The Mindfulness Prescription for Adult ADHD

It was published in 2012 by Shambhala Publications. The foreword was written by the psychiatrist Daniel J. Siegel, known for his writing on mindfulness and interpersonal neurobiology. The book comes with an audio program of guided practices.

Lidia Zylowska is a psychiatrist. She is one of the founding members of the Mindful Awareness Research Center at UCLA. There she ran the first feasibility study that adapted mindfulness training for adults and adolescents with ADHD, and pioneered the development of the Mindful Awareness Practices (MAPs) program for ADHD. She is presented as an associate professor in the psychiatry department at the University of Minnesota. Later she also wrote a separate guide for clinicians together with John T. Mitchell.

I could not reach a verified Turkish edition. The author's site mentions French and Spanish translations, no Turkish. I am writing with the English title.

I opened it with my objection

Telling someone with ADHD to sit quietly and follow their breath had seemed like a joke to me for a long time. Every meditation app I tried turned into a to-do list in the first three minutes. And then I got angry at myself for failing.

I opened the book with this prejudice.

The first surprise was that Zylowska had thought through this objection before me and in more detail than I had. The book's basic design takes into account how mindfulness practice collides with an ADHD mind.

What MAPs does differently

Classic mindfulness programs, for example the eight-week mindfulness-based stress reduction, include long sitting practices. For someone with ADHD this can mean dropping the program in the very first week.

MAPs differs on three points.

The sessions are short. Meditation times are kept shorter than in other programs and the teaching moves step by step.

There is movement and daily life. Alongside sitting practice, walking meditation, body awareness and short pauses scattered through the day take an important place.

Self-acceptance and self-compassion are at the center. The program does not try only to train attention. It also targets how you treat yourself when attention wanders.

The last item became the most important part of the book for me. Attention wandering is not presented as a failure in meditation. Noticing that it has wandered and gently coming back is the practice itself. Someone with ADHD can live this cycle a hundred times in one sitting, and the book suggests reading this as a hundred repetitions.

Reading with this frame, I realized that what I had spent years thinking of as "I can't do meditation" was in fact meditation itself.

The two halves of the book

The book is divided into two parts.

The first part explains ADHD and why mindfulness may help. How the ADHD brain works, what attention and self-regulation are, what mindfulness research says. Here Zylowska also discusses how the mindfulness approach can be combined with other treatments, including medication.

There was a balance in this part that I liked. Zylowska says ADHD can bring both difficulties and relative strengths; she mentions curiosity as one of them. But she does not turn this into a superpower narrative. I did not come across a sentence that belittles the difficulties.

The second part is the eight-step program.

Eight steps

Each step builds on the one before and is designed as one step a week.

1. Coming to the present: attention and the five senses. It starts from the simplest place. Really looking at something, listening, touching.

2. Focus and the wandering mind: mindful breathing. Using the breath as an anchor and noticing when the mind wanders.

3. Directing and anchoring awareness: sound, breath and body. Learning to choose where attention goes.

4. Listening to the body: body sensations and movement. Body scan and awareness in movement. An important step for those who cannot sit still.

5. Observing the mind: awareness of thoughts. Seeing thoughts as events passing through the mind; not counting each of them as reality itself.

6. Working with emotions: awareness of emotions. Noticing an emotion, naming it, being able to stay with it without immediately turning it into a reaction.

7. Skillful communication: mindful listening and speaking. Approaching with mindfulness the communication problems common in ADHD such as interrupting, preparing an answer in your head while listening, and jumping from topic to topic.

8. Slowing down to be more effective: mindful decisions and actions. Putting a small gap between impulse and decision.

The logic of the order is well built. First attention itself, then the body, then the mind and emotions, and last behavior and relationships. The seventh step especially caught me; giving communication such a separate place is rare in ADHD books.

The fifth and sixth steps also touch directly on the difficulties I described in the article on emotion regulation on the site.

Everyday practices

The most useful part of the book, I think, is the short practices placed through the day. There are formal meditations too, but the ones that entered my life were these.

The one I use most is STOP. The letters of the acronym stand for stop, take a breath, observe and proceed. Looking for a few seconds at what is going on in the body, the emotions, the thoughts and the surroundings, then continuing where you left off.

This practice takes thirty seconds. Before sending an email, in the middle of an argument, when I pick up my phone. In ADHD the distance between impulse and action is very short, and STOP tries to place a small gap in that distance.

RAIN is a similar acronym. It too rests on pausing and observing the moment, but is meant especially for when strong emotions come.

