Mindfulness for Autism Jessie Poquérusse, Francesco Pagnini & Ellen J. Langer Advances in Neurodevelopmental Disorders Multidisciplinary Research and Practice Across the Lifespan ISSN 2366-7532 Adv Neurodev Disord DOI 10.1007/s41252-020-00180-9 1 23 Your article is protected by copyright and all rights are held exclusively by Springer Nature Switzerland AG. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy Advances in Neurodevelopmental Disorders https://doi.org/10.1007/s41252-020-00180-9 ORIGINAL PAPER Mindfulness for Autism Jessie Poquérusse 1 & Francesco Pagnini 1,2 & Ellen J. Langer 1 # Springer Nature Switzerland AG 2020 Abstract Objectives An important complement to molecular treatments, psychological interventions for autism spectrum disorder (ASD) are efficient and sustainable. The Western-influenced mindfulness concept is one such particularly powerful psychological construct with widespread benefits spanning health, education, and business spheres. By alleviating the difficulties inherent to certain rigid patterns of cognition and behavior, cognitively fluidifying mindfulness-based interventions anchored in training one’s attention to variability have emerged as promising for improving the well-being of individuals with ASD. The purpose of this paper is to review the evidence supporting these benefits and point to their potential underlying mechanisms. Methods In this conceptual paper, we first review the broad evidence of the benefits of a range of Western-influenced mindfulness interventions for individuals with ASD, after which we deconstruct their underlying intra-individual processes and effects, and, finally, frame these psychological mechanisms in light of current core cognitive theories of ASD. Results This paper highlights the established importance and continued promise of Western-influenced mindfulness training in understanding and improving the psychological health and overall well-being of individuals with ASD. As such, we hope to lay the foundation for avenues of future research on mindfulness-inspired interventions aimed at non-invasively improving the lives of individuals and families affected by ASD. Conclusions This work provides a brief overview bridging Western-influenced mindfulness and cognitive theories of ASD. In so doing, it sheds light on this ripe intersection highly amenable to therapeutic intervention. Keywords Mindfulness . Autism spectrum disorder . Theory of mind . Central coherence . Executive functioning Autism spectrum disorder (ASD) is a disorder of neurodevelopment clinically defined in the Diagnostic and Statistical Manual of Mental Disorders version V (American Psychiatric Association 2013) by difficulties with social interaction and communication along with restrictive and repetitive behaviors. Unconfounded by increased diagnostic acuity, ASD has been rising in diagnostic prevalence, with estimates reaching 1 in 59 children affected in the United States alone (Baio et al. 2018). In addition to the individual challenges it presents, ASD represents a global medical and socioeconomic challenge (Buescher et al. 2014; Lavelle et al. 2014). While multifactorial, ASD’s etiology is largely genetic, with * Jessie Poquérusse email@example.com 1 Department of Psychology, Harvard University, Cambridge, MA, USA 2 Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy conservative heritability estimates consistently surpassing 50% (Gaugler et al. 2014), and disruptions are evident in processes spanning a number of genetically, epigenetically, and environmentally guided brain developmental stages (Courchesne et al. 2018; Poquérusse and Luikart 2017). At a psychological level, a number of developmental differences have been identified, including challenges with emotional understanding and regulation (Poquérusse et al. 2018), theory of mind and social cognition (Baron-Cohen et al. 1985), executive functioning (Hill 2004), weak central coherence (Jolliffe and Baron-Cohen 1999a, 1999b, 2001), and delayed expressive language development (Gernsbacher et al. 2016). To address these interdependent etiologies, substantial work has and is being done at all scales of neuroscience and psychology to develop treatments for ASD, from patient-centric genetic engineering and high throughput screenings for small molecule drug discovery (Sung et al. 2014) to the development of specialized communication devices (Alzrayer et al. 2014; Martínez-Santiago et al. 2018; Tang et al. 2013), social skills training protocols (Choque Olsson et al. 2016; Kerr et al. 2002), anti-anxiolytic social stories (Chung and Chen 2017; Author's personal copy Adv Neurodev Disord Marr and Nackley 2010), and a variety of cognitive and behavioral therapies, both patient- (Cooper et al. 2018; Kincade 2009; Larsson 2013) and caretaker-centric (Brookman-Frazee et al. 2006). Mindfulness Among psychological therapies, mindfulness-based interventions have been recently emerging as a promising tool for individuals with ASD to reshape the mind’s architecture as a complement to molecular biological therapeutic efforts. While first introduced as a concept into social psychology over three decades ago, mindfulness can be distilled into two main nonindependent definitions. Eastern-rooted philosophies traditionally conceptualize mindfulness