Mindfulness and Martial Arts Dissertation

Mindful vs. traditional martial arts toward improved academic grades in children diagnosed with ADHD

While medication and psychotherapy are the current best practice in treating attention deficit hyperactivity disorder (ADHD), their benefits and aim are too peripheral and topical — neither resolving the neurological origin of deficits.

Moreover, many are opposed to these treatments and there are few substantiated and readily accepted alternatives. The consequences of ADHD have a ripple effect — as does the lack of more palatable, efficacious, and proactive interventions for children with the disorder. Research has reported wide-ranging benefits for mindfulness and martial arts, independent of one another, yet research addressing the potential academic benefits of integrating these disciplines for ADHD children has not been found. Based on Siegel’s neurological theory of mindfulness, the executive dysfunction model of ADHD, and research on mindfulness and traditional martial arts, it is proposed that a clinical application of mindfulness-based martial arts will improve the academic performance of children diagnosed with ADHD by strengthening attention and behavioral control. I propose a 4-1/2-week intervention coupled with a 4-1/2-week post intervention observation period, where pre and post student report card grades and teacher ratings on the Brown ADD Scales will be collected to compare the differential impact between two martial arts interventions, differing only on the presence or absence of mindfulness training.

Table of Contents

CHAPTER ONE: INTRODUCTION

Summary of Argument

Theoretical and Conceptual Questions

CHAPTER TWO: REVIEW OF THE LITERATURE

Statement of the Problem

Research Problem

Hypotheses

Definition of Terms

Assumptions, Limitations, Delimitations

CHAPTER THREE: METHODS

Description of Research Design

Participants

Instrumentation/Measures

Procedure

Data Analysis

REFERENCES

APPENDIXES

CHAPTER ONE: INTRODUCTION

Summary of Argument

More than one million young learners become sufficiently disillusioned, frightened or frustrated with their classroom experiences to the extent that they drop out of American schools every year (Matthews, Ponitz & Morrison, 2009). For instance, a White House press release emphasizes that, “Every school day, about 7,000 students decide to drop out of school — a total of 1.2 million students each year,” most reporting that school was not interesting and did not motivate or inspire them (“President Obama announces,” 2010, para 6). As many of these students can be identified by sixth grade (“President Obama announces,” 2010), it is clear that much earlier and innovative efforts are needed to engage these students and offer them early exposure to success.

Family background may exceed a child’s cognitive potential in being the greatest contributor to academic and behavioral success in school. In terms of educational disadvantage, Zill and West (2001) indicate the four most prominent risk factors include being from a single parent family, low income or welfare-dependent family, having parents who did not graduate high school, and parents who speak a language other than English in the home. As the presence of multiple risk factors are most suggestive of potential scholastic difficulties (Zill & West, 2001), it must be considered that the genetic linkage of ADHD may contribute to greater incidences of families with single parents of low income and poor education who often distance themselves from their child’s schooling. Zill and West (2001) state that as these risk factors often repeat in families and are linked to poor educational outcomes, increased aggressive behavior, decreased graduation rates, and much lessened income in the adult workforce, early intervention is vital. “Providing a high quality education for all children is critical to America’s economic future [and] is predicated on knowledge and innovation” (Obama, 2011).

This study proposes an investigation of the differential impact between a mindful martial art intervention and traditional martial art intervention on the academic performance and executive functioning (attention) of children with attention deficit hyperactivity disorder (ADHD). Proponents of this ideal operate based on the assumption that young people who understand what is required of them to think critically and learn effectively can develop individual skills and strategies that promote improved academic outcomes (Schapiro & Livingston, 2000). Proponents of this approach also emphasize the need for early interventions in order to maximize their efficacy. In this regard, Langer and Mondoveanu (2010) point out that, “Mindfulness research suggests immediate interventions to make classroom learning a more mindful experience” (p. 136). Moreover, studies of this type are needed more than ever because of the growing interest in mindfulness training, suggesting that some approaches may be superior to others depending on the setting. As Langer and Mondoveanu (2010) conclude, “Of the several ways to induce mindfulness, surely some are better than others. We need to consider this with respect to particular populations and particular settings. Much research is necessary to understand and delineate the boundaries of the phenomenon” (p. 136). To this end, this study will contribute original research to the psychological, mindfulness, martial arts, and education literature because of the following reasons: (a) targets the critical paucity of research with and early interventions for children with disabilities, (b) will evaluate a more palatable and potentially efficacious alternative to the often parentally opposed treatments of medication and psychotherapy for children with ADHD, and (c) may offer a feasible means of potentially remediating the core neurological deficit of attention dysregulation in children with ADHD, rather than exclusively focusing on the management of surface symptoms.

In spite of the ADHD literature clearly conveying that children with the disorder face a multitude of struggles, the manner in which professionals and lay persons approach the disorder is often quite flawed. Of the children who pursue professional consultation for suspected ADHD, few are evaluated comprehensively or by a mental health professional and few comorbid mental health conditions are identified, though present more often than not (DuPaul, 2009, 2008). Coupled with the lack of proactive interventions in early childhood, these flaws lead to inaccurate diagnosis and unsuccessful treatment — if any at all, given frequent parental opposition to and social and cultural stigma toward medication and psychotherapy. Specifically, few children suspected of having ADHD are evaluated comprehensively, or by a mental health professional (DuPaul, 2009, 2008). Pediatricians, whom generally have limited mental health training, evaluate over two-thirds of children diagnosed with ADHD, of whom over half are immediately prescribed medication (Henrick, 2009). Although comorbid mental health conditions are present more often than not with ADHD, few are identified or treated early and few early (proactive) interventions exist (Banks & Zionts, 2009; DuPaul, 2009, 2008; Fitzpatrick & Knowlton, 2009; Kamphaus & Reynolds, 2007; Kelly & Aylward, 2005). Although considered best practice, few substantiated and readily accepted early interventions exist beyond psychotropic medication and traditional psychotherapy, which rarely are eagerly accepted, have social and cultural stigmas, are costly and inconvenient, and most importantly do not remediate core neurological deficits. Alternatively, there is a lack of proactive interventions in early childhood — interventions that could minimize enduring symptoms or potentially alter the problem-ridden course of this typically lifelong disorder. Specifically, through review of the literature and in consultations with experts, no cost effective alternative is present.

As with many conditions, prognosis improves with timely intervention. Therefore, my primary motivation for investigating ADHD in children is to provide an effective early (proactive) intervention — one that will minimize the high comorbidity rate and damaging frustration experienced by children and families struggling to cope with this condition. Prevalence is of course an additional motivation. National Resource Center on ADHD (2010) reports that 4.5 million children between the ages of 3 to 17 have ADHD. Educationally, these children must persistently manage a notable level of frustration, and when coping strategies fail, they can deteriorate academically, behaviorally, and/or socially and can profoundly impair the learning environment around them. Unmitigated, this can lead to a reciprocal escalation or proliferation of problems where students may “learn” to dislike school. Disengagement and other undesirable developments may amass over time, ultimately leading to teenagers, especially males, with an increased potential of adding to the unacceptably high school dropout rate (Matthews et al., 2009). The problem is clear: The failure to intervene early is costly, and thus the need for early intervention is critical. As these problems often take root early in elementary school, local schools may be the most efficient platform for timely intervention and prevention programs and martial arts offer a unique and promising approach (Zivin et al., 2001). Martial arts benefit youth in a variety of ways, yet beyond needed physical fitness, it also teaches students how to develop self-control (Walters, 1997).

Current research reveals that martial arts can be a powerful influence on children (Diamond & Lee, 2011; Lakes & Hoyt, 2004; Palermo, Di Luigi, Dal Forno, & Dominici, 2006). However, two primary dilemmas exist. First, while truly having become a widely recommended endeavor, martial arts are receiving indiscriminate recommendations, at great parental expense, and there is much room for improvement. A more scientific approach coupled with collaboration between parents, teachers, and martial arts instructors would be most advantageous. For example, Response-To-Intervention (RTI) and progress monitoring are mandated in schools across the country to eliminate unsubstantiated interventions and increase accountability in effort to leave no child behind. Second, studies (primarily with teenagers) reveal that participation in martial arts tends to decrease violent and delinquent behavior, surprisingly little research has been done to document potential academic benefits, particularly for special needs children (Bernstein, 2008; Lee & Kim, 2005; Passmore, 2008; Relos, 2004; Walters, 1997; Webster-Doyle, 2001; Young, 2001; Zivin, Hassan, DePaula, Monti, et al., 2001). As the existing research is largely limited to teenagers who are beyond the prime window of opportunity for prevention or early intervention efforts, this study will focus on children age 8-12, where early connections may inoculate at-risk students and set them on a more favorable trajectory. Terrence Webster-Doyle (personal communication, July 1, 2011) illuminates that by effectively challenging the self-imposed limits of each child, students will quickly realize that they can accomplish much more than they ever thought possible. Essentially, this parallels the old adage that we are each our own worst enemy — the biggest fight for each of us, regardless of age, is within.

Theoretical and Conceptual Framework

Mindfulness psychotherapies are considered the third wave of behavior therapy, preceded by cognitive therapy as the second wave and behavioral therapy as the first wave. Hayes (2004) indicates the first wave was based on establishing empirical support for behavioral principles; the second wave on establishing empirical support for cognitive, behavioral, and emotive principles; and the third wave on expanding empirical support for integrative applications of mindfulness with evidence-based behavioral and cognitive principles. Importantly, the third wave originated from philosophical changes in the field and various research anomalies that were incompatible with contemporary scientific theories (Hayes, 2004). The main difference between second and third wave therapies, beyond integrating mindfulness, is in how problems of control and avoidance are approached. To best capture a solid understanding of the psychotherapeutic growth of mindfulness in the West, a historical trajectory will be illustrated through a review of its predecessors — the eminent historical theories in psychology.

In the 1890s Sigmund Freud conceived his structural and physics-based theory of psychoanalysis — the talking cure. In this legendary “science of the mind” approach, Freud (1965) indicates that behavior is largely determined by one’s childhood, irrational drives, and unconscious conflicts that are protected from awareness by defense mechanisms. Much like what will be discussed of MBCT, Freud’s goal was to make the unconscious conscious and work through issues to rid deviant behavior (Freud, 1965). However, though trail blazing the notion of a talking cure into modern science, the approach was time consuming and unobservable — thus irrefutable in a period of growing scientific scrutiny.

Behaviorism developed concurrently with and as a reaction against the introspective nature of psychoanalysis (Polkinghorne, 2003). It was an antiseptic theory of conditioning which posited that one’s response to environmental stimuli exclusively shaped behavior. Specifically, it focused on behavior instead of consciousness, objective observation rather than introspection, and prediction and management of behavior instead of understanding mental events (Skinner, 1938; Watson, 1913). Skinner (1974) stated, “Thinking is behaving. The mistake is in allocating the behavior to the mind” (p. 104). While behaviorism led the field away from its niche as a science of the mind, it notably positioned psychology as an experimental science. Behaviorism dominated until achieving “intellectual critical mass” in the 1960s (Hunt, 2007, p. 315) with a paradigm shift to cognitive science — the Achilles heel of behaviorism.

