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Mindfulness Meditation for Adults & Teens with ADHD

We have talked about the value of med­i­ta­tion before (see Mind­ful­ness and Med­i­ta­tion in meditationSchools), as a form of well-directed men­tal exer­cise than can help train atten­tion and emo­tional self-regulation.  Which other stud­ies have shown how it strength­ens spe­cific parts of the brain, mainly in the frontal lobe.

Dr. Rabiner shares with us, below, an excel­lent review of a new study that ana­lyzes the ben­e­fits of mind­ful­ness for ado­les­cents and adults with atten­tion deficits. He writes that “although this is clearly a pre­lim­i­nary study, the results are both inter­est­ing and encouraging.”

- Alvaro

Does Mind­ful­ness Med­i­ta­tion Help Adults & Teens with ADHD

– By Dr. David Rabiner

Although med­ica­tion treat­ment is effec­tive for many indi­vid­u­als with ADHD, includ­ing ado­les­cents adults, there remains an under­stand­able need to explore and develop inter­ven­tions that can com­ple­ment or even sub­sti­tute for med­ica­tion. This is true for a vari­ety of rea­sons includ­ing:
1) Not all adults with ADHD ben­e­fit from med­ica­tion.
2) Among those who ben­e­fit, many have resid­ual dif­fi­cul­ties that need to be addressed via other means.
3) Some adults with ADHD expe­ri­ence adverse effects that pre­vent them from remain­ing on medication.

Because of the wide­spread inter­est in new ADHD inter­ven­tions — par­tic­u­larly non-pharmaceutical approaches — I try to cover cred­i­ble research in this area when­ever I come across it. I was thus pleased to learn about a very inter­est­ing study of mind­ful­ness med­i­ta­tion as a treat­ment for adults and ado­les­cents with ADHD that was pub­lished in the Jour­nal of Atten­tion Dis­or­ders [Zylowka, et al. (2008). Mind­ful­ness med­i­ta­tion train­ing in adults and ado­les­cents with ADHD. Jour­nal of Atten­tion Dis­or­ders, 11, 737–746.]

Accord­ing to the authors, “…mind­ful­ness med­i­ta­tion involves expe­ri­en­tial learn­ing via silent peri­ods of sit­ting med­i­ta­tion or slow walk­ing and pur­pose­ful atten­tion to daily activ­i­ties. Relax­ation, although often induced dur­ing the train­ing, is not the sole goal of the activ­ity; rather, the main activ­ity is a cog­ni­tive and intention-based process char­ac­ter­ized by self-regulation and atten­tion to the present moment with an open and accept­ing ori­en­ta­tion towards one’s experiences.”

In recent years, mind­ful­ness med­i­ta­tion has a new approach for stress reduc­tion and has been incor­po­rated into the treat­ment for a vari­ety of psy­chi­atric dis­or­ders, includ­ing depres­sion, anx­i­ety, and sub­stance abuse. Of spe­cial rel­e­vance to the treat­ment of ADHD are find­ings that med­i­ta­tion has the poten­tial to reg­u­late brain func­tion­ing and atten­tion. For exam­ple, research has demon­strated that mind­ful­ness med­i­ta­tion can mod­ify atten­tional net­works, mod­u­late EEG pat­terns, alter dopamine lev­els, and change neural activity.

As con­cep­tu­al­iza­tions of ADHD now increas­ingly rec­og­nize the impor­tance of exec­u­tive func­tion­ing and self-regulation in the dis­or­der, mind­ful­ness med­i­ta­tion — which can be thought of as a type of attention/cognitive exer­cise pro­gram that is focused in improv­ing self-regulation — is a com­ple­men­tary treat­ment that is well worth inves­ti­gat­ing. How­ever, although a few small stud­ies of med­i­ta­tion train­ing in chil­dren with ADHD have yielded promis­ing results, no research on the use of mind­ful­ness train­ing in ado­les­cents and adults with ADHD has been published.

