ADHD & Mindfulness: An Interview with Lidia Zylowska MD

Lidia Zylowska, M.D. is the author of The Mindfulness Prescription for Adult ADHD. She is a UCSC-affiliated psychiatrist who specializes in mindfulness-based approaches to mental health and adult ADHD. She practices in northern California. Dr. Zylowska is a cofounder of UCLA’s Mindful Awareness Research Center, where she conducted the first study of mindfulness-training for adults and teens with ADHD. She frequently speaks about mindfulness as a way to promote psychological wellbeing, and she focuses on making the mindfulness practice accessible to diverse groups of patients and clinicians. Dr. Zylowska's website is www.lidiazylowska.com.

What drew you to the practice of mindfulness training and its role in treating ADHD?

Initially, these two interests developed separately but it really made sense to me to combine them later in my research work at UCLA. As a psychiatry resident, I became interested in holistic approaches and completed a fellowship at the UCLA Center for East West Medicine. That fellowship exposed me to diverse mind-body interventions, including mindfulness. I was very drawn to mindfulness both as a practice for myself and as great complement to psychotherapy. At the time, the mindfulness-based cognitive therapy (MBCT) was being developed for depression and, together with Jon Kabat-Zinn’s mindfulness-based stress reduction program (MBSR), these approaches fueled my interest in mindfulness.

In parallel to my interest in mindfulness I became interested in adult ADHD. I had a couple of patients who had ADHD as adults--a condition I did not learn much about during my early training. As I explored the different facets of ADHD, I wanted to understand it further. After receiving a Robert Wood Johnson research fellowship, I decided to study how mindfulness training can be used for ADHD. To be honest, at first I thought mindfulness would be used predominately to help manage high stress frequently seen in lives of adults with ADHD but it became clearer to me later that this approach can also be helpful in ADHD on many other levels. It can help with self-awareness and ADHD symptoms management (attention and emotion regulation) and foster a more accepting and positive relationship one has with himself/herself and others—and that’s much needed in ADHD.

What are the main tenets of mindfulness training, and how can it help people with ADHD?

The main tenents of mindfulness training are becoming more self-aware, less driven by unhelpful, automatic reactions, and being more compassionate. However, when I speak of mindfulness for ADHD, I often use words that emphasize the connection between the self-regulation challenges of ADHD and the self-regulation training inherent in mindfulness. For example mindfulness training can help with:

1) Developing better awareness of attention and learning to be less distracted.

2) Learning to step back and observe one’s thoughts and feeling so they don’t overly drive our sense of self or understanding of our life. This is very helpful in learning to have more flexible mind and controlling impulsive reactions

3) Managing stress better by having new perspective and less emotional reactivity but also by replenishing the ‘self-regulation’ tank (the latter described so well by Dr. Russ Barkley)

4) Balancing acceptance and change perspectives, i.e. knowing when to be compassionate and accepting of ADHD symptoms and knowing when to encourage a change of an unhelpful pattern in thinking, feeling or actions.

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How can practicing mindfulness change the way the ADHD brain works?

We don’t yet have brain studies that have directly looked at this question; however, we have other research evidence that meditation practice can protect the prefrontal cortex—the area affected in ADHD and responsible for executive functions. For example, a study with long-term meditators done at Harvard University showed that the meditators had thicker (or more developed) pre-frontal brain regions related to attention, self-monitoring, and emotional processing when compared to an average person (1). Another study at Massachusetts General Hospital showed increases in gray matter after an eight-week MBSR course. In this study, the regions that showed changes are known to play a role in learning and memory, processing emotions, thinking about self, and ability to take diverse perspectives (2). I think that in the future, mindfulness research will find improvements in brain regions in children or adults with ADHD but we will also find that these results may be dependent on the type of ADHD a person has or what kind of practice (style or duration) is used.

Is the process and practice of mindfulness training different for children and adolescents than it is for adults? Can parents and children practice mindfulness training together?

Generally speaking, mindfulness practice has to be made accessible and relevant to different age groups. For children, it typically means making the practice briefer, less conceptual, more hands-on, more playful and interactive with others. For example, putting a little bear on a child’s belly to help observe the breath movements or having props like little windmill toy to observe the breath. Using imagery, music, and illustrations can be helpful as well (similar to introducing other subjects to kids). For teens, it helps to introduce mindfulness as something that’s relevant to what they are struggling with (peer relationships, school, strong emotions or self-acceptance). Again, having interactive, playful exercises and encouraging one’s own creativity is a key.

For adults, the training is typically more formal and involves discussions of mindfulness concepts, giving instruction for meditation and then dialoguing about the experience afterwards with others. For adults with ADHD, I generally have found that it helps to incorporate elements of training that you would typically think of with children or adolescents (playful, visual, briefer formal meditation, mindfulness in daily life, creating opportunities for movement) because a lot of adults with ADHD learn in a kinesthetic, visual way and even as adults continue to struggle with inattention and hyperactivity. And certainly, parents and children can practice mindfulness together. The parents are the natural teacher for the child and can model mindfulness to them (and sometimes it is the other way around, as kids can be very attuned to the present moment).

Could you explain the difference between meditation and mindfulness?

Mindfulness is a state of mind that can be strengthen by specific meditation practice; however not all meditation training is mindfulness. The meditation training used to develop mindfulness skills is often called open awareness meditation or, in the Buddhist context, Vipassana meditation. In addition, the word mindfulness can refer to a psychotherapy approach or a quality of a person so it is important to know how one is using the term.

