Yesterday, Susan Kaiser Greenland blogged about the need for rigorous attention training to be considered as an alternative or complementary approach to attention deficit hyperactivity disorder (ADHD).
I am a geneticist and researcher of ADHD, having spent 10 years investigating the neurobiology and genetics of this condition. I also know Ms. Greenland well as a friend and as a Board Member of the Innerkids foundation. Her point about attention training is one of great interest among researchers involved in ADHD, there is growing interest in finding tools that can improve attention for children, adolescents, and adults with ADHD, hence the increasing research on investigating programs such as EEG neurofeedback, attention training computer programs, and meditation.
There is no doubt that the predisposition to ADHD is genetic, about 70-80% of one's risk is thought to be encoded in ones genes. But what exactly does that mean? First, your genes are a blueprint to behavior, they encode for proteins that influence brain structures and functions and thus can impact one's way of thinking, feeling, and acting.
But like the blueprint to a house, there is a great variability in how a house may look depending on vision of the home builder and architect, the building materials used, and the environment wherein the house is built.
Second, genetic does not mean fixed. Environmental changes can greatly change outcome, that is, how genes are expressed (by analogy, the choice of the materials for building the house). For example, phenylketonuria (PKU) is a well-known genetic disorder in which individuals with PKU do not produce a particular enzyme needed to breakdown phenylalanine, an amino acid commonly found in many food products. PKU used to lead to mental retardation, before the genetic basis of this disorder was understood; following its discovery, investigators realized that removing phenylalanine from the diet of children with PKU would eliminate the problem. Thus a simple single gene disorder of mental retardation was completely 'treatable' or 'preventable' by a dietary change (today, there are world-wide newborn screening programs for PKU).
We currently do not understand the genetic basis of ADHD or how these genes would lead to cognitive and behavioral problems seen in individuals with ADHD. Research in genetics by our group and others around the world is beginning to identify likely genetic 'blueprints' in ADHD and investigators exploring the neurobiology of ADHD are beginning to unravel the brain structures and functions involved in ADHD.
As these biological bases are uncovered, we are beginning to view ADHD from a new perspective - as an extreme on a normal continuum of functioning. Much like height and weight and IQ, one's predisposition to ADHD may be thought of as an extreme ---- like the end of a normal bell-shaped curve reflecting such population variability.
Thinking of ADHD this way is no different than how we think of dyslexia as being an extreme along a normal continuum of reading ability, or diabetes as an extreme on a normal continuum of glucose tolerance. Being at the extreme in a population can still be 'impairing' so it does not undermine the concept that ADHD is a 'real' condition, or a 'real' disorder in which children, adolescents, and adults, suffer.
To be a 'disorder' requires impairment and by definition, ADHD is a diagnosed only when there is evidence of impairment in at least two settings (e.g. home and school). The interesting concept to realize when thinking about normal variability in a population and the extremes such as that reflected by ADHD, is the important role a 'culture' or 'environmental' milieu has on defining impairment. If behaviors present in ADHD (forgetfulness, losing things, impulsive, difficulty sustaining attention, etc.) were highly valued in education or our culture, the impairing aspects would disappear and instead the biological blueprint of ADHD would no longer generally result in a 'disorder' status.
A colleague of mine once said, 'we can completely eliminate ADHD by eliminating public education'. I'm not suggesting such a radical change, but what I am suggesting is that we take a look at our own prejudices and biases around ADHD, what we don't know and what we don't understand about how our cultural acceptance or lack there of contributes to impairment of this disorder and perhaps many others.
We need each to attend to how the world may be seen or perceived by another to better understand where blinders may lie. I have a simple example from an adolescent with ADHD to illustrate this point. Here are two descriptions of the same ADHD teen from their film class teacher and their honors chemistry teacher. Film class teacher: "Dylan probably has more ideas spill out of his head in one morning than most of his classmates have all week long. He tries very hard in this class. I commend him for creating what can only be described as his own personal film style (something like Monty Python meets The Matrix). His thought process keeps whirring along but he knows when to shift down a couple of gears to keep everyone on the same path. This trait will hold him in good stead in the coming years. Which by the way, he better be spending in this department!" And, his Honors Chem teacher: "I wish I had better news to report concerning Dylan's work. But his attitude in class never really changed very much.