- Par­tic­i­pants —

Par­tic­i­pants were 24 adults and 8 ado­les­cents (62% female) diag­nosed with ADHD fol­low­ing a com­pre­hen­sive eval­u­a­tion. Eight par­tic­i­pants fell 1 symp­tom short of meet­ing full diag­nos­tic cri­te­ria and were con­sid­ered to have “prob­a­ble ADHD.” The aver­age age was 48.5 for adults and 15.6 for ado­les­cents. About two-thirds were being treated with stim­u­lant med­ica­tion and con­tin­ued on med­ica­tion dur­ing the study. As with many adults and ado­les­cents diag­nosed with ADHD, the major­ity had strug­gled with other psy­chi­atric dis­or­ders in their life­time, with mood dis­or­ders being par­tic­u­larly common.

- Mind­ful­ness Training -

Mind­ful­ness med­i­ta­tion is described as involv­ing 3 basic steps: 1) bring­ing atten­tion to an “atten­tional anchor” such as breath­ing; 2) not­ing that dis­trac­tion occurs and let­ting go of the dis­trac­tion; and, 3) refo­cus­ing back to the “atten­tional anchor”.

This sequence is repeated many times dur­ing the course of each med­i­ta­tive ses­sion. As the indi­vid­ual becomes bet­ter able to main­tain focus on the atten­tional anchor, the notion of “pay­ing atten­tion to atten­tion” is intro­duced and indi­vid­u­als are encour­aged to bring their atten­tion to the present moment fre­quently dur­ing the course of the day.

By direct­ing one’s atten­tion to the process of pay­ing atten­tion, to notic­ing notice when one becomes dis­tracted, and to refo­cus­ing atten­tion when dis­trac­tion occurs, mind­ful­ness med­i­ta­tion train­ing can be thought of as an “atten­tion train­ing” pro­gram. As such, exam­in­ing the impact of such train­ing on indi­vid­u­als with ADHD becomes a very inter­est­ing ques­tion to pursue.

- Mind­ful­ness Train­ing Program —

The mind­ful­ness train­ing pro­gram lasted for 8 weeks; each week included one 2.5 hour train­ing ses­sion and daily at-home prac­tice sessions.

Weekly train­ing ses­sions fol­lowed a con­sis­tent for­mat. The ses­sions began with a short med­i­ta­tion, fol­lowed by a dis­cus­sion of at-home prac­tice, the intro­duc­tion and prac­tic­ing of new exer­cises, plan­ning for at-home prac­tice ses­sions for the fol­low­ing week, and a clos­ing sit­ting med­i­ta­tion. The at-home prac­tice ses­sions con­sisted of “…grad­u­ally increas­ing for­mal med­i­ta­tion and var­i­ous mind­ful aware­ness in daily liv­ing exer­cises.” For the at-home prac­tice ses­sions, par­tic­i­pants received 3 CDs con­tain­ing guided sit­ting med­i­ta­tions that began at 5 min­utes and increased to 15 minutes.

To adapt tra­di­tional mind­ful­ness med­i­ta­tion prac­tice to the unique needs of ado­les­cents and adults with ADHD, sev­eral mod­i­fi­ca­tions to tra­di­tional prac­tice were made. First, the 8-week pro­gram included edu­ca­tional infor­ma­tion on the symp­toms, eti­ol­ogy, and biol­ogy of ADHD. Sec­ond, sit­ting med­i­ta­tions were shorter than required in sim­i­lar pro­grams (45 min­utes of at-home prac­tice is typ­i­cally rec­om­mended) and walk­ing med­i­ta­tion could be sub­sti­tuted for sit­ting med­i­ta­tion. Third, visual aids were incor­po­rated to help explain mind­ful aware­ness con­cepts. And, fourth, a loving-kindness medi­a­tion, i.e., an exer­cise of wish­ing well to self and oth­ers) was incor­po­rated at the end of each ses­sion to address the low self-esteem often asso­ci­ated with ADHD.