What did you find in your research on adults and adolescents with ADHD and the practice of mindfulness (Zylowska et al. 2008)?

Together with my colleagues at the UCLA Mindfulness Research Center, I adapted mindfulness training for ADHD and tested it with a group of adults (n=24) and teens (n=8) with ADHD (3). Our pilot study showed significant pre to post-training improvements in self-reported symptoms of ADHD, anxiety, depression, and stress and these improvements continued 3-months after the training was completed. On cognitive tests given before and after the training, the participants had better performance on selected tests of attention and cognitive inhibition. In particular, we saw an improved ability to pay attention under distracting conditions. These results were very encouraging, however since our study did not have a control group, additional research is on-going to confirm these positive results. A recent controlled study by Australian researchers tested our program with 8 to 12 year old ADHD children and found similar improvements (4). A replication study with ADHD adults is also now being conducted at the Duke University.

In "Step 3 Direct and Anchor Your Awareness: Mindfulness of Sound, Breath, and Body", in your book The Mindfulness Prescription for Adult ADHD, you use the acronym "STOP" to help people practice mindfulness in daily life. Could you explain what each of the letters in "STOP" stand for?

In the acronym S.T.O.P. each letter is a reminder to take a brief step:

S=Stop (or pause) for a moment

T= Take a deep breath

O =Observe mindfully in the moment (for example, you can notice more consciously your body sensations or what you are doing)

P=Proceed with relaxation and awareness.

The last step, Proceed, is also an invitation to utilize choice in your actions (for example, if you noticed being distracted or avoiding something, you can resolve to change that). Of course the change part is not always easy and often requires effort, by with practice (and sometimes together with medications or other ADHD tools) that choice can become easier.

In "Step 6 Manage Your Emotions: Mindfulness of Feelings", you write about the benefits of being positive. Could you explain how a person with ADHD can increase their positive emotions?

Positive emotions can be increased in different ways. One way to have more positive feelings is via neutralizing excessive negative feelings such as harsh negative self-talk or defeated sense of self which are unfortunately all too common in adult ADHD. Being proactive about learning about ADHD and reframing ADHD from a personal deficit to a condition that can treated can make a huge positive shift in one’s life. But it is also important to make time and create opportunities for positive emotions to take place in our lives. Such moments can replenish our energy, lower stress and lead to creative solutions. For example, in addition to scheduling and planning work, it is important to schedule time of play or relaxation, time for loved ones, or time for pursuing one’s creative outlet. Rewarding yourself after job well done, being in nature or being physically active can also leads to experience of positive emotions. Finally, connecting with one’s spiritual side, practicing forgiveness, compassion and gratefulness often creates happiness both inside of us and for others.

One of the guided exercises on the CD included in The Mindfulness Prescription for Adult ADHD is titled "RAIN". What does the acronym "RAIN" stand for?

Like STOP, RAIN is a reminder of how to do a mindful practice. It is a lot like STOP that it is about stopping and observing in the moment, however it used more specifically for observing emotions. Here the emphasis is on accepting and not overly identifying with the emotions since we often struggle with that.

R=Recognize that emotion is happening

A=Accept it

I=Investigate

N=Not-identify / Not personalize

What recommendations would you give to an adult with ADHD who has tried mindfulness training, and feels like he can never empty his mind of thoughts?

I would say ‘you don’t have to empty your mind to practice mindfulness’. Mindfulness practice is about observing your mind, however it is in that moment. Typically when we first practice mindfulness, we find how really busy our mind is (and that may be even more obvious for someone with ADHD). With more practice, or with more intense relaxation, we may experience some quieting of the mind—but that (or the feeling of emptying your mind) is not necessary to have a successful mindfulness experience. Successful practice is being fully aware what is and then using such awareness to choose where you place most attention.

In terms of practice tips, for some people with ADHD I recommend having ‘foreground’ and ‘background’ awareness, for example keeping most attention on the breath and allowing the busy thinking to fall more into the background. For others, the process is more about catching themselves distracted and then returning to the breath. In the latter situation it is important to note that the moment of catching yourself distracted is a moment of mindful awareness.

What are three things an adult with ADHD can do today to start practicing mindfulness training?

1) Become more curious of where your attention goes (i.e. pay attention to attention). Whenever you catch yourself distracted, gently bring attention back to what you intended on doing

2) Periodically ask yourself, “how am I right now?” and practice mini ‘check-ins’ with your breath (or your body) throughout the day. That can make you feel more present in your life.

3) Practice giving yourself patience and compassion when struggling with ADHD. Such attitude form basis for growth, change and thriving with ADHD.

(And of course, check out my book The Mindfulness Prescription for Adult ADHD!)

References:

1. Sara W. Lazar et al., “Meditation Experience Is Associated with Increased Cortical Thickness,” Neuroreport 16, no. 17 (2005): 1893–1897.

2. Britta Hölzel et al., “Mindfulness Practice Leads to Increases in Regional Brain Gray Matter Density,” Psychiatry Research 191, no. 1 (January 2011): 36–43.

3. Lidia Zylowska et al., “Mindfulness Meditation Training in Adults and Adolescents with Attention Deficit Hyperactivity Disorder: A Feasibility Study,” Journal of Attention Disorders 11, no. 6 (May 2008): 737–746.

4. Anna Uliando, at al. Mindfulness training for the management of children with ADHD: A randomised controlled trial (under review).

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