Cognitive psychology, by contrast, asserts that perception of an event shapes experiential reality. Rene Descartes’ (1983, Part 1, article 7) famous quote “Cogito ergo sum” (I think, therefore I am) emphasizes this theory of mind. While earlier cognitive-oriented works of Wundt, Titchener, Brentano, James, and Dewey were displaced during the reign of behaviorism, the cognitive revolution emerged in the 1960s, with works of Piaget and Neisser among the most influential (Solso, Maclin, & Maclin, 2008). Opposing Skinner, Neisser (1967) stated, “Cognition is involved in everything a human being might possibly do” (p. 4). However, whereas behaviorists believed everything to be attributable to behavior, in near parallel, cognitivists overemphasized cognition. The treaty between these paradigms imparted cognitive behavioral therapy (CBT), which presents balanced integration of both perspectives and is considered state-of-the-art in terms of empirical support.

CBT explores the function that thoughts play in behavior and is premised on the notion that by changing thoughts, one can change behavior. The archetype models of Ellis (1962) and Beck (1970) lead to modern CBT comprising of “approximately 80 distinct techniques” (O’Donohue & Fisher, 2008, p. 2) and more than 70 evidence-based treatments (Fisher & O’Donohue, 2010). CBT has become a general classification of psychotherapy with each expression sharing fundamental principles including a collaborative, time-limited, present-focused, and evidence-based approach (Butler, Chapman, Forman, & Beck, 2006). The aim is to help clients first become aware of and then restructure distorted or faulty thinking and the behaviors that are maintaining this thinking (Beck, 2011). Strengths include refutability and active human agency from a wellness orientation (Ledley, Marx, & Heimberg, 2005). Limitations include the foundations on which CBT rests, complexities in comparative analysis with other good psychotherapies, and effectiveness with complicated conditions (Holmes, 2002).

Mindfulness originated from a variety of ancient Eastern traditions, with current research sprouting vastly diverse and empirically supported applications across many Western disciplines (Sears, Tirch, & Denton, 2011). According to Williams (2011), “Finding life difficult isn’t a new problem. People do feel more anxious, stressed and depressed at a younger age than they did 50 years ago, but mindfulness meditation emerged 2,500 years ago” (p. 43). Yet until a surge in the literature began in the mid 1990s, this timeless Eastern philosophy and practice received little professional recognition or acceptance in Western culture (Didonna, 2009). However, since the first Western publication in 1982, the number of scientific publications related to mindfulness has grown exponentially (Didonna, 2009; Kabat-Zinn, 1982). Kabat-Zinn, a molecular biologist and Zen practitioner, is credited with the Western mindfulness movement and with pioneering the first scientific mindfulness application, mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990), in 1979 at the University of Massachusetts Medical Center. What is mindfulness? Kabat-Zinn states, “Mindfulness lies at the core of Buddhist meditative practices, yet its essence is universal [secular]. It has to do with refining our capacities for paying attention, for sustained and penetrative awareness, and for emergent insight that is beyond thought” (Segal, Williams, & Teasdale, 2002, p. viii). According to Langer and Moldoveanu (2000) mindfulness can also open up new avenues to solutions that might go otherwise undiscerned. In this regard, Langer and Moldoveanu (2000) emphasize that, “A mindful alternative would be to consider ‘functional diversity’ as a way of relating to differences among people. If we assumed that people behaving differently from us are not inferior, but rather are viewing the same stimulus differently, we could take advantage of the different perspective they offer” (p. 132).

Though similar to hypnosis, relaxation techniques, and meditation, mindfulness is distinctly different through its deliberative focus on being fully aware and engaged in the experiences of the moment — whatever they may be — rather than seeking escape or avoidance. Hayes (2004) states pain turns into suffering when we try to push it away and he emphasizes this through metaphors such as: Is it easier to drag a heavy weight far behind you or walk with it held closely? Essentially, mindfulness is a deliberate awareness of what human beings most ignore — the present. It is an awareness process, not a thinking process (Harris, 2009).

While philosophical and psychological history is embedded with arguments over the origin and interpretation of behavior, mindfulness has returned Westerners to the original speculations of ancient philosophers and early psychologists in terms of conscious awareness. Most interestingly, Lau and McMain (2005) state that William James predicted the influence Buddhism would eventually have on western psychology. Likewise, other authorities have weighed in on this issue: “Just as philosophy can be seen as footnotes to Plato, so much of contemporary psychology can be seen as footnotes to William James” (Kessen & Cahan, 1986, p. 648).

Psychologically, different theorists deduce different explanations for psychopathology, primarily given individual experiences within the era zeitgeist, which lead to various ways of conceptualizing problems. With depression, Freud may speak of inadequate defenses with vulnerabilities stemming from childhood; Erikson may see unfulfilled potential for adventure; Skinner may perceive a response to reduced positive reinforcement; Bandura may believe in a lack of mastery experiences; Beck may propose negative automatic thoughts generated by underlying dysfunctional beliefs; and Segal may be mindful of a habitual linkage between negative moods and negative thoughts. Overall, it would appear that psychology has completed the “transcendental slide from God, to Nature, to Mind, to Method [, to Function, to Being]” (Kessen & Cahan, 1986, p. 640).

Mindfulness is not about a set of skills or techniques, it is instead a way of being or a way of seeing, one that is helpful in relating to difficult experiences (Jon Kabat-Zinn, personal communication, October 24, 2011). Other authorities also agree that promoting mindfulness in young people can provide a number of valuable outcomes. For instance, Segal et al. emphasize that, “The most enduring changes in patients seem to come from shifts at a deeper level than simply acquiringnewskills and techniquesthough acquisition of those skills might have been the vehicle through which the wider shift occurred” (2002, p. 65). According to Castonguay and Beutler (2006) mindfulness therapy is an experimental intervention that is not focused on the treatment of depression but rather on relapse prevention, and “mindfulness-based treatments have shown some positive results” (p. 92).

With this understanding, it must be appreciated that all techniques utilized in any mindfulness application (i.e., raisin exercise, body scan, conducting routine tasks mindfully, etc.) are mere tools to facilitate attending — as the true essence of mindfulness is about awareness, presence, and love (Jon Kabat-Zinn, personal communication, March 30, 2012). Therefore, it is important to note that while this study involves an intervention integrating mindfulness and martial arts for ADHD children, it relates exclusively to the benefits that may be derived from their practice rather than any physical fighting aspects that might otherwise be involved. Traditional martial arts are not about the fighting, but instead about practitioners finding their way and determining who they are — essentially, a means toward self-improvement. Everyone has a fight in this life, though not necessarily with their fists, but rather with their mind and this is the concept that forms the focus of this study as discussed further in chapter two below.

CHAPTER TWO: REVIEW OF THE LITERATURE

Chapter Introduction

This chapter presents a review of the relevant literature concerning the various aspects of mindfulness, martial arts, attention, ADHD, and education. An examination of the growing calls for early intervention and for the need for early identification and intervention with ADHD children is followed by a discussion concerning the proposed study’s research problem of interest, the statement of the problem, hypothesis and definition of key terms concludes this chapter.

Review and Analysis

Until a recent surge in the literature, the timeless Eastern philosophies of traditional martial arts and mindfulness training had received little professional recognition or acceptance in Western culture (Didonna, 2009). However, despite this long overdue popularity, there continues to be a delay in the psychological literature addressing the potential benefits of these traditional practices for children, particularly special needs children such as those with mental health disabilities. Recent research has reported wide-ranging benefits for mindfulness and martial arts, independent of one another (Chan, Sze, & Dejian, 2008; Palermo, Di Luigi, Dal Forno, & Dominici, 2006; Sears, Tirch, & Denton, 2011), yet research addressing the potential benefits of integrating these disciplines with children is limited and is an identified area of need in the literature (Block-Lerner, Holston, & Messing, 2009; Sears, Tirch, & Denton, 2011). Therefore, I intend to extrapolate from the independent research examining both disciplines and to assimilate the principal findings from my pilot study conducted from August 2009 through March 2010, to further continue to investigate the benefits that might be derived for children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) from an integration of these techniques, i.e., a mindful martial arts clinical intervention.

Among the many reasons for focusing on children, perhaps the most advantageous is the strikingly beneficial and remedial impact that early behavioral interventions can have on children, and their families (Felt, Lumeng, & Christner 2009). While some may argue that remediating parental maladies might be a more important primary focus, I contend that early intervention with children holds the greatest potential investment in long-term life benefits, yet few effective early interventions exist for at-risk children (Banks & Zionts, 2009; Fitzpatrick & Knowlton, 2009; Kelly & Aylward, 2005).

Why focus on mindfulness training for ADHD? The primary reason is due to the prevalence of the disorder in childhood, or at least the prevalence of the diagnosis. ADHD accounts for nearly half of all childhood mental health referrals in the United States (Rhee, Feigon, Bar, Hadeishi, & Waldman, 2001). Although estimates vary, a recent study by Wegrsyn, Hearrington, Martin and Randolph (2012) reports that, “Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed childhood neurobehavioral disorder, affecting approximately 5.5 million children, of which approximately 66% take ADHD medication daily” (p. 107).

Other authorities report that 4.5 million children between the ages of 3 to 17 (7% prevalence rate) have ADHD (NRC, 2010a) and 66.3% are prescribed medication for the disorder (CDC, 2010). However, medication is an incomplete treatment. Although medication may improve a child’s productivity, it does not directly improve deficient skills, academic or executive. In this regard, Singh et al. (2010) report that, “Pharmacotherapy is the standard treatment for ADHD, with the stimulants (i.e., methylphenidate, amphetamine) being the first choice of drugs” (p. 158). There has been some research conducted using non-stimulants such as atomoxetine that indicate these alternatives may be at least moderately effective in treating the symptoms of ADHD (Singh et al., 2010).

The two conventional best practice approaches, pharmacological and/or behavior therapy, have shown mixed results with respect to their efficacy. According to Singh et al. (2010), “The combination of intensive medication management and multi-component behavior therapy was [shown to be] superior to behavior therapy alone and routine community care. However, the superiority of the combined treatment disappeared at the 3-year follow-up” (2010, p. 158). A reported effect size of 0.83 for between-group studies and 0.70 for pre-post studies in a meta-analysis of behavioral treatments for ADHD provides strong support for the effectiveness of behavioral treatments (Singh et al., 2010). Both approaches, pharmacotherapy and behavior therapy, require provision of the treatment by physicians or parents who have received behavior management training (Singh et al., 2010).

