Interviews

ADHD and Mindfulness Study: An Interview with Lidia Zylowska, M.D.
February 2008

By Kelley McCabe

Lidia Zylowka, M.D.., Dr. Zylowska is an adult psychiatrist with an interest in mind-body interventions in psychiatry, particularly mindfulness and spirituality in psychotherapy. Dr. Zylowska completed her medical training at Wayne State University in Detroit, Michigan and her psychiatry training at UCLA. Currently she is affiliated with the UCLA Center for Neurobehavioral Genetics, Center for Psychoneuroimmunolgy and the Center for Neurovisceral Sciences and Women's Health. During her residency training, Dr. Zylowska became interested in complementary and alternative medicine (CAM) and consequently completed a fellowship at the UCLA Center for East-West Medicine and worked as a chief resident of the UCLA Behavioral Medicine Clinic where she piloted a mindfulness-based cognitive therapy for anxiety. In 2003, Dr. Zylowska was awarded the UCLA Robert Wood Johnson Clinical Scholars Program Fellowship during which, in collaboration with the UCLA Center for Neurobehavioral Genetics, she developed Mindful Awareness Program (MAP) for Attention Deficit Hyperactivity Disorder (ADHD). Her current research focuses on the investigation of MAP for ADHD in teens and adults as a model of a self-care approach in mental health.

Kelley: Lidia, Thank you for taking the time to speak with me this afternoon!  I’d like to talk about your research on the impact of mindfulness on adolescents and adults diagnosed with ADHD, but before we do that I’m curious why it is that so many people are diagnosed with ADHD – when it was virtually unheard of 40 years ago?

Lidia: Well, I think it's a combination of two things. One, I think our recognition of the disorder has increased in children - particularly in girls and also in adults. So I think in general there's more awareness of what is ADHD. At the same time we believe ADHD is possibly a result of interaction between genetic pre-disposition as well as early learning or environmental factors.  This interaction may contribute to the fact that we have more prevalence of ADHD over time.  Our current environment not only puts a very high demand on attention but also encourages a significant amount of distraction and multi-tasking.  I think this translates into more impairment if you have ADHD.

Kelley: Yes, very interesting points. And I had read actually not too long ago that physical exercise seems to be a good outlet for kids with ADHD.  I know my kids don't get nearly the physical exercise that I got when I was a kid and I'm just wondering what you think about that.

Lidia: We definitely know that exercise is helpful for a lot of different things, whether it is anxiety, depression or ADHD, and it's particularly helpful for those kids or adults with ADHD who have hyper-activity - since many people report feeling more focused or relaxed after physical exercise.  But I think it's true that our kids are now in a very different environment in school than they used to be.  There's much more emphasis on sitting in class rooms which require a lot of attentional demand and on having to sit for longer periods of time. I think there is perhaps less physical activity; less outlet after school to be active and engaged in more playful activities. Also with all the technology (kids have access to) physical activity has gone down naturally while kids are spending more time in front of their electronic games or in front of computers. More physical activity or even being outdoors would be helpful for the restlessness part of ADHD as well as a way to refresh one’s mind and its ability for focused attention. There’s also a lot of discussion on what's the best way for schools to really address the needs of kids who learn differently or perhaps have different style of processing information…where more creative endeavors versus more traditional teaching would be helpful in our school systems.

Kelley:  Definitely. Well, why don't you tell me a little bit about the work that you've just done?  I've read the study actually several times but I'd love to hear your perspective.

Lidia:  Sure, so what we did with the study was to take typical mindfulness training and make it user friendly for people with ADHD.  We then looked at the feasibility of the training for both adults with ADHD as well as going a little bit younger - to include teenagers – and we hope that this kind of training can be studied with children in the future. Mindfulness meditation is a technique that's derived from Eastern traditions and it is currently used in treatment of depression, anxiety, stress and other kinds of other conditions in psychiatry.  We wanted to use mindfulness, and its apparent self regulation techniques - self regulation of attention, self regulation of emotions - to see if it had a beneficial effect on people with ADHD who often have difficulty with self regulation.  Also, mindfulness is very much about attention: paying attention to attention, tracking your attention, returning your attention to the present moment so it seemed like a natural fit for the symptoms associated with ADHD. 

We developed this program called 'Mindful Awareness Practices for ADHD’, or MAPS for ADHD, which is an 8-week course similar to other mindfulness intervention models.  We wanted to make the so-called formal practice (i.e. sitting or walking meditation) very gradual, keeping in mind that people with ADHD - particularly those with hyperactivity - may having difficulty sitting for longer periods of time.  At the same time, we also emphasized the so-called informal practice aspect of mindfulness training or paying attention in daily life.  For example, really paying attention to sensation of taste when you are eating, paying attention to your breath throughout your day, noticing how you are sitting in a chair in front of a computer, noticing your body while playing sports, and so on.  A big component of the MAPS course was talking about “What is ADHD?” and reframing it as a neurobiological difference that exists on a continuum and can have different types of self-regulation difficulties associated with it.  In this re-framing, curiosity and openness is brought to self-observation, encouraging awareness of both difficulties as well as potential unique positive characteristics that come with ADHD and ultimately developing a better way to work with one’s weaknesses.  Another modification of the course over the traditional 8-week interventions was an emphasis on developing loving kindness - which is sometimes part of mindfulness training and sometimes not.  We thought that aspect was important because there's often low self-esteem in people with ADHD; a kind of reactivity to yourself, negative thoughts, self-criticism, or feeling different.  Overall, the course emphasizes acceptance and self-compassion as a way to promote change.

