- It is the brain's job to filter and make sense of the firehose of stimuli, internal and external, from which we drink every moment.
- ADHD is common, affecting nearly 10% of children and over 10 million adults.
- Mindfulness-based approaches in clinical studies and practice have utility in alleviating ADHD symptoms by targeting core pathways.
by Grant Hilary Brenner
ADHD (attention-deficit/hyperactivity disorder) is a common problem among children and adults. ADHD is characterized by difficulty sustaining attention, completing tasks, and inhibiting impulses, accompanied by distractibility, hyperactivity, or both. ADHD negatively impacts self-esteem, relationships, and academic and professional performance, while people with ADHD also bring highly valued creative, insightful, and innovative contributions, often feeling like they are not meeting their full potential.
The CDC reports that as of 2016, almost 10% of children were estimated to have ADHD, with boys twice as likely to be diagnosed than girls. Children with ADHD often have other conditions, including anxiety and conduct problems, requiring sophisticated individual, family, and educational intervention. ADHD begins in childhood and extends into adulthood for many, often undiagnosed and undertreated. Advocacy group CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) reports that about 10 million U.S. adults have ADHD, persisting into adulthood in up to 80% of these people.
Mindfulness, ADHD, and the Brain
Mindfulness can help to alleviate the core symptoms of ADHD by strengthening specific “mental muscles,” brain circuits associated with attention, executive control, and related functions. Because current treatments are often only partially effective, generally safe and straightforward approaches like mindfulness are useful. With this in mind, authors Gu, Zhu, and Brown (2021) published in the Journal of Nervous and Mental Disease a review of the neuroscience of mindfulness practice in ADHD with a focus on brain circuits and clinical findings.
Mindfulness, they report, improves core ADHD symptoms through the cultivation of “sustained attention, emotional control, somatic [body] awareness, nonjudgmental awareness, curiosity and acceptance of the ‘here-and-now,’ distancing from a self-focused perspective, and openness to present experience.” Mindfulness practice requires individuals to pay even attention to a stimulus, typically one’s own breath, noticing without criticism or pressure when attention wanders, registering what the distraction was (often an anxious thought or worry, sometimes a body sensation, etc.) and gently returning attention to the task at hand.
Gu and colleagues discuss four brain circuits involved in ADHD. While many specific areas of the brain have been found to be involved with ADHD in neuroimaging studies, there is a growing recognition that the brain is a complex system, one in which the whole is greater than the sum of the parts. Understanding how the different parts interact dynamically helps us understand how brain activity translates into lived experience.
- Executive attention circuit. Also called “conflict monitoring and resolution,” this brain network serves to inhibit hasty decisions, helping reduce impulsivity and improve self-editing. The executive attention circuit also makes decisions among conflicting choices or stimuli. Many times, the right answer is not the first thing to come to mind, making inhibition a core executive tool so that the initial stream of usually less original ideas can be passed over to allow better ideas to emerge. Mindfulness has been shown to improve executive attention, affecting brain areas including the dorsal anterior cingulate cortex and basal ganglia, involved with stimuli discrimination and behavioral control, respectively.
- Sustained attention circuit. Sustained attention is critical to performance. If we are not able to focus on a task over time, coming back to it after frequent breaks or interruptions, quality and timeliness suffer. This leads to mental fatigue, poor follow-through, and disorganization. Mindfulness practice recruits brain regions involved with sustaining attention, including areas in the prefrontal cortex1. Mindfulness activates the dorsolateral prefrontal cortex and increases “functional connectivity” in the brain, tuning-up relevant networks across many brain regions. Ongoing mindfulness-based approaches have been shown to improve sustained attention in children and adults.
- Impulsivity circuit. This circuit involves a complicated loop—the "cortico-striato-thalamo-cortical circuit" (CSTC)—connecting cognitive, motor, and habit-based brain areas2. Repeating loops of rigid brain activity lead to repetitive distracting thoughts and difficulty inhibiting disruptive behaviors, leading to the characteristic impulsivity seen in ADHD, e.g., blurting out answers or having trouble waiting for one's turn. People low in baseline mindfulness (“trait mindfulness”) are prone to impulsivity, and mindfulness practices improve performance on measures of impulsivity in the lab, as well as in real-world settings.