Despite their known efficacy, both of these approaches also have inherent limitations to (Singh et al., 2010). For example, pharmacotherapeutic regimens have well documented side effect problems, and between 10 and 20% of young people with ADHD are non-responsive to these interventions (Singh et al., 2010). Likewise, behavior management interventions have a number of limitations, including problems with implementation as a result of the failure of many parents to consistently follow the prescribed protocols, especially during the absence of crises (Singh et al., 2010). A common limitation to pharmacotherapy and behavior management is their lack of a self-management component that helps young people learn the strategies they need to control their behaviors (Singh et al., 2010).

Despite the limitations, there is a growing body of research that supports the use of parent training programs based on behavioral or cognitive behavioral principles to effect behavioral changes in children with ADHD as well as in their parents and family members (Singh et al., 2010). Notwithstanding the reasonable effectiveness of CBT-based interventions for children with ADHD, Singh et al. (2010) caution that the risk exists that parents will resort to some type of aversive or punishment contingencies. According to Singh et al., though, “While effective in the short-term, these procedures typically do not teach the children socially acceptable replacement behaviors and their use by parents may, in fact, initiate coercive parent — child interactions with some children, especially those with oppositional defiant disorder” (2010, p. 158). Consequently, there is a need for parent training initiatives that avoid using punishment contingencies in their parent training programs (Singh et al., 2010).

Worldwide, it is estimated that 8 million adults (4.7% prevalence rate) have ADHD and most are undiagnosed (CHADD, 2011; Wadsworth & Harper, 2007). Although many adults in the United States may seek treatment for comorbid mental health and substance-related conditions, treatment for the ADHD, which could be argued as the origin for ensuing comorbid conditions given the diagnostic age criteria for symptom onset, tends not to occur (Kessler, Adler, Barkley, & Biederman, 2006). In addition, Kessler et al. (2006) further indicate a need for effective intervention to lessen the onset, persistence, and gravity of comorbid conditions. Essentially, ADHD can be a life-long mental health disorder with life-long implications.

ADHD interferes with an individual’s ability to regulate mental and physical self-control in developmentally appropriate ways (NRC, 2009b), centering on issues of persistence and consistency. According to Barkley, “ADHD is now thought to be as much a disorder of self-regulation and executive functioning as it is in attention” (2007, p. 281). The concept of an executive inhibitory dysfunction component in ADHD has been advanced and studied, but the results of the research to date remain mixed and flawed (Nigg, 2001). Despite these limitations, the research to date indicates that at least part of the variance in executive dysfunction is ADHD specific (Nigg, 2001). The severity of the disorder varies as sufferers grow older, but many ADHD patients experience life-long problems, particularly with respect to academic and social performance (Nigg, 2001).

According to Schapiro and Livingston (2010), “Active and dynamic self-regulation represent two fundamentally different sources of control, each of which needs to be considered in the study of successful learners. The first, active self-regulation, involves focused, deliberate control over the cognitive processes. It calls upon appropriate use of clearly defined strategies, such as rehearsal to enhance memory or outlining to organize material. This approach, based upon self-awareness and exacting volition, parallels traditional definitions of self-regulation as contained in the expressions active learning and executive control” (p. 24).The other source of control, dynamic self-regulation, is described by Schapiro and Livingston as being, “More spontaneous, dynamic self-regulation involves an internal disposition that drives interest, curiosity, risk-taking, enthusiasm, and persistence as means for stimulating learning” (p. 24).

When young people become capable of dynamic self-regulation, the educational process is facilitated across the board. In this regard, Schapiro and Livingston emphasize that when students achieved dynamic self-regulation, they “feel free to elaborate and find new connections between the specifics they are learning and broader applications. They readily use what they learn in new contexts. These dynamic qualities advance a student’s disposition to learn” (p. 24). Finally, in contrast to active self-regulation, the distinctive qualities of dynamic self-regulation appear to have a stronger influence on improving academic outcomes generally. For example, Schapiro and Livingston (2010) conclude that, “While the precise biofunctional operation of dynamic self-regulation is less well understood than active self-regulation with its well-defined strategies, dynamic self-regulation accounts for significantly more variance in academic achievement than does active self-regulation” (p. 24).

According to the NRC (2010a), the three most common comorbid conditions include Oppositional Defiant Disorder (41%), Depression (22%), and Anxiety (15%). Learning disabilities are also prevalent. Adaptively, the school environment for ADHD children is often problematic, with academic and social challenges that lead to conflicts with parents, teachers, and classmates. These children often do not complete tasks, requiring considerably more effort than peers to do so, and among many other behaviors are often misunderstood; thus, it is not surprising how frustration, avoidance, and agitation can arise. Children with ADHD are more likely to be retained in a grade, be placed in special education, and to struggle socially (Frick & Silverthorn, 2001). As these children grow older, “Adolescent outcomes of children with ADHD show that they are more likely to drop out of school, to rarely complete college, to have fewer friends and to participate in antisocial activities more than children without ADHD” (NRC, 2009a, para. 4).

Poor impulse control and the inability to consider consequences often lead to unfavorable situations and accidents. Thus in adolescence and adulthood, increased rates of vehicle accidents, sexually transmitted diseases, teen pregnancies, incarceration, drug dependence, and job instability are evidenced (NRC, 2009a). Employment difficulties are common, yet understandable given the challenges presented by occupational and social responsibilities. Marriages are especially vulnerable and marked by conflict and family discord. For instance, “Adults with ADHD very often are lonely and isolated because they haven’t learned the social skills others expect them to have” (NRC, 2009c, para 4). Behaviors such as forgetfulness, irresponsibility, messiness and disorganization, poor communication skills, limited frustration tolerance, and poor time management greatly impede relationships at all ages (NRC, 2010b). However, it is important to note that while many individuals with ADHD struggle with the aforementioned, not all do, as there is a wide spectrum of severity.

Many children with ADHD have comorbid emotional/behavioral issues and a triple threat exists for these youngsters. First, research indicates that many emotional/behavioral issues in early childhood often go under-identified or unidentified, and are strongly connected with problematic academic performance (Kamphaus & Reynolds, 2007). Educationally, these children often deteriorate academically and socially and can profoundly impair the learning environment around them. In general, these issues tend to unfold into a multitude of struggles over time that can destroy self-worth. Of more concern, only 15 to 20% of children with documented emotional/behavioral issues receive any type of mental health services (Kamphaus & Reynolds, 2007). In addition, few effective early intervention programs exist for at-risk children (Banks & Zionts, 2009; Fitzpatrick & Knowlton, 2009; Kelly & Aylward, 2005). The problem is clear: The failure to intervene early is costly, and thus the need for early intervention is critical. As these problems often surface during the elementary years, schools appear to be the most efficient platform for the initiation of timely intervention and prevention programs. A study by Wegrsyn et al. (2012) investigated the use of a nonpharmaceutical alternative in improving academic engagement of ten 5th through 11th grade students who had been diagnosed with ADHD. According to Wegrsyn and her associates (2012), “Participants were asked to play ‘brain games’ for a minimum of 20 minutes each morning before school for 5 weeks. Engagement was measured at three points in time using electroencephalogram, parent and teacher reports, researcher observations, and participant self-reports” (p. 108). The results of this study lent support to the researchers’ hypothesis that brain games use on a daily basis in the classroom can facilitate focusing ability and executive functioning in young learners with ADHD (Wegrsyn et al., 2012). Based on their findings, the authors concluded that, “The results provide hope for those searching for an alternative or supplement to medication as a means of helping students with ADHD engage in the classroom” (Wegrsyn et al., 2012, p. 107).

Current research reveals that other methods of engaging young learners with ADHD such as martial arts can also be a powerful influence on children (Diamond & Lee, 2011; Lakes & Hoyt, 2004; Palermo, Di Luigi, Dal Forno, & Dominici, 2006). However, the research is largely limited to reductions in behavioral issues. Studies have revealed for some time that participation in martial arts tends to decrease violent and delinquent behavior in children, yet little research exists to document the potential academic benefits, particularly for special needs children (Bernstein, 2008; Lee & Kim, 2005; Passmore, 2008; Relos, 2004; Walters, 1997; Webster-Doyle, 2001; Young, 2001; Zivin, Hassan, DePaula, Monti, et al., 2001).

Although thousands of years old, in Western culture it has only been over the past two decades that mindfulness has gained increasing evidence-based recognition within the professional community, scientific literature, and public domain (Didonna, 2009). Simply defined, mindfulness is “the opposite of mindlessness [or]sleepwalking through life [it is]a heightened presence of mind [and a]focused attentiveness” (Sears, Tirch, & Denton, 2011, p. xi). The mindfulness movement in the West is credited to Jon Kabat-Zinn (1990), who pioneered Mindfulness-Based Stress Reduction, or MBSR. Since that time, Kabat-Zinn’s work has influenced the development of Dialectical Behavior Therapy (Linehan, Heard, & Armstrong, 1993); Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999); and Mindfulness-Based Cognitive Therapy (Segal, Williams, & Teasdale, 2002).

While there are specific common factors across psychotherapies, mindfulness is not among them; it is more accurately an independent approach requiring systematic training (Sears, Tirch, & Denton, 2011). Much like any other skill it requires practice, relying heavily on developing multiple modes of attention including arousal, sustained attention, selective attention, alternating (shifting) attention, and divided attention — all of which are weaknesses in ADHD children that impact academic performance. The practice originated from a variety of Eastern traditions, with current research sprouting vastly diverse applications across many contemporary Western disciplines, including psychotherapy. However, while there is impressive empirical support for adult mindfulness applications, including neurological research suggesting the potential to change neural circuitry and structure (Sears, Tirch, & Denton, 2011), research with children remains sparse. The limited research that has been conducted, though, supports the use of mindfulness training to improve academic and social outcomes. In this regard, Singh, Singh, Lancioni, Singh, Winton and Adkins (2010) report that, “Children with ADHD are often non-compliant with parental instructions. Various methods have been used to reduce problem behaviors in these children, with medication and manipulation of behavioral contingencies being the most prevalent” (p. 137).

These best practices, though, are not without their problems and their detractors. For instance, Singh et al. add that, “An objection often raised by parents is that these management strategies require them to impose external control on the children which not only results in the children not learning self-control strategies, but also does not enhance positive interactions between them and their parents” (2010, p. 137). Despite these concerns, though, the research to date suggests that mindfulness training has significant positive outcomes beyond behavior management. In this regard, Singh et al. (2010) emphasize that, “Studies have shown that providing mindfulness training to parents, without a focus on reducing problem behaviors, can enhance positive interactions with their children and increase their satisfaction with parenting” (p. 137).

The plan for the proposed investigation is to expand on and integrate the limited amount of research in the narrowly defined areas of mindfulness, martial arts, and early intervention for children with ADHD. I intend to extrapolate findings to my dissertation in order to better our understanding of how and why these applications may benefit children academically and behaviorally. It is proposed that an increased availability to learn, as a result of decreased behavioral interference and enhanced attention will culminate in improved grades for ADHD students.

