Clinical Handbook of Mindfulness (91 page)

in ADHD.

Mindful Awareness as a Stress Regulation Tool in ADHD

In addition to having alterations in cognitive-emotional regulation, ADHD

individuals may differ from non-ADHD individuals in their stress response or

stress load. There is a large body of research suggesting that stress—such

as parental conflict or prenatal/perinatal insults—can increase the risk of

ADHD or impairment associated with ADHD
(Pressman et al., 2006;
Talge,

Neale, & Glover,
2007).
High rates of family conflict, relationship or marital discord, academic or job underachievement, and lower health-related

quality of life are reported in ADHD
(Adler, 2004;
Escobar et al., 2005;

Pressman et al., 2006).
Several studies show abnormal HPA axis response

in ADHD
(Blomqvist et al., 2007;
Kaneko, Hoshino, Hashimoto, Okano, & Kumashiro,
1993; King, Barkley, & Barrett, 1998;
Sondeijker et al., 2007).

Furthermore, an elevated rate of post-traumatic stress disorder is also found

in ADHD
(Kessler et al., 2005;
Smalley et al., 2007) and supports the hypothesis that ADHD may be associated with alterations in stress response or stress

(allostatic) load. Mindfulness training and other mind-body approaches may

impact ADHD via induction of the relaxation response
(Benson, 1997;
Kabat-Zinn,
1990).

Mindful Awareness and Neuroplasticity—Implications

for ADHD

A growing number of studies suggests that brain activity can be modu-

lated by repeated behavior or experience
(Draganski et al., 2004;
Schwartz, Stapp, & Beauregard,
2005b)
including mental training such as meditation

(Lazar et al., 2005;
Pagnoni & Cekic, 2007).
This neuroplasticity effect—

lasting functional and/structural changes in the corresponding neural cir-

cuitry after a repeated behavior—has been demonstrated in animal (Nudo

et al.,
1996)
and human
(Draganski et al., 2006;
Maguire et al., 2000;

Mechelli et al., 2004)
research, including a study of cognitive training in ADHD
(Olesen, Westerberg, & Klingberg, 2004).
With initially more effortful practice, prefrontal cortical regions are likely to be repeatedly engaged

and thus their function may be improved. In addition, as repeated prac-

tice continues, automatization of a mindful stance and a corresponding shift

from prefrontal cortex to basal ganglia may occur
(Graybiel, 1998).
This automatization of mindful awareness may help bring present-moment awareness “on line” more easily (Schwartz et al., 2005a). In ADHD (as well as

non-ADHD individuals), this could lead to a more automatic disruptions of

periods of “daydreaming” or “spacing out” or “being caught in thinking”

and improved ability to “step back” during periods of intense emotional

response.

Chapter 17 Mindful Awareness and ADHD

327

Mindful Awareness Practices for ADHD (MAPs for ADHD)

The MAPs for ADHD program was developed in the course of a feasibility

study over a 2 year period by Drs. Zylowska and Smalley. The program

was informed by Mindfulness-Based Stress Reduction (MBSR)
(Kabat-Zinn,

1990),
Mindfulness-Based Cognitive Therapy (MBCT)
(Segal et al., 2002)
and the tradition of vipassana meditation. Other mindfulness and acceptance-based approaches as well as ADHD psychosocial approaches provided more

distal influence. The consultants on the study included several experts in

mindfulness including Ms. Diana Winston (a Buddhist teacher), Dr.

Jef-

frey Schwartz (co-author) and Dr. Alan Wallace (a Buddhist scholar). The

mindful awareness training was adapted to meet the unique challenges of

ADHD symptoms and includes psychoeducation about ADHD (Smalley, In

Press a).

Overview of the Program Structure

The MAP program is an 8-week training in Mindful Awareness delivered in

a group format. The program consists of once per week sessions lasting

2.5 h and daily at-home practice. The at-home practice consists of gradually

increasing sitting meditation (i.e., formal practice) and daily life exercises

(i.e., informal practice). Walking meditation can be substituted for sitting

meditation. The participants receive a CD containing guided meditations

ranging in length from approximately 5 min (weeks 1–2), to 10 min (weeks

3–5) and 15 min (weeks 6–8). At each session, the participants receive a

weekly practice form that lists their weekly practice “assignment” and they

are asked to use the form as a visual reminder by placing it in a frequently

visited area (i.e., the refrigerator). The MAPs program for ADHD differs from

other mindfulness-based programs in that it includes (1) a psychoeducation

component on the clinical symptoms, neurobiology and etiology of ADHD;

(2) sitting or walking meditation periods that are shorter than in other sim-

ilar programs (e.g., in MBSR program 45 min of at-home practice is recom-

mended); (3) didactic visual aids explaining mindful awareness concepts; (4)

strategies from ADHD cognitive-behavioral therapy or coaching to help with

mindful awareness practice; and (5) a loving-kindness meditation (an exer-

cise of wishing-well to self and others) at the end of each session to address

the low-self esteem problems often associated with ADHD. While body

awareness is practiced throughout the training in diverse ways (walking,

short movement and stretching exercises, body-breath-sound meditation, and

mindfulness of emotions), longer (45 min) body scan and yoga poses typically

used in MBSR and MBCT are not included. These latter modifications, as well

as omission of a half-day retreat typically included in MBSR or MBCT were

motivated by our desire to balance the intensity of the training and the ease

of delivery within diverse clinical or research settings. Overall, the program

was designed to provide a beginner-level instruction in mindful awareness,

make the training ADHD-friendly and foster a life-long engagement with the

approach.