This was a feasibility study in which we were able to get 25 adults and 8 adolescents to enter the 8-week program and had 18 adults and 7 adolescents finish.  So there was a pretty good adherence to the program - which was a question given that one symptom of ADHD is not being consistent and “staying with the program”.  We were happy to see that the majority of the participants finished and highly rated the training.

Looking at the change before and after the course, we found improvement in self-report of ADHD symptoms.  The symptoms of in-attention and hyperactivity improved significantly – measured before the class, at the conclusion, and - although we did not report this in the paper - we also repeated the measurement 3 months after the training was completed.  We found that there was actually even more improvement at the post 3 month mark than right after the training which was very encouraging.

Kelley: Yes, I would have expected that, that's great.

Lidia:  We also looked at measures of predicting anxiety and depression before and after and we found anxiety and depression improved in adults, although not so much in adolescents.  In addition, we used a battery of tests that are often used to look at cognitive impairment in ADHD.  Even though cognitive impairments are not necessary for a diagnosis of ADHD, it is common to have some trouble with working memory or the ability to hold information “online” for short periods of time. In ADHD, there are frequently so-called cognitive inhibitions or executive function problems, or difficulty being able to ignore distracting information, stay focused on a task, or be organized. 

So we used an executive function test battery that taps into inhibition as well as working memory abilities.  We found improvements on measures of conflict attention and some of the inhibition-implying measures, but not so much improvement on the working memory measures.

In our study we used a computer test of the aspects of attention. The test is called 'Attention Network Test' or 'ANT' and looks at three aspects of attention - alerting, orienting and conflicting. Alerting is the ability to just be alert enough to pay attention, orienting is the ability to shift attention to the target and movement of attention, and then conflict attention is the ability to again pay attention when something else is distracting – and then being able to ignore that distracting information.  Among those 3 aspects, the conflicting attention aspect improved the most significantly.

One limitation of the study was that we didn't have a control group, so that has to be taken into account.  These results are promising, but still preliminary, and our findings will need to be reproduced with a bigger sample a control group.  But overall it is really exciting to see that with this type of mental training, if you can think of mindfulness as a type of mental exercises, you can impact cognition as well as ADHD symptoms.  These results are in-line with some of the work that is already happening within the ADHD world: specifically using mental exercises as a way to impact one’s brain function and help a person with ADHD.  Finally, there are other important benefits to mindfulness, such as better emotional regulation – something that can also be a problem with people who have ADHD.

We think at multiple levels mindfulness can be helpful with attention training, emotional regulation and lowering stress, as well as learning how to relate to yourself in a more loving, kind or compassionate way.

Kelley: That's great – thanks for that summary. So then are you planning a subsequent study?

Lidia: While our study is currently finished, other groups are interested in doing similar work  at UCLA’s Mindful Awareness Research Center (MARC) and elsewhere, wanting to do a follow-on with children or adults.  That would be a really nice way to further validate this study.

Kelley: I have been asked many times if I think using eMindful’s live, interactive virtual classroom (where students and participants can see and hear each other) to teach children about mindfulness would be a good idea.  The rational is children are so great with computers.  Do you think that would be effective? 

Lidia:  That's a good question. I have definitely thought about that – there are a lot of lives touched by ADHD and there have been lots of requests from people not just in the Los Angeles area where we are, but from other states and even all over the world - so I think it would be nice to be able to reach people beyond LA to offer this kind of training.

Kelley:  Yes, I’m wondering if you think the live online class would be as effective or not?

Lidia:  Yes, well I think if there is an interactive component, and members can really interact with each other, and participants really feel like they are a part of a group, then, yes, I think it would be effective. 

Involving parents in this kind of learning can also be helpful as parents are natural teachers to their children, can model mindful communication, and can use mindfulness as a tool for their own well-being and managing stress of parenting.

Another application is adults with ADHD who were diagnosed as adults, grew up thinking that they were different and not quite knowing why.  As a result there is a need for adults with ADHD to connect with other people who are like them and to have a sense of belonging.  The idea of creating an online community of these adults has always been interesting to me.   A community in which you can bring mindfulness to this issue of learning about yourself and accepting yourself as you are – but at the same time being able to keep working at it.  We often talk about balancing when talking to individuals with ADHD - being able to accept something that is difficult, but not giving up - you can work with the difficulties of ADHD and still bring compassion to that work.

KelleyMcCabe is the founder and CEO of eMindful and eMindful Bariatrics. She is an ordained Interfaith Minister, registered in the state of New York, and a hospital chaplain at the Indian River Medical Center. Kelley began her career on Wall Street, where she worked for 20 years as a senior executive in technology for such companies as Salomon Brothers, Lehman Brothers, and Citigroup. Kelley has an M.B.A. from New York University. She is currently teaching mindfulness meditation at the Center for Spiritual Care in Vero Beach, FL.