- Hyperactivity circuit. The CTSC is also implicated in hyperactivity, via motor areas of the brain which lead to constant movement, per ADHD criteria “as if driven by a motor.” Difficulty sitting still, fidgeting, being unable to play quietly, and related hyperactivity symptoms, interferes with task performance, distracts nearby others, and may be misinterpreted as oppositional or intentionally hurtful, leading to additional problems. Consistent practice of mindfulness-based approaches over several week clinical trials improved hyperactivity as well as network connectivity. Brain scans showed mindfulness activated the medial prefrontal cortex, involved with decision-making and memory, and the posterior cingulate cortex, related to memory, self-awareness, and self-control.
Translating Knowledge into Practice
These four brain circuits in turn underpin the “big three” brain networks: 1) the default mode or resting-state network, defining mental activity when we are not engaged in a particular task; 2) the executive control or cognitive control network, involved with the allocation of mental resources including attention, memory retrieval, and emotion regulation; and 3) the salience network, which tunes what we pay attention to depending on what is most important at that time.
Unlike “discipline” meditations which enforce stricter focus, mindfulness practice recognizes that attention wanders for everyone. It is in gently drawing ourselves back to the task where we practice a range of self-regulatory skills. Bringing attention back to the breath is the “rep” that builds mental muscle, strengthening brain circuits, and, according to the Hebbian doctrine3, "Neurons which fire together, wire together." Crucially, the non-judgmental orientation of mindfulness practice reduces self-criticism and perfectionism (Flett et al., 2020).
Mindfulness is helpful in many conditions, including chronic pain, depression, anxiety, and others, but for some may do more harm than good. Compassion-based practices, which add cultivating loving kindness along with mindfulness, may offer additional benefit especially for those with particularly strong self-criticism.
Consistent mindfulness-based practices can provide relief from ADHD symptoms and augment current treatment4. Understanding the function of key brain circuits provides a concrete basis to explain how mindfulness works. Having concrete explanations for what causes problems and how different approaches actually impact the brain increases motivation and commitment by defining therapeutic targets and demystifying complex mechanisms.
1. The prefrontal cortex, where key neurotransmitter such as norepinephrine and dopamine are low in ADHD, is also a medication target. Medications including stimulants increase activity in this brain region.
2. The CSTC is also implicated in Obsessive-Compulsive Disorder (OCD) and other conditions. As the name suggests, signals run from the cortex, through the striatum where habitual behaviors and conditioned responses are re-enforced, to the thalamus which is a sensory and motor relay and regulates alertness, back to the cortex.
3. The term Hebbian learning derives from the work of Donald Hebb , who proposed a neurophysiological account of learning and memory based on a simple principle: ‘When an axon of cell A is near enough to excite a cell B and repeatedly or persistently takes part in firing it, some growth process or metabolic change takes place in one or both cells such that A's efficiency, as one of the cells firing B, is increased.’ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006178/
4. Given that attention and executive function are affected in conditions other than ADHD including developmental trauma, anxiety and mood disorders, and with learning differences, it’s important to properly diagnose in order to guide treatment. Because stimulant medications are often prescribed for ADHD, risking potentially serious adverse reactions makes it important that treatment is appropriate. For therapeutic and behavioral approaches, careful evaluation is equally important to ensure that interventions are targeted and effective.
Gu Y, Zhu Y, Brown KW. Mindfulness and Attention Deficit Hyperactivity Disorder: A Neuropsychological Perspective. J Nerv Ment Dis. 2021 Nov 1;209(11):796-801. doi: 10.1097/NMD.0000000000001388. PMID: 34292276.
Flett, G.L., Nepon, T., Hewitt, P.L. et al. Why Perfectionism Is Antithetical to Mindfulness: a Conceptual and Empirical Analysis and Consideration of Treatment Implications. Int J Ment Health Addiction (2020). https://doi.org/10.1007/s11469-020-00252-w.
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