Reflecting on Baumeister’s (1997) theory of self-regulation, Lakes and Hoyt (2004) indicated that effective self-regulation increases one’s capacity for success while also reducing self-destructive behavior. In addition, Brown (2005) found that Tae Kwon Do training aided affective regulation but did not improve attention deficits. However, the theory proposed by Daniel Siegel (2007) regarding the neurological mechanisms of mindfulness and the brain, specifically the intrinsic quality of focused attention and social implications, certainly seems to target the aforementioned weaknesses experienced by ADHD children. Therefore, it is proposed that an increased availability to learn, as a result of decreased behavioral interference and enhanced regulatory functioning, attention, and self-care, will culminate in improved grades for ADHD students.

Research Problem

The research problem of interest to this study concerned mindfulness as an early intervention for children with ADHD. As there is an indicated need for applications with children in the mindfulness literature, the scope of this paper will focus on mindfulness as an early intervention with potentially long-term effects for children with ADHD. My interest in this topic is also led by the fact that early behavioral interventions can have strikingly beneficial impacts on children, and their families (Felt, Lumeng, & Christner 2009). However, few truly effective early interventions exist for at-risk children (Banks & Zionts, 2009; Fitzpatrick & Knowlton, 2009; Kelly & Aylward, 2005) and Kessler, Adler, Barkley, and Biederman (2006) specifically indicate a need for effective interventions to lessen the onset, persistence, and gravity of comorbid ADHD conditions. Based on the evidence that exists from adult mindfulness applications, I contend that a mindfulness-based early intervention for children holds great potential for possibly altering the intensity and course of ADHD, while also likely minimizing the long-term detriments that result from on-going exposure to repeated frustration and failure.

Statement of the Problem

ADHD is a chronic and behaviorally defined mental health disorder that accounts for nearly half of all childhood mental health referrals in the United States (Rhee, Feigon, Bar, Hadeishi, & Waldman, 2001). The disorder interferes “with an individual’s capacity to regulate activity level (hyperactivity), inhibit behavior (impulsivity), and attend to tasks (inattention) in developmentally appropriate ways” (National Resource Center on ADHD [NRC], 2009d). Additionally, it may also relate to organization, processing speed, short-term working memory, emotional management, and sustained motivation and alertness. In essence, it is an inability to adequately regulate mental and physical self-control. The ability to adequately regulate mental and physical self-control is an important issue because these aspects of movement and variation of perspective have traditionally been regarded as being factors that adversely affect attention, while stillness and constancy have been traditionally regarded as being the antecedents of paying attention (Carson, Shih & Langer, 2001). According to Carson and her associates (2001), though, “These assumptions, however, are at odds with what cognitive researchers have discovered about the nature of attention, namely, that attention is drawn to, and held by, novelty rather than stillness and constancy in the environment” (p. 183). The danger exists, therefore, that educators, parents and clinicians alike may be mislead by conventional approaches to interpreting this type of behavior as being a behavioral disorder. In many cases, though, such behaviors are simply part of youthful exuberance rather than a psychological disorder. In this regard, Jacobelli and Watson (2008) emphasize that, “Let’s take the highly energetic child for example. This is the little guy or gal who just loves to explore and has a hard time paying attention to any one thing for very long. This exuberant child might be excited by everything from the circular, spinning rack at the dress shop in the mall, to a lone insect that’s found its way to the child’s classroom desktop” (p. 9). When these types of young learners are diagnosed — and saddled — with ADHD, the question is begged as to what sets these students apart from their peers who may also act out in this fashion from time to time? As Jacobelli and Watson ask, “What will determine whether or not this child is labeled ADHD? If given this label, what is it that differentiates the child from other intense, highly energetic, or stressed kids who are not diagnosed with ADHD?” (p. 9).

Experts in the field now believe that ADHD is as much a disorder of self-regulation and executive functioning as it is of attention (Amen, Hanks, & Prunella, 2008; Barkley, 2007; Brown, 2007; Jennings, 2003). Self-regulation pertains to the ability to adapt mental and physical self-control. Executive functioning pertains to the brain’s management system. Executive functions guide sections of skills to enable balanced production, just as the section leaders in an orchestra guide sections of instruments to enable balanced production. Brown (2007, p. 22) states that ADHD is “not a simple behavior disorder but rather a complex syndrome of impairments in the management system of the brain.” Given the above metaphorical example, Brown states that the individual musicians often work quite well, but the conductor and section leaders are unable to efficiently direct and integrate the output to perform a task. Hence, skills are cued by clusters of executive functions and deficiencies are now the proposed source of academic, social, emotional, and/or behavioral deficits in ADHD.

Moreover, ADHD impacts individuals of all ages and cultures (American Psychiatric Association [APA], 1994). It is reported that 4.5 million children between the ages of 3 to 17 (7% prevalence rate) have ADHD (NRC, 2010) and 66.3% are prescribed medication for the disorder (Centers for Disease Control and Prevention, 2010). The condition affects boys to girls 4:1 in the United States (Frick & Silverthorn, 2001). Research indicates that girls suffer fewer ADHD symptoms than boys, yet present higher rates of comorbid internalizing disorders and learning problems, while boys exhibit higher rates of disruptive behavioral disorders (Balint, Czobor, Komlosi, et al., 2009). Symptoms are usually first observed in the toddler years and initial diagnosis is most common during elementary school, with symptoms typically lessening throughout adolescence and adulthood (APA, 1994). However, in adolescence, symptoms may be subtle yet more disabling than in childhood (Brown, 2007). Though features vary with maturity, many individuals face lifelong adaptive, social, medical, and comorbid psychiatric challenges that create endless obstacles to be countered.

Symptoms typically worsen in large group settings, situations requiring sustained mental effort, or those lacking inherent appeal or novelty — such as the classroom. School presents academic and social challenges that lead to conflicts with parents, teachers, and classmates (APA, 1994). Academically, children with ADHD are more likely to be retained in a grade, be placed in special education, and drop out of school (Frick & Silverthorn, 2001). As a rule, these children are consistently inconsistent and require much more effort to complete tasks than do peers. Socially, the majority struggle and are often misunderstood (Children and Adults with Attention Deficit Hyperactivity Disorder [CHADD], n.d.; NRC, 2009f). Relationships tend to be tense and fragile as a result of decreased self-regulation of one’s actions and reactions (CHADD, n.d.).

Given these complications, it is not surprising how frustration, avoidance, and agitation can arise. Children with ADHD, Combined Type tend to be unpopular and socially rejected, while children with ADHD, Primarily Inattentive Type tend to be shy and withdrawn (Frick & Silverthorn, 2001). According to the NRC, “Adolescent outcomesshow that they are more likely to drop out of school, to rarely complete college, to have fewer friends and to participate in antisocial activities more than children without ADHD” (2009a, para. 4). Likewise, Lensch (2000) emphasizes that, “One area often associated with ADHD is that of social deficits. Many children with ADHD have difficulty getting along with others” (p. 51). The preponderance of the research to date concerning ADHD has concentrated on cognitive and behavioral aspects. As Lensch (2000) points out, though, “If social dysfunction puts an ADHD student at even greater risk for poor outcomes, mechanisms need to be developed to identify social deficits” (p. 51). These difficulties also lead to high rates of antisocial and delinquent behavior, with a substantial prevalence of Oppositional Defiant Disorder (ODD) or conduct disorder. For adults, employment and marital difficulties are common due to occupational and social responsibilities.

Poor impulse control is another serious complication and one which unfortunately often leads to unfavorable situations and accidents as a result of an inability to look before leaping, or to consider consequences in advance. Medically, children with ADHD present increased rates of hospitalizations, emergency room visits, comorbid psychiatric disorders, and overall medical costs (NRC, 2009b). In adolescence and adulthood increased rates of vehicle accidents, sexually transmitted diseases, teen pregnancies, and arrests are evidenced (NRC, 2009b).

Comorbidity rates are high, with up to two-thirds of those diagnosed with ADHD having at least one co-occurring condition, which tends to greatly interfere with academic and social performance (NRC, 2009e). According to the NRC (2010), the three most common comorbid conditions include Oppositional Defiant Disorder (41%), Depression (22%), and Anxiety (15%). Learning disabilities and social/emotional deficits are also common (NRC, 2009e; Frick & Silverthorn, 2001).

Although exact etiology of ADHD is unknown, heredity clearly makes the largest contribution to the presence of this neurobiological disorder (CHADD, 2011). Deficits have been linked to several specific brain regions and neurotransmitters. The neurotransmitters include dopamine and norepinephrine, which facilitate executive communication and orchestrate cognition (Brown, 2007).

Research on structural and functional imaging has mapped neurotransmitter dysregulation to the prefrontal cortex with notably reduced volume and activation in this and other brain areas (APA, 2005; Boles, Adair, & Joubert, 2009; NRC, 2009c,d; Wadsworth & Harper, 2007). The cerebellum has also been consistently implicated with structural anomalies and reductions in overall volume (Mackie, Shaw, Lenroot, Pierson, et al., 2007), as has the basal ganglia and corpus callosum (Frick & Silverthorn, 2001). Durston (2008) reported that development of cortical gray matter in ADHD children is delayed an average of three years compared to non-ADHD children and thus provides evidence of developmental delays in ADHD.

Optimal treatment outcomes at this time rely on multidisciplinary efforts, which do not appear to be syncing as well as they could, or should. Moreover, Semrud-Clikeman, Walkdowski, Wilkinson and Butcher (2010) emphasize that because children with ADHD will have different executive functioning profiles, they will inevitably respond differently to interventions. In a disorder characterized by inconsistency and immediacy, it appears that an unacceptable percentage of diagnostic procedures and professional practices react in kind, with little attention to the necessary details. Hendrick (2009) conducted a survey of nearly one thousand children with ADHD and found 69% were diagnosed by pediatricians; 56% were immediately prescribed medication; 30% did not obtain a physical exam; nearly 50% did not receive a hearing test; and 65% of parents indicated that a plan for managing the condition was never offered. Additionally, while teachers offer an abundance of invaluable information pertaining to a child’s historical daily performance, within an environment known to be a challenge for children with ADHD, 32% (of the sample) reported that information was never requested from the child’s teachers and nearly 50% never included a teacher interview or classroom observation of the child (Hendrick, 2009).

In light of the chronic course and comorbidity rate of ADHD, current treatments do not present the level of effectiveness that is truly needed long-term. Cognitive behavioral treatments have fallen short for children. Although benefits are noted for attention and impulsivity in laboratory measures, there is minimal generalization to home and school environments (Frick & Silverthorn, 2001). Medication is an incomplete treatment, often misconstrued as the quick-fix society seeks. A panacea it is not. Although prescribed medication is considerably well researched and may improve some children’s productivity by increasing executive communication in the brain, and has also been found to reduce self-medicating substance abuse in adolescents and adults with ADHD (NRC, 2009a; Wadsworth & Harper, 2007), not all children respond favorably, many parents are firmly opposed, side effects exist, and used alone it yields limited success. Medication must be augmented by peripheral treatments, such as behavioral parent training and classroom behavior management. These most laborious efforts may, at best, superficially reduce undesirable behavior and increase desirable behavior, yet do not fix the core problems, nor do they directly improve deficient academic or executive skills. There is a great need for effective treatment innovations for ADHD and recent brain imaging studies reveal promise in reports of functional and anatomical changes resulting from mindfulness practices.