The audio program has guided practices such as mindful breathing, body scan, walking meditation, RAIN and loving-kindness practice. For me formal practice without the recording was almost impossible; a voice accompanying acts as an anchor where attention slips.

From group program to book

MAPs was actually designed as a group program. In the study by Mitchell and colleagues, the program was run as two-and-a-half-hour group sessions once a week for eight weeks, with daily practice at home.

The book adapts this program for a reader who will work alone. This adaptation has a cost: the outside structure the group provides, the weekly appointment and seeing others live the same difficulty are not in the book.

Knowing this did me good. When I struggled to keep up the practice, instead of thinking the problem was me, I could see that a support found in the original form of the program was missing. If possible, doing it with a friend, in an online group, or at least at a fixed hour helps close the gap.

Why it makes sense for ADHD

The reasoning for why mindfulness practice may suit ADHD is built in the first part of the book, and I find it convincing.

When ADHD is treated as a self-regulation problem, directing attention deliberately to a place, noticing when it wanders and bringing it back looks like a skill that can be trained directly. Mindfulness practice runs exactly this cycle again and again.

There is a similar logic for emotions. Putting a small distance between noticing an emotion and acting on it can help reduce impulsive reactions.

The reasoning being convincing does not mean the method's effect has been proven. The research section below is about exactly this distinction.

Alongside medication

Zylowska does not present mindfulness as an alternative to medication. The book says openly that the two approaches can be used together.

This is important, because the field of mindfulness and meditation can sometimes slide into a discourse against medication. There is no such tone in this book. The medication decision is made with a physician; mindfulness practice is something that can be tried independent of that decision.

What the research says

The word "prescription" in the book's title set off an alarm in me and I looked at the research side separately.

The first study. The study published by Zylowska and colleagues in 2008 showed that the program was feasible in a mixed group of adults and adolescents with ADHD. Participants' self-reported ADHD symptoms, depression and anxiety, and their performance on some attention tasks improved. But this was a feasibility study with no control group. It cannot say how much of the improvement was due to the program and how much to time or expectation.

A small randomized study. Mitchell and colleagues ran a pilot study with twenty adults comparing the program with a waiting list. A marked improvement in ADHD symptoms was found both in their own reports and in clinician ratings. On executive function tasks in the laboratory, however, no difference emerged between the groups. Twenty people is a very small sample and a waiting list is a weak comparison.

A larger study. In the study run by Hoxhaj and colleagues in Germany in 2018, 81 adults not on medication were assigned to an eight-week MAPs program or to structured psychoeducation. ADHD symptoms decreased in both groups. The mindfulness program did not come out ahead of psychoeducation.

Meta-analysis. The meta-analysis published by Cairncross and Miller in 2020, scanning studies published up to the end of 2014, found that mindfulness-based approaches showed moderate effects, across ten studies for inattention and nine for hyperactivity-impulsivity. The studies of this period, as seen in the examples above, mostly have small samples.

Looking at it together, the picture is this: mindfulness practice may help reduce symptoms in adults with ADHD and appears safe. But it has not been shown to be more effective than a well-built psychoeducation, and the evidence is not at the same level as the evidence for medication or cognitive behavioral therapy.

For this reason the word "prescription" seems to me a bit too ambitious. The book's own text is more measured than its title; but a reader who sees the cover may open it with a different expectation. I covered the subject more broadly in the article does meditation work in ADHD.

Where I struggled

It asks for regularity. An eight-week program, practice every day even if short. For a reader with ADHD the hardest part is coming back to practice every day. The book is aware of this but cannot completely remove this obstacle.

The language is soft in places. The language of mindfulness literature can sometimes be too gentle, too general. Someone looking for a concrete technique may become impatient in some chapters.

Not enough alone with heavy symptoms. For someone with serious loss of function, newly diagnosed, or not yet started on treatment, this book should not be the first step.

For whom, at what stage

For someone who has been diagnosed, has made the basic treatment decisions with their physician, and has understood the picture to some degree.

Especially for someone who struggles with emotional reactions, impulsivity and a harsh inner voice toward themselves. The book's emphasis on self-compassion touches directly on what I described in the article on shame and self-compassion on the site.

It is also a good second chance for someone who tried meditation before and gave up with "it's not for me."

The best way is to read the book one step a week. Read the first part in one sitting and move on to the second, then read one step each week and that week do only the practice of that step. You do not have to finish the eight weeks. I did not either; I took STOP and the fifth step and left the rest. The book's emphasis on self-compassion made it easier for me not to experience this as a failure.