328

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

Overview of the Program Content

The program begins with a session devoted to introduction of the partici-

pants, overview of ADHD and mindful awareness, and basic sitting medita-

tion instructions. The introduction involves a “Getting to know you” exercise

in which everyone (including the trainers) are asked to share a playful aspect

of themselves with the group (e.g., “Tell us about your hobby”). The partic-

ipants are also asked to reflect on their intention for being in the class. The

initial introductions set the tone of the class as both a playful and a reflective

process. The ADHD psychoeducation is provided in the first two sessions

and re-frames the impairment or “deficit” aspects of ADHD by highlighting

ADHD as a “neurobiological difference.” Thus, ADHD represents one extreme

on a spectrum of functioning which can come with both non-adaptive and

potentially adaptive aspects
(Jensen et al., 1997;
Smalley, 2008). This framework de-stigmatizes ADHD and fosters openness and curiosity in observing

one’s own ADHD characteristics. Visual aids explaining some of the con-

cepts are used to reinforce learning and to accommodate diverse informa-

tion processing styles that may be more common in ADHD. The rationale for

using mindful awareness in ADHD is presented by discussing common self-

regulation difficulties found in this condition. The emerging neuroscience of

mindful awareness is reviewed to highlight the potential of mental training

to change brain function and structure with long-term practice. We believe

that a review of the scientific rationale reinforces the motivation to engage in

this kind of training. The raisin exercise
(Kabat-Zinn, 1990)
and a basic 5-min sitting meditation on mindfulness of the breath are used to experientially

introduce mindful awareness practice. Formal meditation is de-mystified and

basic sitting meditation instructions are provided using either a meditation

cushion or a chair. The 5-min sitting meditation (done with a CD) plus the

“Telephone breath” (taking a mindful breath every time the phone rings) are

the at-home practice for week 1.

Session II: Difficulties in practicing meditation such as distractibility, rest-

lessness, and boredom are discussed and emphasized as common for every-

one but also with recognition that they may be particularly difficult for

those with ADHD. The approach of returning to the framing of ADHD as

an extreme along a normal continuum of functioning discourages the feel-

ings of separateness often voiced by ADHD individuals and appears to foster

increased self-compassion by recognition of difficulties we all face as part

of the “human condition”
(Leary, Tate, Adams, Allen, & Hancock, 2007a).

While difficulties are explained and validated, participants are encouraged

to work with the difficulties as much as they can and take responsibility for

their actions. This is similar to the attitude used in ADHD coaching where

gentle yet firm support is used to help with quick discouragement, lack of

persistence or inconsistent effort often reported in ADHD. In dealing with

difficulties with distraction, it is emphasized that “it is not about staying with

your breath but returning to your breath” to encourage persistence even in

the context of frequent distractions. Mindful observation includes maladap-

tive habits frequently associated with ADHD such as being oppositional, irri-

table, overly reactive, procrastinating or avoidant of attention requiring tasks.

Session III. Mindful awareness of sound is introduced using a short musical

piece during which the participants are asked to observe their experience of

Chapter 17 Mindful Awareness and ADHD

329

listening including shifts of attention to different instruments, evoked feel-

ings, imagery or thought associations. This is followed by a meditation dur-

ing which the participants are asked to pay attention to the predominant

present-moment experiences of body sensation (e.g., pain, feeling or rest-

lessness), breath or a sound. While attentional movement from one stimulus

to the next is often familiar to the ADHD individual, being aware of the “grab-

bing” and changing of attention from an “impartial observer” stance is often

a new experience. The participants are asked to practice mindful awareness

throughout the week by using using cueing questions of “where is my atten-

tion right now?” or “what am I doing right now?” and bringing yourself back

to the intended task. Visual reminders such as sticker dots or a frame with

a word “breathe” are recommended as environmental reminders to connect

with the present-moment awareness
(Safren, 2006)

Session IV: Counting the breath meditation is introduced as an alternative

way to train concentration. Body awareness is fostered through gentle body

movement, mindfulness of pleasant/unpleasant and neutral sensations and

ways to work mindfully with pain. Mindful awareness of a daily activity are

reinforced by an exercise such as putting on or taking off shoes mindfully, or

practicing mindfulness when placing important items such as one’s keys or

wallet.

Session V: Mindful awareness of thoughts is introduced by using a picture

of sky and clouds to contrast the concept of meta-awareness (represented

as the blue sky) versus present-moment experiences (represented by clouds

with different labels such as “thought,” “feeling,” “image,” “sound,” or “body

sensation”). As many individuals with ADHD feel their minds are constantly

“on the go,” we also suggest that the numerous thoughts and feelings they

experience (probably more than the “average” individual) may provide them

with a greater capacity for practicing awareness. Overly negative or criti-

cal thoughts are explored using an exercise in a dyad and reporting self-

judgments to the partner. In clinical practice, ADHD individual often report

low-self esteem and endorse overly critical self-judgments. The difference

between being judgmental or judging (as in discerning) is discussed and non-

judgmental awareness is explained as a step in the learning process that leads

to discernment, choice and mindful action. As part of at-home practice, the

participants are asked to count moments of being hypercritical or judgmental

(to self or others) throughout one typical day.

Session VI: Mindful awareness of emotions is fostered via a short didactic

on function and acceptance of emotions. Common difficulties in regu-

lating emotional states in ADHD are discussed and a RAIN mnemonic

(Winston, 2003)
is introduced to help establish mindful awareness during emotional responses. The mnemonic stands for R (recognize), A (accept), I

(investigate), and N (non-identify/not-personalize). A sitting mediation using

imagery of a recently emotionally evoking event is used as an exercise in

applying the mnemonic to evoked emotions. A longer loving-kindness medi-