Mindful

I remember watching my nine-year-old son receive his diagnosis of attention-deficit/hyperactivity disorder. As I listened to his doctor’s questions—Did he often lose things? Did he often interrupt people? Did he often have trouble finishing tasks?—it struck me that he wasn’t alone in answering all those questions with a “yes.” I was 48 years old, and could have easily filled a large suitcase with all the sunglasses, jewelry, cell phones, and notebooks I’d lost over the years.

Newspaper deadlines had kept my distraction more or less in check during the dozen years I’d been a foreign correspondent, based in Mexico and Rio de Janeiro. A full-time assistant and the constant excitement of scandals, coups, and natural disasters also helped me stay focused. But then I’d moved back to the California suburbs to freelance and raise my two kids—combining hyper-responsibility with minimal structure and even less support, with plenty of bent fenders and burned pots as the embarrassing results. Worse, far worse, was what I feared was the toll on my husband and children of my ready-fire-aim disposition, as, under stress, I’d blurt out insults and threats.

All of which helps explain why I, too, was soon in the patient’s chair, receiving my own diagnosis and officially joining the club—a large and rapidly expanding club—of several million adult Americans who struggle with ADHD.

In the decade since I first found my peeps, I’ve made a point of learning everything I could about this perplexing disorder. I’ve interviewed top experts, read scores of scientific studies and books, and authored and co-authored three books on the topic. I’ve also test-driven every one of the major and most of the minor recommended treatments that belong to what I’ve come to think of as the ADHD industrial complex. This includes medication, neurofeedback, special diets, exercise programs, and, yes, mindfulness meditation, which in recent years has gained increasing prestige as evidence accumulates of its effectiveness as a strategy to manage clinical-grade distraction.

There’s a lot more to say about mindfulness as a treatment for ADHD. But first let’s clear up two common misunderstandings about the neuro-predicament that has become a kooky hallmark of our frazzled era.

10 million + US adults affected by ADHD—an estimated 4.4% of Americans aged 18 to 44 suffer some degree of disability from ADHD, according to a 2006 survey by the National Institutes of Mental Health.

A Genuine Glitch

The most damaging misperception about ADHD is that it’s nothing more than a convenient excuse for slackers, spineless parents, and prescription stimulant addicts. Yet however much the label has in fact been abused, it’s also estimated that more than 16 million American children and adults genuinely suffer from this mostly genetic disorder—more hereditary than schizophrenia, and nearly as hereditary as height.

The classic symptoms of restlessness, impulsivity, and distraction derive from a glitch in the way the brain processes dopamine, a crucial neurotransmitter that affects motivation, interest, and self-control. Longitudinal studies have shown that those of us with authentic ADHD suffer many more accidents, injuries, academic failures, divorces, and periods of unemployment throughout our lives than our “neurotypical” peers. We also, not surprisingly, have significantly higher rates of anxiety, low-self esteem, depression, and suicide attempts. People joke about ADHD, but on balance it’s not really all that funny.

The other big myth about ADHD is that it’s only a problem for kids. True, the disorder typically arises in early childhood, detected by vigilant parents and teachers. At last count, more than 6 million youth—one in nine kids between four and 17 years old—have been diagnosed, according to the Centers for Disease Control and Prevention. To be sure, the number of adults diagnosed is less clear—we’re much less carefully tracked, and many of us have learned to cope with and disguise our symptoms—but researchers believe that serious symptoms persist into adulthood for more than half of all children who have the disorder. A 2006 survey by the National Institutes of Mental Health estimated that 4.4% of Americans aged 18 to 44 suffer some degree of disability from ADHD. That works out to roughly 10 million Americans.

In a startling milestone, in 2015 the number of American adults taking ADHD medications surpassed that of children, accounting for 53% of some 63 million prescriptions, according to data compiled by Shire Plc, which makes the top-selling Vyvanse treatment. The number of adult prescriptions is now increasing twice as fast as that of the overall market.

From this, we can infer that millions of adults are seeking help to cope with distraction. But—alas—we can’t infer that they’re actually being helped. Research suggests that prescription medication, usually in the form of stimulants such as amphetamines or methylphenidate (brand name Ritalin), can help about 80% of those diagnosed with ADHD. But quite often even when people find that the meds improve their focus, they can’t tolerate common side effects including insomnia, loss of appetite, high blood pressure, and irritability. That’s just one reason many experts I’ve interviewed consider medication as simply one potential tactic among many possible approaches, all of which have their strengths and weaknesses (See “What You Can Do about It,” below).

And that brings us back to mindfulness, which is gaining new respect among researchers and clinicians as a therapy for people with ADHD as evidence accumulates of its particularly beneficial impacts.