William James, one of the iconic historical figures in American psychology, predicted the influence that Buddhism would eventually have on western psychology (Lau & McMain, 2005). Until a recent surge in the literature, the timeless Eastern philosophy of mindfulness had received little professional recognition or acceptance in Western culture (Didonna, 2009). This popularity is long overdue, as evidenced by the fact that recent research has reported wide-ranging benefits for mindfulness (Chan, Sze, & Dejian, 2008; Sears, Tirch, & Denton, 2011), a practice linked to psychological well-being. However, there continues to be a delay in the psychological literature addressing the potential benefits of mindfulness practices for children (Block-Lerner, Holston, & Messing, 2009; Sears, Tirch, & Denton, 2011), particularly special needs children such as those with ADHD (Jon Kabat-Zinn, personal communication, October 24, 2011; Richard Sears, personal communication, August 5, 2011).

Simply defined, mindfulness is “the opposite of mindlessness [or]sleepwalking through life [it is]a heightened presence of mind [and a]focused attentiveness” (Sears, Tirch, & Denton, 2011, p. xi). Though similar to hypnosis, relaxation techniques, and meditation, mindfulness is distinctly different through its deliberative focus on being fully aware and engaged in the experiences of the moment — whatever they may be — rather than seeking escape or avoidance. It relies heavily on developing multiple modes of attention including arousal, sustained attention, selective attention, alternating (shifting) attention, and divided attention — all of which are weaknesses in ADHD children that impact academic performance (Sears, Tirch, & Denton, 2011).

While there is impressive empirical support for adult mindfulness applications, including neurological research suggesting the potential to change neural circuitry and structure (Sears, Tirch, & Denton, 2011), research with children remains limited. Siegel’s (2007) theory regarding the neurological mechanisms of mindfulness and the brain, specifically the intrinsic quality of focused attention and social implications, certainly seems to target the weaknesses experienced by ADHD children. The theories encompassing mindfulness-based cognitive behavior therapy, meditation, and mindfulness-based Yoga and Thai Chi are likely to improve self-regulation and executive functioning capacities of ADHD children (George McCloskey, personal communication, September 16, 2011). “This connection between the ability to regulate attention and well-being is profoundly exemplified in mindfulness or mindful awarenessand ADHD” (Zylowska, Smalley, & Schwartz, 2009).

A study by Rinsky and Hinshaw (2011) followed an ethnically and socioeconomically diverse sample of 140 preadolescent girls with ADHD and 88 matched comparison girls for a period of 5 years in an effort to determine whether childhood levels of executive function would predict adolescent multi-informant outcomes of social functioning and psychopathology, including comorbidity between externalizing and internalizing symptomatology. These researchers used well-established measures of planning, response inhibition, and working memory, along with a control measure of fine motor control as predictors (Rinsky & Hinshaw, 2011). According to the study’s authors, “Independent of ADHD vs. comparison group status, (a) childhood planning and response inhibition predicted adolescent social functioning and (b) childhood planning predicted comorbid internalizing/externalizing disorders in adolescence” (Rinsky & Hinshaw, 2011, p. 368). In addition, the findings that emerged from this study showed that mediation analyses was a predictor of whether adolescent social functioning mediated the prediction from childhood executive functioning to comorbidity at follow-up (Rinsky & Hinshaw, 2011). Furthermore, the subjects with ADHD adolescent comorbidity mediated the prediction from childhood executive functioning to social functioning at follow-up. Based on these findings, the authors conclude that early interventions should target executive functioning disabilities besides just behavioral symptoms in young learners with ADHD (Rinsky & Hinshaw, 2010).

Likewise, a study by Thorell, Rydell and Bohlin (2012) investigated executive functioning (i.e., response inhibition and working memory) at age 8-1/2 years with respect to ADHD symptoms and attachment representations at one-year follow-up. The study’s authors report that, “Well-validated laboratory measures of both executive functioning and attachment representations were used. Additive, interaction, as well as mediation effects were investigated” (Thorell et al., 2012, p. 517). The results showed that attachment disorganization and executive functioning were independently related to ADHD symptoms, even when using conduct problems as a covariate; no significant interaction effects were found and executive functioning was not found to act as a mediator between attachment disorganization and ADHD symptoms (Thorell et al., 2012). In conclusion, attachment disorganization had a significant effect on ADHD symptoms, independent of both executive functioning and conduct problems, which suggests that the parent — child attachment is a factor that needs to be included if we are to more fully understand the development of ADHD.

According to Greenberg (2011), Kabat-Zinn and others have incorporated various aspects of yoga and meditation into mindfulness therapy. Mindfulness practices have been shown to have a positive impact on many aspects of brain functioning (Davidson, Kabat-Zinn, Schumacher, Rosenkranz, Muller, Santorelli, et al., 2003). Mindfulness incurs a distinct mental state that has been found to effect changes in brain activation levels, produce significant and potentially permanent changes in neural and immune functioning, and also supports the theory of brain functioning plasticity (Davidson et al., 2003). Likewise, subjects participating in Kabat-Zinn’s mindfulness-based stress reduction (MBSR) program for chronic pain patients (1990) reported that “the mental effort expended to avoid painful sensations accounted for a significant proportion of their suffering. The subjective experience of pain diminished as the unpleasant aspects of experience were increasingly accepted” (Germer, Siegel & Fulton, 2006, p. 75). Although it is possible for anyone to disengage from their conscious thinking processes temporarily through simple breathing exercises or other techniques, mindfulness therapy requires more rigorous activity. According to Germer et al., formal mindfulness meditation typically requires about 45 minutes of daily practice, a commitment that clients that are not specifically seeking MBSR may not be willing to make. Therefore, “Informal, everyday mindfulness exercises are most easily integrated into psychotherapy” (Germer et al., 2005, p. 113).

These findings support other recent studies suggesting that meditative practice can create long-term changes in transient neural states with sustained aspects of neural functioning. The resilience of these changes is related to the length of meditative practice (Cahn & Polich, 2006). In addition, results of a pilot study on a mindfulness training program for adults and adolescents with ADHD supports the feasibility and potential utility for application with children with ADHD. Improvements were evidenced on measures of attention, cognitive inhibition, and self-reported ADHD symptoms (Zylowska, Ackerman, Yang, Futrell, Horton, Hale, Pataki, & Smalley, 2008). Empirical observations suggest that mindfulness therapy can be more effective when used in combination with other CBT therapies (Fedoroff, 2011).

A recent study by van de Weijer-Bergsma, Formsma, de Bruin and Bogels (2012) evaluated the effectiveness of an 8-week mindfulness training for 10 young learners aged 11-15 years diagnosed with ADHD. In addition, the effectiveness of concomitant Mindful Parenting training for 19 of the participants’ parents was also evaluated (van de Weijer-Bergsma et al., 2012). The researchers used questionnaires and computerized attention tests prior to, immediately following, 8-weeks post-intervention and 16 weeks post-intervention. The researchers cite the following as key findings:

After mindfulness training, adolescents’ attention and behavior problems reduced;

After mindfulness training, adolescents’ executive functioning improved as reflected on self-report measures as well as by father and teacher report;

Improvements in adolescents’ actual performance on attention tests were found after mindfulness training;

Fathers, but not mothers, reported reduced parenting stress;

Mothers reported reduced overreactive parenting;

Fathers reported an increase in overreactive parenting;

No effect on mindful awareness of adolescents or parents was identified;

Effects of mindfulness training became stronger at 8-week follow-up, but diminished at 16-week follow-up (van de Weijer-Bergsma et al., 2012).

The authors conclude that these findings help to contribute to the growing body or research concerning the efficacy of mindfulness training for young people with ADHD as well as their parents (van de Weijer-Bergsma et al., 2012). The authors also add that while mindfulness training is an effective approach, “maintenance strategies need to be developed in order for this approach to be effective in the longer term” (van de Weijer-Bergsma et al., 2012, p. 787).

Another study that investigated the effectiveness of an 8-week mindfulness training for children aged 8-12 with ADHD together with concomitant mindful parenting training for 22 of their parents by Oord, Bogels and Peijnenburg (2012) also used questionnaires to gather information concerning ADHD symptoms, parenting stress, parental overreactivity, permissiveness and mindful awareness before, immediately following the 8-week training and again at 8-week follow-up. According to Oord et al. (2012), the results of their study support the use of mindfulness training for young learner with ADHD as well as their parents; the authors caution, though, that these findings are preliminary and require further investigation with respect to teacher-ratings of the effectiveness of these treatment protocols (Oord et al., 2012). In sum, there is a growing body of evidence that suggests differences in mindfulness can be explained by ADHD status and interventions that increase mindfulness may improve symptoms of ADHD and increase self-directedness (Smalley, Loo & Hale, 2009).

In conclusion, ADHD can be a long-term mental health disorder with life-long implications. It indiscriminately impacts individuals of all ages and cultures with significant adaptive deficits in self-regulation and executive functioning. Difficulties can mount exponentially and comorbidity rate is high. While diagnostic procedures may require some scrutiny, given many unidimensional and haphazard diagnoses, more importantly there is a great need for effective long-term treatment innovations. Medicating nearly every child who presents some form of difficulty certainly is not the answer. However, mindfulness applications appear promising with potential to remediate the self-regulation and executive dysfunctions that are at the root of this disorder. The challenge is clear: The failure to intervene early can be costly and thus the need for early intervention is critical. As these problems often surface during the elementary years, schools appear to be the most efficient platform for the initiation of timely intervention and prevention programs.

Hypothesis

The following hypotheses will be confirmed or refuted:

Hypothesis 1: Children trained in this mindful martial arts technique will demonstrate significant improvement in academic performance as measured by pre- and post-intervention academic grades.

Hypothesis 2: Children trained in this mindful martial arts technique will differ significantly from the control group, only receiving martial arts training, on academic performance as measured by pre- and post-intervention academic grades.

Hypothesis 3: Children trained in this mindful martial arts technique will demonstrate significantly less regression to their baseline in academic performance at the 9-week post-program follow-up, as measured by grades from the fourth nine-week grading period, than the control group receiving only martial arts training.

These hypotheses are based upon observational outcomes and academic grade records of participants in my pilot study (briefly described below), as well as extrapolation from the literature on martial arts, mindfulness, behavioral improvement, self-regulation, and attention capacity.

Definition of Terms

The study will use the definitions of key terms and acronyms that are set forth in Table 1 below.

Table 1

Definition of Key Terms and Acronyms

Term/Acronym

Definition

Academic performance

For the purposes of this study, academic performance defined as graded performance on report cards.

