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Bruno A. Cayoun, PsyD

The role of somatosensory feedback in Attention Deficit Hyperactivity Disorder: three cases treated with Mindfulness–integrated CBT. Bruno A. Cayoun, PsyD. APS Conference 2008 - Hobart Australia. Attention Deficit Hyperactivity Disorder (ADHD): Definition & Subtypes in DSM-IV.

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Bruno A. Cayoun, PsyD

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  1. The role of somatosensory feedback in Attention Deficit Hyperactivity Disorder: three cases treated with Mindfulness–integrated CBT Bruno A. Cayoun, PsyD APS Conference 2008 - Hobart Australia

  2. Attention Deficit Hyperactivity Disorder (ADHD): Definition & Subtypes in DSM-IV • “…A major disorder of self control” (Barkley, 1999). • Predominantly Inattentive (ADHD-PI) • deficits in selective and sustained attention, speed of information processing and memory retrieval • Predominantly Hyperactive-Impulsive (ADHD-HI) • persistent and maladaptive symptoms of hyperactivity and impulsivity • Combined type (ADHD-C) • All symptoms are present

  3. ADHD – Causes and Deficits • Etiology is essentially unknown (NHMRC, 1997) • Genetic, neurophysiological, cognitive, familial and environmental factors • Current views (Barkley, 1997; Sergeant, 2000) • Inhibitory dysfunction as a primary deficit • Decreased ability to regulate motor output or inhibit a response • Associated deficits • Deficit in sustained attention (Heaton et al., 2001) • Dysfunctional reinforcement (Zentall, 1985; Johansen et al., 2002) • Slower general processing speed (Cayoun et al., 2008) • Deficit in Cognitive Flexibility (Tannock et al., 1995; Cayoun et al., 2008)

  4. Mindfulness Three complementary definitions • Sustained attention: “…paying attention on purpose, from moment to moment, and nonjudegmentally” (Kabat-Zinn, 1994). • Cognitive flexibility: “…a state of continuous category formation. A mindful individual creates new approaches to events and situations. He or she is not bound by previously formed rigid attitudes; rather, the mindful person, situated in the present, explores a situation from several perspectives” (Margolis & Langer, 1990). • Inhibitory control: “…mindfulness is achieved through the development of experiential awareness and equanimity, which is the ability to remain unperturbed by an event experienced within the framework of one’s body and thoughts as a result of objective observation” (Cayoun, 2003).

  5. Practice & Operationalisation: 2 Main Aspects 1. Concentration on breathing (“shaping” attention) • Training in sustained attention, meta-cognitive awareness, inhibitory control and attention switching • Benefits include decreased distractibility from irrelevant thoughts and sensory stimuli and cognitive flexibility 2. Systematic body scanning to develop equanimity • A generalised interoceptive exposure and response prevention procedure • Requires inhibitory control to prevent learned responses and foster acceptance • General Aims • Develop greater self-awareness, objectivity, acceptance and detachment with each experiences

  6. General Benefits of Mindfulness Training • Development of metacognitive awareness • Awareness and acceptance of one’s thoughts • Maladaptive thoughts are reprocessed more neutrally (Teasdale, Segal, & Williams, 1995; Chambers, Chuen Yee Lo, & Allen, 2006) • Development of experiential acceptance (i.e., awareness and acceptance of thoughts and body sensations) • Practice of systematic body scanning (two 30-min sessions per day) • Unilateral, Bilateral and Sweeping methods • Facilitates skill transfer • Promotes neuroplasticity in prefrontal inhibitory networks and somatosensory pathways (Davidson et al., 2003; Carey, Bhatt & Nagpal, 2005; Lazar et al, 2005) • Increases internal locus of control (see Witkiewitz, Marlatt, & Walker, 2004)

  7. Main Associated Brain Structures • Parietal Lobe (Interoceptive Awareness) • Plays a major role in • the overall allocation of attention • Monitoring of body sensations • Frontal Lobe (Metacognitive Awareness) • Plays a major role in • control of attention • “online” decision and execution of behaviour • Inhibitory control of reactive behaviour

  8. Neuroplasticity Research • Lazar et al. (2005) • Anatomical MRI measured cortical thickness in 20 long-term mindfulness meditators and 20 matched controls. • Cortical thickness was greater (P < 0.0001) in the prefrontal (BA 9/10) and somatosensory cortices of the meditators relative to controls. • These areas correlated with Mf practice experience • Since behavioural inhibition lies particularly within the orbital-frontal regions of the prefrontal cortex (Barkley, 1999) there may be implications for ADHD • Between-group differences in prefrontal areas were most pronounced in older adults, suggesting that “mindfulness might offset age-related cortical thinning • There may be implications for dementia

  9. Areas 1, 2, 3 are central to interoceptive awareness Unilateral scanning Bilateral scanning Partial sweeping Sweeping en masse Transversal scanning Sweeping in depth (From FitzGerald & Folan-Curran, 2002) Somatosensory Networks And Body Scanning Techniques

  10. (Adapted from FitzGerald & Folan-Curran, 2002) (Adapted from Banich, 1997, p.30)

  11. Somatosensory Cortex and Body Scanning Techniques WEEK 1 WEEK 2 WEEK 3 WEEK 4

  12. Case Study (N = 4) • Participant 1 • 12 year-old boy • Referred by his GP for ADHD-HI leading to peer rejection, anxiety and depression • Father diagnosed with ADHD-C • Participant 2 • 38 year-old male • Referred by her GP for severe depression and ADHD-C • Participant 3 • 31 year-old female • Referred by her GP for depression and ADHD_PI • Participant 4 • 58 year-old female • Referred by her GP for depression, anxiety and ADHD_HI

  13. T Score T Score T Score T Score ? 100 ? 100 ? 100 ? 100 Pre-Treatment Post-Treatment 3-month Follow-up Pre-Treatment Post-Treatment 3-month Follow-up 95 95 95 95 90 90 90 90 85 85 85 85 80 80 80 80 75 75 75 75 70 70 70 70 65 65 65 65 60 60 60 60 55 55 55 55 50 50 50 50 45 45 45 45 40 40 40 40 35 35 35 35 ? 30 ? 30 Emotional Working Plan/ Org. of Inhibit Shift Control Initiate Memory Organize Materials Monitor BRI MI GEC ? 30 ? 30 Inhibit Shift Emotional Self Initiate Working Plan Task Org. of BRI MI GEC Control Monitor Memory Organize Monitor Materials Behavior Rating Inventory of Executive Functions (BRIEF) Child Adult Male

  14. T Score T Score T Score T Score ? ? 100 100 ? ? 100 100 Pre-Treatment Post-Treatment 95 95 95 95 90 90 90 90 85 85 85 85 80 80 80 80 75 75 75 75 70 70 70 70 65 65 65 65 60 60 60 60 55 55 55 55 50 50 50 50 45 45 45 45 40 40 40 40 35 35 35 35 ? ? 30 30 ? ? 30 30 Inhibit Inhibit Shift Shift Emotional Emotional Self Self Initiate Initiate Working Working Plan Plan Task Task Org. of Org. of BRI BRI MI MI GEC GEC Control Control Monitor Monitor Memory Memory Organize Organize Monitor Monitor Materials Materials Behavior Rating Inventory of Executive Functions (BRIEF) – 2 Adult Females

  15. Relationship between Global EF and Somatosensory Feedback

  16. Summary • Mindfulness training was effective in addressing ADHD symptoms in half the clients despite high comorbidity • Effectiveness of treatment was dependant on ability to feel body sensations and prevent reactivity • A gender effect? • Need for research

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