Life-management skills—impulse control, planning, organizing, keeping track of details in working memory—are part of the brain’s executive function. When it’s not functioning well, everyday life can go haywire.

Peer-reviewed Prestige

Studies abound suggesting benefits of mindfulness for the general population, particularly in reducing stress and anxiety. Given the unique stress and anxiety of living with ADHD, it seemed logical for researchers to explore whether training attention could make life easier for the most attention-challenged people.

“ADHD and mindfulness are two sides of the same coin,” says Mark Bertin, a developmental behavioral pediatrician in upstate New York, who uses mindfulness in his clinical practice treating children and families coping with ADHD.

“ADHD shows what it’s like to live with impaired executive function, which in many ways makes it hard to manage everyday life,” says Bertin, who regularly writes for mindful.org.   “On the other side of the coin, mindfulness shows the benefits of better executive function, making everyday life easier to manage.”

By “executive function,” Bertin is referring to key cognitive skills such as impulse control, planning, organizing, and “working memory”—the ability to keep two or more things in mind at the same time. “These are all life-management skills, and when they’re impaired, as with ADHD, it can affect not just work and school but daily activities like eating, driving, and managing your to-do list,” he says. “That causes a lot of stress and overwhelm, and when you’re feeling like that, it makes it even harder to make skillful choices.”

The first research breakthrough came in 2008, with the results of a small study published in the Journal of Attention Disorders, reporting on a trial of using mindfulness as a treatment for ADHD. Eight researchers, led by Lidia Zylowska, a psychiatrist at the University of California at Los Angeles, enrolled 32 adults and adolescents in an eight-week class based in part on Jon Kabat-Zinn’s popular Mindfulness-Based Stress Reduction program. Their results were so encouraging that other researchers soon began testing the same hypothesis. In May 2015, Zylowska and two colleagues summarized several of these subsequent studies, conducted with children, teens, and adults with ADHD, in the journal Cognitive and Behavioral Practice. Their conclusion: there was “promising preliminary support” for the treatment approach.

The emphasis here is on “preliminary.” As the review pointed out, many of the studies were small and lacked comparison samples, or “control groups.” The authors called for more rigorous studies—and more are being done.

Even so, in a recent interview Zylowska called mindfulness “a lifesaver.”

“It has made a huge difference in my own as well as my patients’ life,” said the psychiatrist, who these days lives in Los Gatos, California, where she divides her attention among her clinical practice (comprising mostly adults with ADHD), her teaching of clinicians, and raising her eight-month-old child.

Boys with ADHD tend to be more hyperactive and impulsive, and naturally attract more attention. Girls, with some exceptions, are more day-dreamy. They can slip under the radar, accumulating a buildup of mistakes, failures, injuries, accidents, and self-slights.

Zylowska was first drawn to study ADHD in 2003, when when she was in her late twenties and seeing patients at a UCLA clinic. A new mother was confiding how painfully overwhelmed she was feeling during what she knew should be a happy time. Before the baby came, she had been able to cope with stressful demands at work by taking lots of breaks and recharging herself in nature, but this was no longer possible.

The therapist found herself nodding in recognition.

She was then in the last year of her residency, transitioning from being rigorously scheduled to having much more free time to pursue her own interests. She found herself missing the structure, and worrying that she was sinking into a “rabbit-hole” of indecisiveness, spending too much time alone in her office, chatting on the phone with friends, or obsessing over what should have been routine administrative tasks.

“What resonated for me was this sense of at times having so much going on yet being paralyzed,” she recalled.

Zylowska was already interested in mindfulness. But that moment at the clinic ignited her curiosity about whether mindfulness might be of special use to people with ADHD.

In 2004, she and Susan Smalley, an accomplished researcher and now a professor emeritus in the department of psychiatry at UCLA, established the university’s Mindful Awareness Research Center. Three years later, they collaborated on the seminal study published in 2008.

“We initially faced a lot of skepticism from our colleagues,” Zylowska recalled. “Some said it was a setup for failure: You’re asking people who can’t sit still and focus to sit still and focus.”

To the skeptics’ surprise, the majority of the pilot-study patients not only endured through the eightweek course, but reported—and demonstrated—improvements in focus and mood.

Even so, Zylowska and Smalley thought they could make mindfulness even more user-friendly for people with ADHD, and so went on to devise a new, customized training program. Their eight-week course on “Mindful Awareness Practices for ADHD” features brief periods of sitting meditation—15 minutes at the most— combined with other modifications such as walking meditation, counting breaths, and imagery. Group discussions touch on concerns common to people with ADHD, such as that they talk too much and don’t listen enough.

1 in 9 youth diagnosed with ADHD – According to the Centers for Disease Control and Prevention, more than 6 million kids between four and 17 years old have been diagnosed.