- Mea­sures -

Pre– and posttest assess­ments included indi­vid­ual self-report scales of ADHD, depres­sion, and anx­i­ety as well as sev­eral cog­ni­tive tests that were admin­is­tered when par­tic­i­pants were off med­ica­tion. Atten­tion was assessed using a com­put­er­ized assess­ment called the Atten­tion Net­work Test that mea­sures 3 aspects of atten­tion: alert­ing (main­tain­ing a vig­i­lant state of pre­pared­ness), ori­ent­ing (select­ing a stim­u­lus among mul­ti­ple inputs), and con­flict (pri­or­i­tiz­ing among com­pet­ing tasks). Neu­ropsy­cho­log­i­cal tests that assessed work­ing mem­ory and the abil­ity to shift atten­tion sets (Trails A and B) were also included. At the end of the train­ing, par­tic­i­pants were also asked to rate their over­all sat­is­fac­tion with the training.

- Results -

Seventy-eight per­cent of par­tic­i­pants (25 of 33) com­pleted the study. On aver­age, par­tic­i­pants attended 7 of the 8 weekly train­ing ses­sions. Adults reported an aver­age of 90 min­utes and 4.6 ses­sions per week of at-home med­i­ta­tion prac­tice; ado­les­cents aver­aged 43 min­utes and 4 ses­sions of weekly at-home prac­tice. Both ado­les­cents and adults who com­pleted the pro­gram reported high lev­els of sat­is­fac­tion with it — aver­age scores above 9 on a 1 to 10 sat­is­fac­tion scale.

Seventy-eight per­cent of par­tic­i­pants reported a reduc­tion in total ADHD symp­toms, with 30% report­ing at least a 30% symp­tom reduc­tion (a 30% reduc­tion in symp­toms is often used to iden­tify clin­i­cally sig­nif­i­cant improve­ment in ADHD med­ica­tion tri­als). Because the major­ity of par­tic­i­pants were receiv­ing med­ica­tion treat­ment, for many these declines rep­re­sent improve­ment above and beyond what ben­e­fits were already being pro­vided by medication.

On neu­rocog­ni­tive test per­for­mance, sig­nif­i­cant improve­ments were found on the mea­sure of atten­tional con­flict and on sev­eral other neu­ropsy­cho­log­i­cal tests (i.e., Stroop color-word test and Trails A and B) but not for mea­sures of work­ing memory.

For adults, sig­nif­i­cant reduc­tions in depres­sive and anx­i­ety symp­toms were reported. Com­pa­ra­ble reduc­tions in these symp­toms were not evi­dent in adolescents.

- Sum­mary and Implications -

Results from this study indi­cate that mind­ful­ness med­i­ta­tion train­ing may be a ben­e­fi­cial com­ple­men­tary treat­ment approach for ado­les­cents and adults with ADHD. Pos­i­tive find­ings include: 1) the absence of any reported adverse events; 2) highly favor­able rat­ings of the treat­ment by par­tic­i­pants; 3) reduc­tions in self-reported ADHD symp­toms reported by over three quar­ters of par­tic­i­pants, even though the major­ity were already being treated with med­ica­tion; 4) sig­nif­i­cant improve­ment on sev­eral of the neu­ropsy­cho­log­i­cal mea­sures; and, 5) reduc­tions in depres­sive and anx­i­ety symp­toms for the adults.

The authors are appro­pri­ately cau­tious in dis­cussing their find­ings and sug­gest that the study sup­ports the “…fea­si­bil­ity and poten­tial util­ity of mind­ful­ness med­i­ta­tion in at least a sub­set of adults and ado­les­cents with ADHD.” They are care­ful to note, how­ever, that this was a pilot study with a small sam­ple, and that the reported pre-post changes in behav­ioral and neu­rocog­ni­tive mea­sures should be “…con­sid­ered exploratory given the absence of a con­trol group and reliance on self-report mea­sures of psy­chi­atric symptoms.”

