulation; a process that begins to emerge at around

3 years of age and continues development through adolescence into early

adulthood
(Davidson et al., 2006; Diamond, 2002).
Reviews of imaging studies investigating brain differences in ADHD
(Bush et al., 2005)
show under-active prefrontal cortical functioning on executive function tasks along with

differences in structures related to attention (e.g., anterior cingulate). Indi-

viduals with ADHD often show deficits on various measures of attentional

processes including alerting, orienting and/or conflict attention. Alerting

refers to how attention is readied and sustained; Orienting defines how atten-

tion is placed (disengaged and reengaged) and conflict attention is defined

as the process of inhibiting an automatic response in order to attend to a less

automatic response
(Fan, McCandliss, Sommer, Raz, & Posner, 2002).
While most research supports deficits in conflict attention in ADHD (Loo et al.,

324

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

2007;
Seidman, Biederman, Faraone, Weber, & Ouellette, 1997)
neural processing differences in alerting and orienting are also found (Konrad, Neufang,

Hanisch, Fink, & Herpertz-Dahlmann,
2006).

Given the multiple attention/cognitive impairments in ADHD, mindful

awareness training can be seen as either a remediation (compensatory) or

rehabilitation (reversal) approach in this condition. The diverse processes

involved in formal and informal mindfulness practice are likely to repeat-

edly engage executive function (attention, working memory and inhibition)

potentially leading to strengthening of these abilities and broad changes in

self-regulatory abilities. As attention is at the core of mindfulness practice

(i.e., “paying attention to attention”) all attentional systems (alerting, orient-

ing, and conflict)
(Fan et al., 2002)
are likely to be involved. In formal practice (sitting or walking meditation) attention is continually engaged in the

following steps: (1) bringing attention to an “attentional anchor” (usually a

sensory input such as breath); (2) noting that distraction occurs and letting

go (or non-grasping) of the distraction; (3) re-focusing or re-orienting atten-

tion back to the “attentional anchor.” Attentional monitoring and attentional

conflict as well as orienting attention may be particularly critical in carrying

out this process. Other mindfulness meditation exercises train flexibility of

attentional focus by varying focus from narrow to broad and engendering

the so-called open awareness or “receptive attention” (Jha, Krompinger, &

Baime,
2007).
Mindful awareness in daily life (or informal practice) in which the individual checks his/her awareness/attention throughout the day may

continue to engage the same attentional networks as in formal practice but

perhaps offer modalities to generalize from the educational or clinical setting

where the practices may be introduced.

Emerging empirical research is demonstrating that attention and their net-

works can be modified by meditation training in different non-clinical or

clinical populations. A study by
Jha (2007)
showed that intensive (1-month retreat) training with long-term meditators improved alerting attention but

less-intensive (8-week non-retreat setting) training with novices impacted

orienting attention. At the same time, long-term meditators appeared to have

better conflict attention abilities than novices at the beginning of the study. A

review of different meditation studies implicate activation of the anterior cin-

gulate (ACC) and the prefrontal cortex
(Cahn & Polich
,
2006)
structures that are involved in the development of conflict attention and self-control/self-regulatory capacities and the modulation of cognition and emotion in adults

(Creswell, Way, Eisenberger, & Lieberman, 2007;
Lieberman et al., 2007).

Pagnoni and Cekic (2007)
demonstrated that long-term meditators when

compared to healthy controls did not show typical age-related declines in

attentional performance and had less age-related gray matter volume reduc-

tion in several brain regions, particularly the putamen. Additionally, improve-

ments in response on an attentional blink test, or more effective allocation

of attentional resources, were noted after in experienced meditators after an

intensive 3-month training
(Slagter et al., 2007).

Overall, what specific attentional processes are most affected by mind-

ful awareness training may depend on the type and duration of mindful-

ness practice or pre-existing cognitive strengths or vulnerabilities. Future

research with ADHD individuals—an extreme along the attention/cognitive

spectrum—will further shed light on these questions.

Chapter 17 Mindful Awareness and ADHD

325

Mindful Awareness as an Emotional Regulation Tool

in ADHD

A relatively new line of emerging ADHD research is an interest in affect reg-

ulation and aspects of temperament and character traits with ADHD (Lynn

et al.,
2005;
Panzer & Viljoen, 2005; Plessen et al., 2006).
High rates of comorbidity of mood, anxiety, substance abuse and behavioral disorders in ADHD

have been noted for a long time
(Cantwell, 1996;
McGough et al., 2005)

indicating potential vulnerability to affect dysregulation in ADHD. Deficits in

inhibition and impulse control have also been proposed to relate to difficul-

ties in emotional regulation
(Barkley, 1997;
Nigg & Casey, 2005).
An increasing number of studies are investigating affective processing in ADHD and

differences in affect recognition and labeling
(Braaten & Rosen, 2000;
Pelc, Kornreich, Foisy, & Dan,
2006; Rapport, Friedman, Tzelepis, & Van Voorhis,

2002;
Yuill & Lyon, 2007).
Recent neuroimaging studies suggest that brain regions associated with affect regulation (amygdala, ventralmedial prefrontal

cortex) may differ in structure and function in ADHD (Cardinal, Winstanley,

Robbins, & Everitt,
2004;
Plessen et al., 2006).
In addition, Novelty-seeking (NS)—a temperament trait that impacts affect regulation and potentially

stress reactivity is elevated in ADHD
(Lynn et al., 2005;
Stadler, 2007; Tyrka,

2006).

The emotional regulation differences in ADHD support the hypothesis

that affect regulation is a key continuum underlying ADHD liability and pro-

vides further rationale for using mindfulness as a complementary treatment

in ADHD. Mindfulness training teaches engagement in emotional states in

a way that is neither avoidant, flooding, nor dissociative, but rather “mind-

fully observing and staying present with the emotion.” This framing brings

curiosity, openness and acceptance/willingness toward emotional experi-

ences as well as a degree of distancing or dis-identifying from the emo-

tion that can be helpful in cases of emotional over-engagement (depres-

sion or anger problems) as well emotional avoidance (e.g., anxiety disor-

ders)
(Teasdale et al., 2003).
Attention on breathing, used in both formal and informal exercises, can induce relaxation and lower physiological arousal,

a core aspect of emotional experience. Shifting attention to a neutral focus

(e.g., breath, soles of the feet, or an external object) can be used to dis-

engage from particularly intense emotional states. Mindfulness training has

been shown to prevent relapse in chronic depression
(Teasdale et al., 2001),

improve impulsive behavior in patients with borderline personality disor-

der
(Bohus et al., 2004),
reduce aggressiveness in adolescents with conduct disorder
(Singh et al., 2007),
and improve outcomes in substance abuse

(Marlatt et al., 2004),
and generalized anxiety disorder
(Roemer & Orsillo,

2007).
Induction of a mindful awareness state was shown to reduce nega-

tive affect in response to aversive pictures
(Arch & Craske, 2006)
and emotionally provocative events
(Broderick, 2005).
Higher levels of a dispositional mindfulness correlated with buffering of amygdala response to neg-

ative affect via the prefrontal cortex in an affect labeling task (Creswell

et al.,
2007).
In the course of mindfulness training, the processes likely to be invoked—engagement of the conflict attention, a reappraisal of emotional states (i.e., detachment from and observation of emotions), and train-

ing in equanimity and appropriate self-compassion promote adaptive emo-

326

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

tional regulation
(Leary, Tate, Adams, Allen, & Hancock
,
2007b;
Mauss, Cook, Cheng, & Gross,
2007).
Overall, the body of literature supports mindfulness training as a tool for enhancing emotional regulation with likely efficacy