ADHD

Attention deficit hyperactivity disorder (Barkley, 2007)

Attention deficit hyperactivity disorder

The conceptualization of ADHD remains dynamic (Lensch, 2000). What is known is that ADHD is a highly heritable neurobehavioral disorder that affects between 8 and 12% of children worldwide; the prevalence of ADHD in the United States varies between 2 and 16%, depending on the sample size, diagnostic criteria used, informants, impairment status, age and gender of the children, and clinical vs. community samples (Singh, Singh, Lancioni, Singh, Winton & Adkins, 2010). While young people who are diagnosed with ADHD are typically characterized by inattention, hyperactivity and impulsivity, many display behavior problems such as non-compliance and aggression. It is likely that the children displaying these behaviors also have comorbid psychiatric disorders (e.g., oppositional disorder, mood, anxiety) and learning disorders (dyslexia, executive function deficits) (Singh et al., 2010, p. 157). A great deal of research has been conducted in the area of ADHD over the years, but there remains a paucity of a consistent definition of the disorder (Barkley, 1990). According to Nigg (2001), ADHD refers to multiple subtypes that are used in two ways: (a) in some cases, it is used as an umbrella term to refer to unspecified subtypes. This usage is made obvious by reference to ADHD subtypes in the immediate context; (b) in other cases, ADHD refers to the DSM-IV combined type, to DSM-H1-R

ADHD, to children who are selected on the basis of elevated rating scale scores as well as to samples of children and adults who are hyperactive and hyperkinetic. In addition, DSM-IV-TR stipulates onset for some ADHD symptoms by age 7, although a DSM-5 Work Group is considering symptom onset as late as age 12. Initial onset or a dramatic worsening of longstanding ADHD symptoms in middle-age or older adults is atypical for this neurodevelopmental disorder (Pollak, 2012).

BADDS

Brown Attention-Deficit Disorder Scales (Brown, 1996).

Children

For the purposes of this study, this term refers to young people aged 17 years and under.

Martial arts

This term refers to any of several arts of combat and self-defense (as karate and judo) that are widely practiced as sport (Merriam-Webster, 2001).

Mindfulness

Mindfulness psychotherapies are regarded as the third wave of behavior therapy, following behavioral therapy as the first wave and cognitive therapy as the second wave (Hayes, 2004).

Assumptions, Limitations, Delimitations

A limitation of the proposed study concerns the dearth of timely and relevant research with respect to the efficacy of other mindfulness-based interventions for comparison. Therefore, researchers are only able to report the results of their studies as they emerge, and these findings will contribute to an improved understanding of ADHD. The limited research to date with mindful-based interventions indicates these alternatives may be efficacious in promoting improved academic outcomes (Castonguay & Beutler, 2006). As with any such enterprise, though, a great deal of misguided research will inevitably precede more complete understanding concerning the operation of ADHD in young people (Lensch, 2000). The findings that emerge from the study will largely be delimited to similarly situated schools. Finally, in a process that remains better described than understood, mindfulness-based interventions may help precipitate personal changes in behavior that translate into academic achievement and a reduction in disruptive classroom behaviors (Castonguay & Beutler, 2006).

CHAPTER THREE: METHODS

Description of Research Design

The plan for the proposed research is to expand on and integrate the limited amount of work that has been done in the narrowly defined areas of mindfulness, martial arts, and early intervention for children with ADHD. It is the intention of the proposed study to extrapolate findings to a dissertation in order to better understand how and why these applications may benefit children academically and behaviorally. It is proposed that an increased availability to learn, as a result of decreased behavioral interference and enhanced attention will culminate in improved grades for ADHD students.

In addition, it is the intent of this study to examine the differential benefit in academic performance for children with ADHD between a mindfulness-based martial arts course and a traditional martial arts course (mindfulness training not provided). The martial art conditions will serve as the independent variable, while student report card grades and the Brown ADD Scales will serve as the dependent variables. The Brown ADD Scales help to assess a wide range of symptoms of executive function impairments associated with ADHD/ADD. These normed rating scales are available to elicit parent report and teacher report for children ages 3 to 7 yrs and 8 to 12 yrs. For 8 to 12-year-olds, a normed self-report version is also available. For adolescents (12-18 yrs) and for adults, normed rating scales elicit self-report and collateral report on a single form.

One manual for the Brown ADD Scales for Children and Adolescents and another for the Brown ADD Scales for Adolescents and Adults provide age-based norms and detailed information about how to administer and interpret the Brown ADD Scales and the Brown ADD Diagnostic Forms. A software program is available to assist in scoring the Brown ADD Scales and to produce a printed report with age-based scores that can be shared with patients, their families and their clinicians.

A treatment group, comparison group, control group design was originally desired, as incorporating a third group would strengthen my research design and results, yet due to an earlier attempt resulting in insufficient parental interest, the study was terminated. Interest was determined to have been poor out of parental concern that their children would only have a one out of three chance of participating in the martial arts condition. In counteraction to that outcome both groups in the proposed study will receive the same martial arts training, except that the treatment group will also receive mindfulness instruction as part of the training. Random selection will not be implemented given the anticipated small sample size.

The heavy focus of mindfulness toward developing various modes of attention and awareness in the moment, in addition to the structure and discipline inherent to the martial arts, seem to offer a very promising approach toward improving the academic performance/grades of children with ADHD. While martial arts will provide exercise to sharpen thinking, mindfulness will provide relaxation to clear thinking.

Participants

All third through fifth grade students with a diagnosis of ADHD and signed parental permission for research participation attending School X and School Y (as described further below) will be welcome.

Instrumentation/Measures

The Brown Attention-Deficit Disorder Scales (BADDS) will be completed by each participant’s classroom teacher as a pre-test/post-test/follow-up measures of student attention. Published in 2001, the BADDS is based on Thomas Brown’s cognitive impairment model of ADHD, which focuses on the underlying executive dysfunctions that are the proposed source of academic, social, emotional, and/or behavioral deficits in ADHD. This instrument, and its executive dysfunction model of ADHD, is supported by the work of renowned experts in the field (Amen, Hanks, & Prunella, 2008; Barkley, 1997; Nigg, 2001). Favorable reviews have been offered by Jennings (2003), Kaufman and Kaufman (2001), Oehler-Stinnett (2001), and Wilkinson (2003). “The breadth of coverage of the theoretically-based elements of executive functions dovetails with contemporary discussions about the nature of primary, secondary, and tertiary deficits of ADHD” (Jennings, 2003, n.p.).

Teacher ratings on the Brown Attention-Deficit Disorder Scales (BADDS), an instrument which endorses the theory that academic deficits in children with ADHD are most directly linked to executive dysfunction, will be used to offer ancillary data to report card grades. Repeated measures ANOVA will be conducted to compare groups on both report card grades and results of the BADDS over time, with paired-samples t-tests conducted as a follow-up on significant findings.

Individual report card grades for each student, as recorded by his/her classroom teacher, will be monitored as the primary measure of pre- and post-intervention academic performance. To add ancillary dimensions to participant report card grades and more accurately depict the changes to academic performance, pre- and post-intervention behavioral ratings of executive functioning, as it applies to ADHD symptoms, will be collected. Teacher ratings on the Brown Attention-Deficit Disorder Scales (BADDS) will be used to gain these added dimensions and to maintain respondent consistency with teacher recorded report card grades. Because it is unlikely that students will show improvements of an entire letter grade, using grades in the form of percentages (95%, 90%, 85%…) in each of the main report card areas (reading, writing, math) will be more likely to show any improvement.

The BADDS are based on Thomas Brown’s cognitive impairment model of ADHD, which was conceived through his extensive review of the theoretical literature. This model uniquely focuses on the less overt executive functions that Brown contends play a central role in ADHD, rather than the conventional practice of focusing on characteristic surface behaviors which strictly adhere to DSM-IV criteria and do not account for recent developments in the literature. Brown’s theoretically-based item pool departs from DSM-IV criteria and has expanded to developments in the understanding of how executive functions relate to ADHD, offering “a more refined and accurate clinical picture” (Wilkinson, 2003, para. 5).

Reviews of this instrument, from the Mental Measurements Yearbook with Tests in Print database, are largely positive (Jennings, 2003; Kaufman & Kaufman, 2001; Oehler-Stinnett, 2001; Wilkinson, 2003). Oehler-Stinnett (2001, para. 2) indicates the BADDS are “one of the few measures that captures the cognitive and motivational components of functioning that might contribute to problems[for individuals] with ADHD.” In addition, Brown’s theory is supported by the work of the foremost experts on ADHD including Daniel Amen (2008), Russell Barkley (1997), and Joel Nigg (2001).

The BADDS comprise 50 items which may be independently completed in 10 to 20 minutes by a child’s teacher. Ratings are based on a four-point Likert-type scale (i.e., 0 = Never, 1 = Once a Week or Less, 2 = Twice a Week, and 3 = Almost Daily). In addition to screening and comprehensive assessment integration, the instrument is also indicated for monitoring response to interventions in educational or clinical settings. “The scales yield a profile ofabilities/impairments in attention, working memory, executive functions, cognition, affect, and behavior” (Jennings, 2003, para. 1). Six cluster scores capture the dimensions of Brown’s theory: Organizing, Prioritizing, and Activating to Work; Focusing, Sustaining and Shifting Attention to Tasks; Regulating Alertness, Sustaining Effort and Processing Speed; Managing Frustration and Modulating Emotions; Utilizing Working Memory and Accessing Recall; and Monitoring and Self-Regulating Action. The publisher’s computer scoring software (i.e., Brown ADD Scales Scoring Assistant) will be used.

Reliability data for ages 8 to 12 reveal strong internal consistency for clusters and total scores (.73 to .91) and strong test-retest reliability (teacher corrected coefficients .84 to .93), yet decreased rater correspondence reflected lower interrater reliability (.46 to .57). Strong evidence of validity is presented. Internal validity across clusters (.62 to .84) and cluster-total score coefficients (.81 to .96) are presented. Evidence for criterion-related validity is revealed through the ability to discriminate between clinical and non-clinical groups with statistical significance. Evidence for convergent and divergent validity is provided by intermeasure correlations with the Achenbach Child Behavior Checklist (CBCL), Behavior Assessment System for Children (BASC), and Conners’ Rating Scales. Comparability to the CBCL for ages 8 to 12 ranged from -.05 (CBCL Somatic Complaints and BADDS Memory) to .70 (CBCL Attention Problems and BADDS Attention), revealing similarities and distinctions as expected given differing content. Correlations between BASC Attention Problems and the BADDS ranged from .50 to .91. Correlations between the Conners’ ADHD Index and BADDS Inattention and Combined Totals ranged from .68 to .82. Correlations between the Conners’ Hyperactivity scale and BADDS Monitoring and Self-Regulation clusters was .79.