Getting Rid of the Grease

For adults who’ve spent lifetimes coping with clumsy distraction, the practice of mindfulness and its accompanying teachings of acceptance and compassion for oneself and others can also be particularly helpful in coping with what Holly Seerley, a therapist in Mill Valley, California, calls the “greasy buildup” of the disorder. “That includes all the low self-esteem and negative self-talk,” says Seerley, who has led ADHD support groups for the past decade. “Like when you tell yourself, ‘I screwed up again. What a loser. I can’t believe I did that.’ ”

It’s all a matter of being able to shift your attention—a core feature of the practice. Says Bertin: “You just move from the judgment to the idea that this is how things are, and I’m working on it.”

For Deb Rowley, a psychotherapist and ADHD coach in Madison, Wisconsin, who was diagnosed with ADHD in 2009, this ability to shift away from negative thoughts is much more important than simply striving to have a still mind.

Rowley is one of millions of women who grew up struggling with ADHD and yet slipped under the radar, avoiding diagnosis, while boys of the same age got tracked and treated. Boys have historically been about three times as likely to be diagnosed as girls, although for adults, the rates are evening out. That’s because ADHD often manifests differently in boys than it does in girls. Boys tend to be more hyperactive and impulsive, and naturally attract more attention, while girls, with some exceptions, are more day-dreamy. The trouble with this picture is that by the time girls grow up, we’ve accumulated much more of that “greasy buildup” of repeated mistakes, failures, injuries, accidents, and near-to-the-ground self-esteem. Women with ADHD are significantly more prone than men to anxiety, depression, and suicide attempts.

Rowley has strong memories of being a distractible “social butterfly” as a child. “My first-grade teacher once tied me to my chair with my belt,” she said, although she added that “it was in the nicest possible way. I really liked that teacher.”

It wasn’t until she turned 42 that she ended up getting her diagnosis. “People kept telling me I seemed depressed,” she says. As it turned out, she was struggling not only with ADHD but with chronic physical health problems that recently led to a diagnosis of fibromyalgia.

She tried stimulants, but found, paradoxically, that they made her feel sleepy. She could never seem to figure out a helpful dose. But earlier this year, she first tried mindfulness, and has become a devotee. As she wrote in an email:

Relationships can become healthier when individuals hold their tongues periodically! I personally loved the first few times I heard my own voice inside my head calmly say, “Wow. Look at that…you’re pausing right now. You’re not going to react right back…you’re going to gently respond in a moment. Woot! Woot!” (Folks with ADHD often have to have their own personal celebrations!).

Rowley now enthusiastically recommends mindfulness training to her coaching clients, although she cautions them that it’s not inherently an ADHD-friendly approach. “I don’t say that because it’s impossible to sit still and clear your mind,” she said. “I say that because there has to be routine and you have to practice, and if you don’t, you won’t get anything out of it. So it’s really good to have a buddy or be in a class to keep you motivated.”

Her other advice to clients: “I tell them it’s not a luxury to smell the roses. It’s a treatment.” As awareness of ADHD expands and the number of adults diagnosed increases, there’s a bright side for the “neurotypicals.” Given that daily distractions and stress are also becoming more common, amid the fiercest bombardment of cognitive stimuli we humans have ever experienced, you might think of us folk born with clinical-grade distraction as our era’s coal-mine canaries. While we struggle with a biologically rooted handicap, we may simply be just a little further out on a continuum on which everyone else is now moving. The savviest of us are becoming pioneers for remedies, including mindfulness, that are sure to have increasing universal appeal.

My own journey with mindfulness has been one of fits and starts. Over the past decade, I’ve spent hundreds of hours trying, and usually failing, to sit and quiet my mind, and hundreds more in yoga classes, which are much easier to bear, despite how much I still watch the clock. As part of my initial research into possible treatments for ADHD, I even spent five days at a silent retreat at the Spirit Rock Meditation Center, just up the road from where I live—and even though I did it “lite,” taking notes throughout, skipping several meditation sessions to hike, and finding far too many excuses to talk to the staff—it was one of the most powerfully beautiful experiences I’ve had.

In the spirit of self-compassion, I’m trying not to judge myself harshly for all the times I’ve fallen off the mindfulness wagon, or for all the little tricks I’ve used to make my practice easier. I remember hearing the meditation teacher B. Alan Wallace say that counting the breath is like using “training wheels.” I think of that phrase almost every time I count—and then I usually think: that’s better than no wheels at all.

These days, my newest mindfulness crutch is one of the many commercial iPhone apps now on the market, and I must say it’s so far working quite well. I’ve managed to stick to a routine in which I wrap myself in a blanket first thing when I wake up and listen to the narrator on headphones for 20 minutes. Again, it may be training wheels, but they’re still better than none at all.