He didn't seem to take any of the work seriously. He needs to do serious (not more) work on a daily basis. He needs to pay attention in class (take notes???) and he needs to turn in all the stuff that other students turn in. If he has questions he needs to ask them (unless they are the off-subject kind he often raises unexpectedly in the middle of a discussion). That means work is the only alternative to continued poor performance". Same kid, different classes, one praising, one strongly critical. In this simple illustration is the world of the ADHD individual.....very inconsistent - one moment perhaps receiving praise and encouragement, the next moment receiving harsh criticism and shame. Far too often the latter outweighs the former in the ADHD individual's world and over time that sort of 'environment' (the land in which the house is built) reeks a sort of havoc on one's self esteem and world view. The creativity and passion in areas in which they may have strengths may become crushed or weakened by areas in which they have difficulties.
This illustration brings me back to the beginning, meditation or medication. Medication is currently the most effective treatment for ADHD, stimulant medication being successful in reducing aspects of impairment in some 70% or more of children and adolescents with ADHD. It is a very successful mode of intervention, particularly when it is tailored to the individual child by a psychiatrist or experienced clinician in treating ADHD. Medication can often be greatly helpful in those areas that a child, adolescent, or adult have difficulties.
Despite many studies investigating non-medication interventions in ADHD, no behavioral program has proven as successful in the treatment of ADHD as medication. This conclusion may change radically in the following years as we begin to understand the genetic underpinnings of ADHD. In the genomic era of medicine, we will likely determine specific genes that influences one's predisposition to ADHD. With such information we can design better medications interventions (tailored to the genetic blueprint) and more importantly developed 'preventive' modalities that can be delivered earlier in life, prior to the onset of symptoms of impairment.
Here is where meditation and other forms of attention training, memory training, or certain behavioral training tools may become even more and more important. We are only now beginning to understand how gene _expression is regulated and what environmental factors can trigger gene _expression. One area of intense interest by our group at UCLA is exactly how meditation or other forms of self-directed attention can impact gene _expression, in other words, can one learn to self-regulate one's own gene _expression? There is growing evidence from neurobiological studies of long term meditators that brain structure and function can change as a consequence of meditation; even in novice meditators, there is evidence for cognitive change in attention from meditation.
Changes in brain activity likely reflect variability in gene regulation, turning on and off genes involved in cellular growth, proliferation and communication. This is a very young field of research that will ultimately blossom as we uncover the etiological of ADHD at a genetic and neurobiological level.
Psychologists have long known that practice makes perfect. I was always so struck by the number of hours it takes to be 'proficient' at various activities. Did you know it only takes 50 hours to learn to play the harmonic well but 1250 hours to do the same for a violin? And to become a high school level competitive swimmer takes some 6000-8000 hours of practice. Yet, how much time do we as a culture allocate for 'training' attention? I would suggest very few, perhaps none with attention being the sole focus of training.
Meditation is a very old tool for training attention, and one that has had over 2500 years of development (largely in Buddhist, Hindu, and other Eastern traditions). It is now an increasing area of interest for investigators exploring the brain and mind (the aspects of our human nature that cannot be objectified completely).
My colleagues and I have just completed a study of meditation as an adjunct to treatment in ADHD. The results look very promising and the work will be submitted for scientific review and publication shortly. Translating the tools of meditation into a secular Western education requires significant effort and Ms. Greenland and InnerKids have done that work for children, pre-K through middle school.
Other groups are developing programs appropriate for teens to adulthood. Until such meditation programs are easily accessible and rigorously evaluated using scientific tools of investigation, they are not likely to receive widespread appeal. As we and others begin to rigorously evaluate meditation as a means of honing attention for individuals with and without ADHD, we can begin to explore our own abilities to self-direct brain processes (and gene _expression involved in such processes). Most importantly, these sorts of practices tend to increase one's awareness of one's own attitudes, biases, etc. and how it feels to be in another's shoes. Through this sort of cultivation of awareness, we can likely emerge as a kinder society in general, reducing impairment for those that think or feel in a way different from the norm.
So medication is an effective means of intervention in ADHD today and may be more so or less so in the future. We must only continue to explore and discover the most effect means of reducing impairment for ADHD; science is a process of continuous discovery; what we know today will change tomorrow.