Some of the defining features and attributes of the BADDS that make the instrument especially salient for the purpose of this study include the following:

Unlike scales that focus on ADHD symptoms, the BADDS is said to measure deficits in executive functioning underlying ADHD.

Separate versions for youths 3 — 7 years, 8 — 12, and 12 — 18 are worded to indicate developmentally relevant manifestations of ADHD. For ages 3 — 7, separate parent and teacher forms are available (44 items). For ages 8 — 12, separate versions for parent, teacher, and youth self-report (50 items). The adolescent version can be administered to the adolescent and/or the parent (40 items).

Scale measures the following: Organizing, Prioritizing and Activating to Work; Focusing, Sustaining and Shifting Attention to Tasks; Regulating Alertness, Sustaining Effort and Processing Speed; Managing Frustration and Modulating Emotions; Utilizing Working Memory and Accessing Recall; and Monitoring and Self-Regulating Action (for ages 3 — 7 and 8 — 12).

Takes just 10 — 15 minutes to administer.

Moreover, Corcoran and Walsh (2006) cite the following in support of the instrument’s reliability:

Internal consistencies are acceptable for clinical samples, excellent for the normative sample.

Inter-rater agreement between parents and teachers is low to moderate for ages 3 to 7 and 8 to 12, somewhat better than other scales. For ages 8 to 12, agreement between the children’s self-report and parent-or-teacher self-report is also low to moderate (p. 156).

With respect to the validity of the BADDS instrument, Corcoran and Walsh (2006) report that:

Convergent validity for the BADDS is evidenced by moderate to excellent correlations with the parent and teacher versions of the CBCL, the BASC, and Conners Ratings Scales.

Divergent validity is shown by lower correlations between BADDS and internalizing measures.

Discriminant validity established by the differences between children with ADHD and the normative samples (p. 156).

While the central goal of the study is to evaluate potential gains and maintenance of gains in academic achievement, per student report card grades, the BADDS is expected to add further dimension and more accurately depict potential changes in academic performance. However, only teacher ratings will be requested. The reasoning for excluding parent ratings is that the primary focus of this dissertation will be on academic grades. Moreover, even the most robust rating scales available for children are prone to contamination by subjective responding. In an earlier study I requested a narrative response to accompany quantitative ratings across a pre/post test measure and adult expectations often appeared positively correlated with student improvement over time. That is, narratives were often incongruent with quantitative ratings, suggesting that adult expectation (“the bar”) was raised as students improved. While this is important from a behavioral perspective, it constrains measured improvement over time. Therefore, while parents are undeniably the experts on their child in terms of depth and breadth of knowledge, the variables of grades and attention in this study are more directly linked to classroom performance, though of course not exclusively (e.g., parental view toward the importance of education). In addition, teacher ratings may be less biased and offer a more suitable comparison, given the number of same-age peers available in which teachers may compare participant’s attention in academic activities.

Procedures

From the population obtained as described above, random assignment to either a treatment or control group will be performed. Both groups of students will participate during the third nine-week grading period of the 2012-2013 school year. There will be two sessions weekly, each one-and-a-half hours in duration, for a total of 17 sessions per group over a 4-1/2-week period. Sessions will be conducted in the school gymnasium immediately following afternoon dismissal (3:00-4:30 PM). The treatment group sessions will be conducted on Mondays and Wednesdays. The control group sessions will be conducted on Tuesdays and Thursdays.

This research will be conducted at X Elementary School and will include students from Y Elementary, a neighboring school four miles away. Respectively, X and Y are large (862 and 1002 students) public schools located in working-class suburban neighborhoods. School demographics are: 63% and 19% Caucasian, 11% and 26% Hispanic, 18% and 48% African-American, 4% and 2% Asian/Pacific Islander, and 4% and 5% Multiracial as depicted graphically in Figure 1 below.

Figure 1. Demographics of School X and School Y

The school populations consist of overlapping conditions of: 5% and 22% English Language Learners and 11% and 10% special education, respectively. Participants will be third through fifth grade children who have previously been diagnosed with ADHD by a medical doctor or licensed psychologist. There will be no use of the sub-classifications of ADHD, whether the child is prescribed medication, or if comorbid conditions exist to exclude participants. However, comparative data will be gathered across both the sub-classifications of ADHD and comorbid conditions so that post hoc analyses can be conducted to evaluate whether any of these distinctions influenced results.

The school principal will send notices home with all third- through fifth-grade students about this research study being conducted at the school and invite parents to voluntarily enroll their child (if diagnosed with ADHD) as a research participant. Two preparatory parent meetings will be conducted at the school to discuss and answer questions regarding the research and participation. Informed consent will be discussed, highlighting potential risks and benefits of participation, and parent/child rights as study participants will be thoroughly explained.

Academic percentile grades from each student’s report card will be collected across all four grading periods during the 2012-2013 school year. The fourth nine-week grading period will serve as a post-program (9-week) follow-up to monitor regression toward baseline in both groups.

Data Analysis

The data analysis will include the conduct of repeated measures, analysis of variance, or ANOVA, to compare the dissertation groups on report card grades and attention measured by the BADDS instrument over time, with paired-samples t-tests conducted as a follow-up on significant findings for each of the 50 items on the instrument. The ANOVA is a method of testing the null hypothesis that several group means are equal in the population which is accomplished by comparing the sample variance that is estimated from the group means to that estimated within the groups (SPSS topics, 2007). The paired-samples t-test procedure is used to compare the means of two variables for a single group by computing the differences between values of the two variables for each case and then testing whether the average differs from 0 (SPSS topics, 2007). The results of the ANOVA will be presented in tabular and graphic formats, and the findings interpreted in a narrative fashion to evaluate the potential gains and maintenance of gains in academic achievement, per student report card grades. Each of the BADDS instruments will be coded consecutively (i.e., A-1, A-2, etc.) together with the corresponding percentile grades for all participants to ensure participant anonymity for each round of measurement. The coded list of participants will be kept in a secure place (i.e., a locked desk or safe) and destroyed upon completion of the research.

A pilot study was conducted with the same mindfulness-based martial arts intervention. The study involved 85 elementary school students (no exclusion criteria) from one school who were randomly assigned to either a treatment or wait-list control group. All participants received the same intervention, with the wait-list controls participating later in the school year. Students were monitored behaviorally and academically over eight months (8/2009 through 3/2010). Results of repeated measures ANOVA, followed-up by paired-samples t-tests on significant findings, revealed dramatic behavioral improvement. Specifically, parent and teacher behavioral ratings collectively showed significant improvement with medium effect size [F (5, 285) = 4.69, p = .002, ?2 = .06] and little behavioral decay over time. That is, four months after the treatment group completed the intervention, their behavioral ratings remained better than baseline. Academically, results were inconsistent across children with various exceptionalities (e.g., those with internalizing or externalizing problems and those receiving gifted, regular, or special education programming). However, a promising indication lay in the fact that the greatest academic impact was observed among a subset of children (N=28) diagnosed with ADHD [F (7, 160) = 2.21, p = .04, ?2 = .09]. Grades for these children significantly improved and remained above baseline at the four-month follow-up in both writing and math, although not in reading.

References

Amen, D.G., Hanks, C., & Prunella, J. (2008). Preliminary evidence differentiating ADHD

using brain SPECT imaging in older patients. Journal of Psychoactive Drugs, 40(2),

139-46.

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders

(4th ed.). Washington, DC: Author.

Banks, T., & Zionts, P. (2009). REBT used with children and adolescents who have emotional and behavioral disorders in educational settings: A review of the literature. Journal of Rational – Emotive & Cognitive Behavior Therapy, 27(1), 51-65.

Barkley, R.A. (1997). Behavioral inhibition, sustained attention, and executive functions:

Constructing a unifying theory of ADHD. Psychological Bulletin, 121(1), 65-65-94.

Barkley, R.A. (2007). School interventions for attention deficit hyperactivity disorder: Where to from here? School Psychology Review, 36(2), 279-286.

Barkley R.A. (2011). Barkley Adult ADHD Rating Scale-IV. New York: Guilford Press.

Baumeister, R.F. (1997). Esteem threat, self-regulatory breakdown, and emotional distress as factors in self-defeating behavior. Review of General Psychology, 1(2), 145-145-174. Bernstein, L. (2008). Yes, I can. Current Health 1, 32(2), 26-29.

Block-Lerner, J., Holston, M.A., & Messing, M. (2009). Seeing through clearer eyes:

Mindfulness and acceptance-based behavioral interventions in the school. New York:

Taylor & Francis.

Brown, T.E. (1996) Brown Attention Deficit Disorder Scales. San Antonio, TX: Psychological

Corporation.

Brown, T.G. (2005). The long-term effects of Tae Kwon Do training on measures of attention.

(Unpublished doctoral dissertation). Fielding Graduate University, Santa Barbara, CA.

Carson, S., Shih, M. & Langer, E. (2001). Sit still and pay attention? Journal of Adult

Development, 8(3), 183-190.

Castonguay, L.G. & Beutler, L.E. (2006). Principles of therapeutic change that work. New York: Oxford University Press.

Centers for Disease Control and Prevention (2010). Increasing Prevalence of Parent-Reported

Attention Deficit Hyperactivity Disorder Among Children. Morbidity and mortality weekly report, 59(44);1439-1443.

Children and Adults with Attention Deficit Hyperactivity Disorder (2011). Frequently asked questions. Retrieved on August 22, 2011, from http://www.chadd.org/AM/Template.

cfm?Section=FAQs&Template=/CM/HTMLDisplay.cfm&ContentID=6080

Chan, A., Sze, S., & Dejian, S. (2008). Traditional Chinese mind-body exercises improve self-control ability of an adolescent with Asperger’s disorder. Journal of Psychology in Chinese Societies, 9(2), 223-237.

Corcoran, J. & Walsh, J. (2006). Clinical assessment and diagnosis in social work practice. New York: Oxford University Press.

Diamond, A., & Lee, K. (2011). Interventions shown to aid executive function development in children 4 to 12 years old. Science, 333(6045), 959-964.

Didonna, F. (2009). Introduction: Where new and old paths to dealing with suffering meet. In F.

Didonna (Ed.), Clinical handbook of mindfulness (p. 1-14). New York: Springer.

Fedoroff, P. (2011, July). Treating sexual desire disorders: A clinical casebook. Canadian Journal of Psychiatry, 56(7), 442-443.

Felt, B.T., Lumeng, J., & Christner, J. (2009). Multimodal treatment of attention-

Deficit/Hyperactivity disorder in children. American Family Physician, 79(8), 640- 642.

Fitzpatrick, M., & Knowlton, E. (2009). Bringing evidence-based self-directed intervention practices to the trenches for students with emotional and behavioral disorders. Preventing School Failure, 53(4), 253-266.

Frick, P.J., & Silverthorn, P. (2001). Psychopathology in children. In H.E. Adams & P.B.

Sutker (Eds.), Comprehensive handbook of psychopathology (3rd ed., pp. 881- 920).