At this writing I’m on Day 23—and counting.


Time to See a Psychiatrist?

“It’s natural to wonder to what extent this is a culturally created disorder, given that pretty much everyone these days feels distracted and overwhelmed,” notes Oregon Health & Science University psychiatry professor Joel Nigg, author of What Causes ADHD? But how can you tell for sure whether you have a genuine biological malady or merely a brain that has been Twitterized? There’s no blood test or brain scan (despite what you may have heard) that can diagnose ADHD—or any other psychological disorder, for that matter. Instead, a clinician will ask you questions from a checklist of the classic symptoms—forgetfulness, distractedness, impulsivity, and difficulty finishing tasks— and deliver a diagnosis only if those problems are chronically impairing your performance at school or at work. For a preview, you can ask yourself a few questions.

1 – Do I have more problems prioritizing my work and activities than most people I know?

2 – Do I have more trouble planning ahead than almost anybody else I know?

3 – Do I very frequently make careless mistakes and fail to finish tasks on time?

4 – Has this been typical of me for a long time? (Note here that the vast majority of people who have ADHD have had substantial symptoms by age 12.)

5 – Is there no other obvious explanation, such as drug addiction, a head injury, a sleep disorder, or— we really hope not—early signs of dementia?

6 – Have these issues caused me clear problems in my work and/ or relationships?

7 – Do I have any (and possibly many) close relatives also suffering from chronic distraction and impulsivity?


Let’s assume that a psychologist or psychiatrist, or even, as is increasingly the case, the family doctor, has diagnosed ADHD. Now that you know you’ve got it (or a friend or family member has told you they have it), what—along with mindfulness—can help? Here are a few of the most promising approaches, which can of course be combined.

Medication

Prescription medications are by far the most popular treatment for ADHD in children and adults, and research shows that the medications—usually stimulants such as amphetamines or methylphenidate (brand name Ritalin)—can help about 80% of those diagnosed with ADHD. But the downsides include possible side effects, such as insomnia and loss of appetite, on top of risks of dependence and abuse.

Exercise

I occasionally take prescription stimulants, and tend to mainline coffee, but my drug of choice is exercise: usually a swift hike, swim, or yoga class. Substantial research confirms that exercise revs up our brains, while releasing natural pain-relievers (endorphins) and antidepressants (serotonin). That’s why John Ratey, M.D., an associate clinical professor of psychiatry at Harvard Medical School, and author of Spark: The Revolutionary New Science of Exercise and the Brain, says that for some people with ADHD, intensive exercise may actually substitute for stimulants, while for most, it is a helpful complementary tactic.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) can yield benefits in as few as 12 one-hour sessions. In CBT, you learn to recognize and avoid destructive thoughts and beliefs. Such toxic thoughts—“I’m stupid,” “I’ll never succeed”—are common among people with ADHD. Research indicates that medication combined with Cognitive Behavioral Therapy is more effective than meds alone. There is also the eight-week Mindfulness-Based Cognitive Therapy program.

Neurofeedback

Neurofeedback, or biofeedback for the brain, has been drawing considerable attention recently as a potentially helpful, drug-free therapy for ADHD and especially for the stress and anxiety that so often accompanies it. The underlying theory is that people can learn to alter their own brain waves through practice and repetition. You do that practice with electrodes attached to your scalp, which send information to a computer program that provides rewarding or discouraging feedback. Some recent studies show positive results, but the scientific consensus is that more “gold-standard,” peer-reviewed research is needed. Moreover, neurofeedback is expensive, since most therapists recommend 40 sessions or more, at an average of $100 per session, and the field remains so unregulated that it can be hard to find a qualified practitioner.


5 Helpful Books on ADHD

Mindful Parenting for ADHD
By Mark Bertin/New Harbinger (2015)

ADHD: What Everyone Needs to Know
By Katherine Ellison & Stephen P. Hinshaw/Oxford (2015)

The Mindfulness Prescription for Adult ADHD
By Lidia Zylowska/ Trumpeter (2012)

The Family ADHD Solution
By Mark Bertin/St. Martin’s (2011)

Cognitive Behavioral Therapy for Adult ADHD
By Mary V. Solanto/Guilford (2011)

This article also appeared in the April 2016 issue of Mindful magazine.
Katherine Ellison

Katherine Ellison is a Pulitzer-Prize-winning journalist and author of three books on ADHD, most recently including ADHD: What Everyone Needs to Know, written with Stephen Hinshaw, vice-chair for psychology at the University of California, San Francisco, and published in 2015 by Oxford University Press.

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