Given the promis­ing results obtained in this pilot study, there is a clear need for a more exten­sive research on mind­ful­ness med­i­ta­tion train­ing as an inter­ven­tion for ADHD. In the mean­time, although mind­ful­ness med­i­ta­tion could not be con­sid­ered a sci­en­tif­i­cally sup­ported treat­ment for ADHD, it may have ben­e­fits as a com­ple­men­tary treat­ment and is highly unlikely to have any adverse effects.

I find it both encour­ag­ing and excit­ing that there seems to be grow­ing inter­est among ADHD researchers to explore the sci­en­tific sup­port for com­ple­men­tary approaches such as mind­ful­ness med­i­ta­tion train­ing and to sub­ject a wider range of treat­ments sub­jected to rig­or­ous sci­en­tific research. This has not always been the case and it would be won­der­ful if this trend were to con­tinue. I hope that the authors of this study are already in the midst of the con­trolled trial that they call for and will cer­tainly con­tinue to cover these kinds of inter­est­ing inves­ti­ga­tions in Atten­tion Research Update as they appear in the literature.

Rabiner_David– Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teaches the online course  How to Nav­i­gate Con­ven­tional and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

For related and mind­ful read­ing, you will enjoy:

- Mind­ful­ness and Med­i­ta­tion in Schools for Stress Management

- From Med­i­ta­tion to Mind­ful­ness Based Stress Reduc­tion (MBSR)

- On being positive

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11 Responses

  1. Thanks for this sum­mary and review — I ref­er­enced your post on my pri­vate prac­tice site, where I pro­vide links to help­ful infor­ma­tion for fam­i­lies and the gen­eral public.

  2. FYI — I also posted this on my home­page site, Kmareka, and there were some good reader comments:

    http://kmareka.com/?p=1852

  3. Nina says:

    My younger brother who is 25 yrs is suf­fer­ing from ADHD he was diag­nosed of the same at the age of 15 years and was treated on ritalin for 7 months. After which he was suf­fer­ing from severe blink­ing of the eye after con­sum­ing the med­i­cine. Which was the only side effect. Now he has a job but his con­cen­tra­tion to the job (work­ing as a front office exec­u­tive in a 5 star hotel) is min­i­mal. Is there any way I can get any help in get­ting him treated com­pletely of this dis­or­der?
    ——————

    Nina

  4. I have also been work­ing with teens and adults who have var­i­ous chal­lenges, one off them being ADHD. As a Mind­ful­ness Teacher and Psy­chol­o­gist in West Los Ange­les, I use these prac­tices to help sup­port them with a more non­judg­men­tal form of atten­tion con­trol. They usu­ally come out with more than just the relief of ADHD symp­toms, but also with an expanded sense of com­pas­sion for them­selves and deeper con­nec­tion with life. The rea­son is this goes beyond train­ing the mind but can be con­sid­ered a train­ing for advanced live­ing :). Thank you for this article.

    Elisha Gold­stein, Ph.D.

  5. Alvaro says:

    Kier­sten, thank you for your visit. Nice to “meet” you.

    Nina: your brother may ben­e­fit from vis­it­ing a good doc­tor, and prob­a­bly a neu­ropsy­chol­o­gist. No gen­eral advice is enough to help one very spe­cific case.

    Elisha: thank you for shar­ing your expe­ri­ence. Have you found spe­cific chal­lenges work­ing with peo­ple with atten­tion deficits, or have you had a smooth expe­ri­ence engag­ing them with mindfulness?