New York: Springer Science+Business Media, LLC.

Germer, C.K., Siegel, R.D. & Fulton, P.R. (2005). Mindfulness and psychotherapy. New York:

Guilford Press.

Greenberg, D. (2011, July 1). Spirituality and psychiatry. The Israel Journal of Psychiatry and Related Sciences, 48(3), 219-221.

Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (1999). Acceptance and Commitment Therapy:

An Experiential Approach to Behavior Change. New York: Guilford.

Jacobelli, F. & Watson, L.A. (2008). ADD/ADHD drug free: Natural alternatives and practical exercises to help your child focus. New York: AMACOM.

Jennings, K.E. (2003). [Review of the test Brown Attention-Deficit Disorder Scales]. In B.S.

Plake, J.C. Impara, and R.A. Spies (Eds.), The fifteenth mental measurements yearbook.

Lincoln, NE: Buros Institute of Mental Measurements. Retrieved from Mental

Measurements Yearbook with Tests in Print database.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell.

Kamphaus, R.W., & Reynolds, C.R. (2007). BASC-2 behavioral and emotional screening system. Minneapolis: Pearson.

Kaufman, N.L. & Kaufman, A.S. (2001). [Review of the test Brown Attention-Deficit Disorder

Scales]. In B.S. Plake and J.C. Impara (Eds.), The fourteenth mental measurements yearbook. Lincoln, NE: Buros Institute of Mental Measurements. Retrieved from Mental

Measurements Yearbook with Tests in Print database.

Kelly, D.P., & Aylward, G.P. (2005). Identifying school performance problems in the pediatric office. Pediatric Annals, 34(4), 288-98.

Kessler, R.C., Adler, L., Barkley, R., & Biederman, J. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. The American Journal of Psychiatry, 163(4), 716-23.

Lakes, K.D., & Hoyt, W.T. (2004). Promoting self-regulation through school-based martial arts training. Applied Developmental Psychology, 25, 283-302.

Langer, E.J. & Moldoveanu, M. (2000). Mindfulness research and the future. Journal of Social

Issues, 56(1), 129 — 139.

Lee, J.S., & Kim, J.T. (2005). Parental attitudes of children with developmental disabilities toward the value of Taekwondo practice. Research Quarterly for Exercise and Sport,

76(1), 106-107.

Lensch, C.R. (2000). Making sense of attention deficit hyperactivity disorder. Westport, CT:

Bergin & Garvey.

Linehan, M.M., Heard, H.L., & Armstrong, H.E. (1993). Naturalistic follow-up on a behavioral treatment for chronically parasuicidal borderline patients. Archives of General

Psychiatry, 50, 971-974.

Matthews, J.S., Ponitz, C.C. & Morrison, F.J. (2009). Early gender differences in self-

regulation and academic achievement. Journal of Educational Psychology, 101(3), 689

National Resource Center on ADHD. (2009a, August). Myths and misunderstandings.

Retrieved on August 30, 2011, from http://www.help4adhd.org/en/about/myths

National Resource Center on ADHD. (2009b, August). The science of ADHD. Retrieved on August 30, 2011, from http://www.help4adhd.org/en/about/science

National Resource Center on ADHD. (2009c, August). Interacting with others: Tips for adults with AD/HD. Retrieved on August 30, 2011, from http://www.help4adhd.org/en/living/relandsoc/WWK15S

National Resource Center on ADHD. (2010a, April). Statistical prevalence. Retrieved on August 30, 2011, from http://www.help4adhd.org/en/about/statistics

National Resource Center on ADHD. (2010b, August). Marriage and partnership. Retrieved on August 30, 2011, from http://www.help4adhd.org/en/living/relandsoc/marriage

Nigg, J.T. (2001). Is ADHD a disinhibitory disorder? Psychological Bulletin, 127(5), 571-598.

Oehler-Stinnett (2001). [Review of the test Brown Attention-Deficit Disorder Scales]. In B.S.

Plake and J.C. Impara (Eds.), The fourteenth mental measurements yearbook. Lincoln,

NE: Buros Institute of Mental Measurements. Retrieved from Mental Measurements

Yearbook with Tests in Print database.

Oord, S., Bogels, S., & Peijnenburg, D. (2012, February). The effectiveness of mindfulness training for children with ADHD and Mindful Parenting for their parents. Journal of Child & Family Studies. 21(1), 139-147.

Palermo, M.T., Di Luigi, M., Dal Forno, G., & Dominici, C. (2006). Externalizing and oppositional behaviors and karate-do: The way of crime prevention: A pilot study. International Journal of Offender Therapy and Comparative Criminology, 50(6), 654-660.

Passmore, B. (2008). Orient success. The Times Educational Supplement, 18-20.

Pollack, J. (2012, August). Distinguishing between adult ADHD and mild cognitive impairment.

Current Psychiatry, 11(8), 48-53.

President Obama announces steps to reduce dropout rate and prepare students for college and careers. White House. Retrieved from http://www.whitehouse.gov/the-press-office/president-obama-announces-steps-reduce-dropout-rate-and-prepare-students-college-an.

Relos, M. (2004). Getting a kick out of martial arts. Current Health 1, 27(5), 14.

Rhee, S.H., Feigon, S.A., Bar, J.L., Hadeishi, Y., & Waldman, I.D. (2001). Behavior genetic approaches to the study of psychopathology. In H.E. Adams & P.B. Sutker (Eds.),

Comprehensive handbook of psychopathology (3rd ed., pp. 53- 84). New York: Springer

Science+Business Media, LLC.

Rinsky, J.R. & Hinshaw, S.P. (2011, July). Linkages between childhood executive functioning and adolescent social functioning and psychopathology in girls with ADHD. Child

Neuropsychology; 17(4), 368-390.

Sears, R.W., Tirch, D.D., & Denton, R.B. (2011). Mindfulness in clinical practice. Sarasota:

Professional Resource Exchange.

Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford.

Schapiro, S.R. & Livingston, J.A. (2000, Fall). Dynamic self-regulation: The driving force behind academic achievement. Innovative Higher Education, 25(1), 23-37.

Semrud-Clikeman, M., Walkowiak, J., Wilkinson, A., & Butcher, B. (2010). Executive

functioning in children with Asperger Syndrome, ADHD-Combined Type, ADHD-

Predominately Inattentive Type, and controls. Journal of Autism & Developmental

Disorders, 40(8), 1017-1027.

Siegel, D.J. (2007). The mindful brain: Reflections and attunement in the cultivation of well-

being. New York: Norton.

Singh, N.N., Singh, A.N., Lancioni, G.E., Singh, J., Winton, A.S. & Adkins, A.D. (2010).

Mindfulness training for parents and their children with ADHD increases the children’s compliance. Journal of Children and Family Studies, 19, 157 — 166.

Smalley, S.L., Loo, S.K. & Hale, T.S. (2009). Mindfulness and attention deficit hyperactivity disorder. Journal of Clinical Psychology, 65(10), 1087-1098.

SPSS topics. (2007). SPSS Version 11.0 for Windows (student version). [DVD]

Thorell, L.B., Rydell, A.M. & Bohlin, G. (2012, September). Parent — child attachment and executive functioning in relation to ADHD symptoms in middle childhood. Attachment & Human Development, 14(5), 517-532.

van de Weijer-Bergsma, E., Formsma, A.R., de Bruin, E. & Bogels, S.M. (2012, October). The

effectiveness of mindfulness training on behavioral problems and attentional functioning in aAdolescents with ADHD. Journal of Child and Family Studies, 21(5), 775-787.

Wadsworth, J.S., & Harper, D.C. (2007). Adults with attention deficit hyperactivity disorder:

Assessment and treatment strategies. Journal of Counseling and Development: JCD,

85(1), 101-110.

Walters, K.P. (1997). Mind, body, and spirit: The benefits of martial arts training. Reaching Today’s Youth: The Community Circle of Caring Journal, 2(1), 30-33.

Webster-Doyle, T. (2001). My first martial arts book. Trumbull, CT: Weatherhill, Inc.

Wegrzyn, S.C., Hearrington, D., Martin, T., & Randolph, A.B. (2012). Brain games as a potential nonpharmaceutical alternative for the treatment of ADHD. Journal of Research

on Technology in Education, 45(2), 107-130.

Wilkinson, W.K. (2003). [Review of the test Brown Attention-Deficit Disorder Scales]. In B.S.

Plake, J.C. Impara, and R.A. Spies (Eds.), The fifteenth mental measurements yearbook.

Lincoln, NE: Buros Institute of Mental Measurements. Retrieved from Mental

Measurements Yearbook with Tests in Print database.

Williams, M. (2011, March 6). Combining cognitive behavioural therapy with ancient meditation techniques, mindfulness therapy can help anyone who leads a frantic life. The Mail on Sunday (London, England), 43.

Young, R.J. (2001). It can be done. The Exceptional Parent, 31(5), 32-34.

Zivin, G., Hassan, N.R., DePaula, G.F., Monti, D.A., et al. (2001). An effective approach to violence prevention: Traditional martial arts in middle school. Adolescence, 36(143),

Get Professional Assignment Help Cheaply

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Why Choose Our Academic Writing Service?

Plagiarism free papers
Timely delivery
Any deadline
Skilled, Experienced Native English Writers
Subject-relevant academic writer
Adherence to paper instructions
Ability to tackle bulk assignments
Reasonable prices
24/7 Customer Support
Get superb grades consistently

Online Academic Help With Different Subjects

Literature

Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.

Finance

Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.

Computer science

Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!

Psychology

While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.

Engineering

Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.

Nursing

In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.

Sociology

Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.

Business

We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!

Statistics

We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.

Law

Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.

What discipline/subjects do you deal in?

We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.

Are your writers competent enough to handle my paper?

Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.

What if I don’t like the paper?

There is a very low likelihood that you won’t like the paper.

Reasons being:

When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.

In the event that you don’t like your paper:

The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
We will have a different writer write the paper from scratch.
Last resort, if the above does not work, we will refund your money.

Will the professor find out I didn’t write the paper myself?

Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.

What if the paper is plagiarized?

We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.

When will I get my paper?

You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment Help Service Works

1. Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2. Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3. Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4. Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!

Mindfulness and Martial Arts Dissertation

Get Professional Assignment Help Cheaply

Why Choose Our Academic Writing Service?

Online Academic Help With Different Subjects

Literature

Finance

Computer science

Psychology

Engineering

Nursing

Sociology

Business

Statistics

Law

What discipline/subjects do you deal in?

Are your writers competent enough to handle my paper?

What if I don’t like the paper?

Reasons being:

In the event that you don’t like your paper:

Will the professor find out I didn’t write the paper myself?

What if the paper is plagiarized?

When will I get my paper?

Will anyone find out that I used your services?

How our Assignment Help Service Works

1. Place an order

2. Pay for the order

3. Track the progress

4. Download the paper

Why Choose Us?

Why Hire Our Writers?

How to place an order: