Three to five percent of children are currently diagnosed with attention deficit hyperactivity disorder (ADHD), or approximately 2 million children in the United States. This disorder is characterized by a combination of symptoms of inattention, hyperactivity, and impulse behavior that is age inappropriate and significantly interferes with customary age-related activities.
As there are no objective diagnostic markers for ADHD, diagnosis involves standardized subjective evaluations and judgments performed by qualified professionals. Although many factors have been considered as possible causative agents in ADHD – ranging from genetics, to early brain train trauma, nutrition, and environmental influences – the cause of this disorder is unknown. ADHD can be accompanied by alterations in normal brain development and morphology that are most likely correlative rather than causal.
The inability to identify a singular causative agent has led to multimodal treatment efforts. These include singly or in combination: medication, behavioral therapy targeted at skill building, environmental adjustment, and coordinated and supportive efforts of family, practitioner, counselor, and teachers. Combined treatment appears to offer some relief although medications are often accompanied by significant side effects. Symptoms may diminish or dissipate as adulthood is approached, although a significant number of individuals may carry these symptoms at varying intensity into later life.
An Integral Perspective
Given the absence of specific identifiable causal agents or circumstances, limited effectiveness of current approaches, and significant and often unacceptable side effects of medications it may be of value to consider alternative understandings and approaches to this disorder.
From an integral perspective there are four major aspects to the human experience. These include: consciousness, biology, interpersonal relationships and social interactions. In order to embrace the wholeness of human life we must understand and address issues of health and disease from each of these arenas of human experience. Failure to do so results in an inability to consider the multi-dimensional nature of health and disease. This leads to partial understandings and partial remedies. The value of the integral perspective is that it reminds us to consider the multi-dimensional nature of the human experience. However, it is essential to remember that although these four aspects of human experience may appear distinct, and can be addressed separately, they are in actuality inseparable from each other. Human life is a unified and integrated experience.
The current understanding and treatment of ADHD is largely limited to conventional perspectives, understandings, and capacities. For example, we are most familiar with attributing health and disease to biological factors, and not surprisingly changes in brain function and physiology are primary targets of investigation. Similarly, our focus on pharmacologic therapies results in an emphasis on drug therapy. These are valuable approaches but their cultural bias suppresses and limits serious consideration of alternative understandings and therapies.
Psychological interventions such as cognitive and behavioral therapy have entered the mainstream of medicine following the seminal work in the late 19th century of the psychologist William James. As a result, psychological understandings and approaches to ADHD have extended our perspective beyond an exclusive focus on biology. Finally, our more recent understanding of social and cultural influences on health and disease has further broadened our understanding and approach. In the best circumstances each of these elements can be brought together to address the complex and poorly understood phenomenon of ADHD.
Consciousness and Health
Yet we are lacking a very significant perspective on this disorder and its treatment. Our preoccupation with the biological sciences and less so with the psychological sciences, has diverted our attention from an exploration of the healing capacities of the uniquely human domain of consciousness.
Human consciousness is a series of ascending developmental levels of experience. Broadly speaking these ascend from basic instinctual and patterned behavior, to rational cognitive thought, to the open, expansive, and non-cognitive domain of spiritual consciousness. An individual’s developmental level of consciousness and its character – healthy or afflictive – is a major factor in health and disease, particularly in those arenas of human experience that are strongly influenced by consciousness.
There can be no argument that ADHD is a particular human phenomenon related to the unique character of human consciousness. I propose that further advances in the understanding, treatment, and potential alleviation of ADHD may depend on our willingness to consider the important role of consciousness and incorporate the understandings and practices of a contemplative medicine into current multimodal treatment approaches.
ADHD and Contemplative Theory
The microscope and its extended versions are central to investigative and therapeutic biological medicine. Contemplative practice, specifically meditation, is central to contemplative medicine. Biological medicine is focused on physiology. Contemplative medicine is focused on alleviating mental suffering, training attention, and enhancing the quality of human life through contemplative practice. There is little doubt that ADHD, seen from the perspective of biology, is conceptualized as an anatomical, developmental, or physiological disturbance. However, when seen from the perspective of consciousness theory it is understood as a disturbance of consciousness.
Contemplative theory poses two levels of distraction or inattention. The first level, the most fundamental one, is an unconscious and conditioned loss of an open natural and naked awareness – our mind’s still, unobstructed, and natural essence. A simple way of grasping this is to experience the brief gap between two thoughts. This gap offers a glimpse of our natural resting consciousness, a natural state of being that we can no longer sustain beyond such brief glimpses. As a result of faulty mind habits we unknowingly wander away from our inner home and, distracted from this ground consciousness, we become drawn into a tight relationship with cognitive mental activity. This habit of falling into cognition and distraction by straying from ground consciousness is deeply ingrained. It is the first and most primary level of mental distraction.
The second level of mental distraction results from and follows this enmeshment in cognitive activity. When our mind is taken over by mental chatter, our experience instantaneously moves in one of two directions. First, our awarnenss may fix or ruminate on a single mental movement – thought, feeling, or visual image. Or, this second level of distraction as is most common to ADHD may show up as a floating distraction. The mind floats from one mental movement to another – the hallmark of inattention. This enmeshment with the cognitive process is reflected in our physiology and expressed in the outer world through speech and action. What follows in the instance of floating distraction is an outward projection of impulsive and hyperactive behavior that corresponds to the hyperactive mental activity seen in ADHD.