  6. Hi Alvaro,
    It’s impor­tant to first pref­ace that mind­ful­ness is not a panacea, but is a skill­ful way to approach many of our chal­lenges in daily life. With that said, it’s not for every­one at the time they come in for sup­port. So, it hasn’t been smooth all the time, how­ever, more and more I am see­ing a greater accep­tance to actu­ally prac­tice. Fol­low through can be an issue, but then that is gris for the mill as we dis­cuss what got in the way of prac­tice which cre­ates a grow­ing aware­ness for the fol­low­ing expe­ri­ences. A big part of this is notic­ing when you’re becom­ing judg­men­tal and being harsh on your­self for not being able to attend. This only serves to cre­ate more chaos in the brain and get in the way. With cul­ti­vat­ing a non-judgmental aware­ness to our aware­ness :), we become more skill­ful at pay­ing atten­tion to the things we want to and liv­ing the lives we want.

    Elisha Gold­stein, Ph.D.

  7. Alvaro says:

    Elisha: I agree, noth­ing is a panacea. But it is very goodd news that we have tools at our disposal.

    Thank you for shar­ing your experience.

  8. Thank you for this. Quite cor­rectly this is not a panacea .
    How­ever I’ve found that teach­ing and coach­ing chil­dren, youth and adults Mind­ful­ness, Relax­ation Response skills and med­i­ta­tion ( I know where does one start and the oth­ers end) helps them gain a sense of con­trol over their inner world. A very valu­able com­mod­ity these days.

  9. Michael, I agree. Learn­ing how to man­age atten­tion and reg­u­late emo­tions would help many kids (and adults) be more pro­duc­tive and happy.

  10. Tom says:

    Thank you for this arti­cle shed­ing light on the pos­si­bil­i­ties for med­i­ta­tion to help with ADHD.

    I’m just curi­ous, why is the ADHD research on Neu­ro­feed­back crit­i­cized by Dr. Rabiner for
    1. not hav­ing large enough par­tic­i­pants
    2. not using ade­quate con­trols
    3. not offer­ing ran­dom­ized con­trolled trials?

    …when this mind­ful­ness study was like­wise small, sug­gested no sig­nif­i­cant con­trols, and appear­ently was not ran­dom­ized? But there’s no men­tion of the need for bet­ter con­trols and big­ger stud­ies here.

    Here is his arti­cle on Neu­ro­feed­back:
    http://www.sharpbrains.com/blog/2008/01/25/how-strong-is-the-research-support-for-neurofeedback-treatment-of-children-with-adhd/

    I’m not a sup­porter of Neu­ro­feed­back and actu­ally do not believe that it’s the solu­tion to ADHD. I feel that effec­tive med­i­ta­tion (though not nec­es­sar­ily mind­ful­ness) is a much bet­ter route.

    I’m just inter­ested in the dif­fer­ent treat­ment of this study, com­pared to Dr. Rabiner’s access­ment of Neu­ro­feed­back, for which there are actu­ally more peer-reviewed con­trolled stud­ies than mind­ful­ness for ADHD. It seems Dr. Rabiner was much more scru­ti­niz­ing of the NF research than he is of research on mind­ful­ness. I’m sure he has a good rea­son but am very curi­ous. Is he a Bud­dhist? Is he into mind­ful­ness him­self and there­fore more favor­able to it?

  11. Dag A. Solberg says:

    Thank you for giv­ing me a review of this inter­est­ing topic. I work as a spe­cial­ist in Fam­ily med­i­cine i Nor­way. Unfor­tu­nately this method is not dis­cussed very much among experts in my coun­try. I attended a course on mind­full­ness 3 weeks ago, which opened my eyes of the pos­si­bil­i­ties of this approach.
    I have a ques­tion for you;

    Mind­full­ness is known for open­ing up for strong emo­tions and at the same time mak­ing it pos­si­ble to tol­er­ate an emo­tion, a mem­ory, with­out flee­ing, with­out shut­ting it out. This , I think , may be an effe­cient way of accept­ing dif­fi­cult emo­tiona. How­ever; many patients have a his­tory of abuse and hard losses in their lives. What cri­te­ri­aes do you use in order to avoid Too strong reac­tions, and what do you think is the best way to find the “right” patients?

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