In summary the cycle of mental events is as follows: the initial distraction from natural ground awareness – the primary distraction – is followed by the spontaneous emergence of the cognitive process – thoughts, feelings, and images. Cognitive activity may then take the form of a focused fixation or a floating fixation. The result is outer behavior in the form of speech and action that corresponds to the specific character of mental activity. This is the perspective form which contemplative theory understands and approaches ADHD. It is seen as a functional disturbance of an undeveloped and faulty consciousness.
The Practitioner-Client Relationship
Contemplative practice follows contemplative theory. Its aim is to alleviate suffering and promote human flourishing – an enduring health, happiness, and wholeness. Both are perceived as accomplished by the alleviation of the dysfunctional aspects of consciousness and the simultaneous expansion of the mind’s capacities. There are various steps in the pursuit of this goal. I will address only the more basic and essential steps.
Central to the implementation of contemplative practice is the role of the teacher/healer. In modern times this is frequently ignored or considered of secondary importance. We have lost this powerful healing modality as a result of our reliance on generic diagnostic categories, methodologies, and instrumentation. We label and justify this as clinical distance and objective medicine. Metaphorically, the laboratory has gradually replaced the ritual of the ear gently being placed on the chest listening for the sounds of the beating heart in an unspoken communion of healee and patient.
However difficult it may seem in modern times the relationship between the patient with ADHD and the teacher/healer must be re-invigorated with deep empathy, patience, heart, and presence. This is at the core of all healing and in particular the healing that arises from contemplative practice that is traditionally taught in the context of and empowered by this core relationship. This cannot be substituted by group activities, brief visits, or team approaches. Each individual is unique in capacity, temperament, and needs. Diagnosis and care cannot be generic. The one-to-one healing relationship at the core of contemplative practice must be close, personal, and present.
Contemplative theory and practice have directly addressed the issue of inattention, distraction, and dysfunctional behavior with countless methodologies – contemplative and behavioral. Contemplative methodologies begin with one of various techniques whose aim is train attention through the use of the mental faculties of mindfulness and vigilance. These approaches are best tailored to the individual, their age, capacities, and temperament. This may mean frequent fine-tuning of the frequency and duration of mindfulness meditation, and shifting its form, focus and timing in both the formal meditative session and the post-meditation period of daily activities. This may change week-to-week as new skills are developed or new obstacles arise.
It may be helpful to note, particularly for the client with ADHD, that it is a tradition in the East to encourage the beginner to practice meditation for “short periods many times.” Because our habit of distraction is so deeply ingrained it is difficult for the beginner to hold attention beyond a few moments. Strong efforts to do so will only lead to frustration, anxiety, and sense of failure. Short moments of meditation many times allows for the experience of attention to be gradually entrained in the mind while avoiding the negativity engendered by strained effort. In time the individual can naturally extend and stabilize the state of attention gathering new skill, capacity, and confidence at his/her own pace. This is an example of one of the many nuances of mind training.
It is not my intent here to cover the scope of contemplative methodologies appropriate for clients suffering from ADHD. And in actuality that would likely be of little use as the practitioner must be actively involved in contemplative practice to fully understand – theoretically and directly – the essence and subtleties of these approaches. Intellectual understanding is insufficient as is practice experience that is limited to a small number of approaches.
Assisting an individual in training attention requires great flexibility on the part of the healer/teacher. When proper motivation is present and the appropriate practice is skillfully taught and applied every individual can experience a capacity to work with his/her mind that was previously unknown. However brief and unstable the experience of attention or inner stillness may at first be the fact that it is possible to re-train the mind is often a relief and revelation. It is essential to clearly point out and re-enforce this possibility the moment it is realized in the individual’s personal meditative experience. The issue is no longer the possibility of attaining a focused mind but rather one of extending and stabilizing what has already been discovered within through personal effort. Helplessness and confusion is replaced by hope and empowerment.
It is important to re-emphasize here that the human mind is plastic and trainable, if it was not there would be little use for any form of mind training. This is supported by recent neuroscientific research which demonstrates that functional and morphologic change is possible through mental training well into adult life, whether it be that of the master pianist or an individual suffering from ADHD.
The Larger Issue
The individual with ADHD is the proverbial tip of the iceberg. Inattention, mental distraction, and the excesses of outer activity are reflections of an untrained and undeveloped consciousness. For most of us we call this lesser level of ADHD “normal.” In actuality it is the social norm in Western culture. However, when seen from the perspective of a fully developed inner life, with its qualities of clarity, wisdom, inner peace, and universal embrace, this social norm is seen as merely a culturally acceptable lesser level of dysfunction.
The greater teaching of ADHD may be its role in highlighting the universal and pervasive dilemma of an undeveloped consciousness. The disabilities experienced by the individual with ADHD may one day be seen as an instructive microcosm of the accepted and less seen disabilities challenging all individuals. Our aim should not be limited to returning those with overt symptoms to “normal,” but rather, assisting all individuals in attaining the full possibilities of the human condition which result from the intentional development of a higher consciousness.
By adding contemplative practice to the multimodal approach now used to control the symptoms of ADHD we can bring to bear a powerful set of methodologies specifically directed at training attention, and mental calm. These methodologies, whose theoretical base and practical application have been well developed and time-tested, are diverse and highly nuanced. They are grounded in the practitioner/client relationship and can be tailored to a wide range of individual capacities, temperaments, and dispositions.
Beyond their capacity to train attention these very same techniques can assist the individual in moving beyond the relief of symptoms to a greater well-being. Exposure to these approaches in childhood or young adulthood will allow individuals many years in which to learn and fully develop an important group of life-enhancing skills and practices. Although our initial effort is to ameliorate disturbing and dysfunctional symptoms, our larger goal should be to assist the individual in “using” the gift of ADHD as a step to a higher level of living.