as a moment-to-moment, nonjudgmental awareness of one’s present experience (KabatZinn 1982, 1990). In contrast, Western-influenced concepts, born of Langer’s original social psychological definition, simply define the essence of mindfulness as a heightened attention to variability and openness to novelty (Langer 1989; Langer and Piper 1987). Eastern-based mindfulness has long been known to be physically and psychologically beneficial to individuals with ASD. Mindfulness-based cognitive therapy, which teaches individuals to be present in the moment in a nonjudgmental and accepting way (Kabat-Zinn 1990; Williams et al. 2008), increases well-being in addition to reducing anxiety, depression, rumination, somatization, distrust, and interpersonal sensitivity in individuals with ASD (Kiep et al. 2015; Spek et al. 2013). Similar mindfulness-based trainings, including in the form of joint mindfulness-based stress reduction (MBSR) and cognitive behavioral therapy (CBT) programs, have been shown to reduce anxiety, depression, and aggression in individuals with ASD (Cachia 2017; Sizoo and Kuiper 2017), while programs for individuals with ASD, directly focused on enhancing and directing attention, increasing awareness of bodily sensations, feelings and thoughts, and increasing self-control, improve social communication and emotional and behavioral functioning (Ridderinkhof et al. 2018). In addition to patient-centric interventions, similar mindfulnessbased interventions may benefit individuals with ASD by training their social environment as well to be more mindful (Singh et al. 2014). In contrast to the Eastern-influenced concept, Westerninfluenced concepts, born of the original social psychological definition, simply define mindfulness as a heightened attention to variability and openness to novelty, a mindset rooted in and fostering a creative, divergent, and non-algorithmic mode of thinking (Langer 1989). It is well established that this approach is robustly embedded in and promotes (1) a greater awareness of and sensitivity to one’s environment, alongside a state of heightened present involvement, engagement, and wakefulness; (2) an openness to new information and increased awareness of context and multiple perspectives, such as those relevant to problem-solving and interpersonal harmony; and (3) a resulting increased ability to create new categories for structuring perception, including a loosening of certain stereotypes and archetypes. Health benefits include stress reduction, decreased addiction, and increased longevity and well-being; work-related benefits include sharpened cognitive acuity, creativity, productivity, and performance, and social benefits range from enhanced emotional awareness to greater relationship satisfaction (Langer and Moldoveanu 2000). Such Western-influenced mindfulness training is particularly promising for individuals with ASD. Indeed, the less timeand logistically intensive Western mindfulness trainings— not necessarily contingent on an institution or planned schedule—are relatively simple in implementation. Hereinafter, we will refer to Langer’s Western-influenced construct of mindfulness as simply ‘mindfulness’, while integrating spheres of overlap with the Eastern-influenced construct of mindfulness, assessing how it fits into the broader scheme of and provides therapeutic potential targeted to core cognitive theories of ASD. Mindfulness and ASD A contributing factor to anxiety and a cognitive hallmark of ASD is a certain rigidity of thought and behavior, which, in the Western-influenced construct, is the reverse of mindfulness (Langer 1989), and can be loosened through mindfulness training. Without probing the causal or consequential nature of this rigidity of thought and behavior in ASD, training individuals to be more mindful by paying closer attention to environmental nuance, in general, allows them to grow aware of and desensitized to its constant state of flux and intrinsic ambiguity (Langer 2005). Alongside this, realizing that verbal, perceptual, and cognitive limits are human-generated, and thereby malleable, helps individuals live in a more relaxed, dynamic state with respect to their perceptions and actions. A specific example, and one highly relevant to our medical times, is that of medical labels. While ubiquitous and logistically useful, such biased labels should neither be perceived as fixed nor identity-defining (Davis 1979). Despite the computational necessity for the human mind to navigate the world by dynamically creating categories and other mental and conceptual shortcuts, mindfulness training as defined by deliberate attention to variability—including the intrinsic variability and nuance of linguistic labels—fluidifies such categories in a way that may end up being less stigmatizing and self-fulfilling for individuals with ASD. It is important to note here that, even if the rigidity of ASD is a self-protective, disengaging reaction to the ubiquitous mindlessness of others, mindfulness training may enable help individuals stay in tune to subtle differences Author's personal copy Adv Neurodev Disord and improve their moment-to-moment integration of the mindful/mindless cues of their social entourage. The ideal outcome is a heightened ability to person, time, and domain—specifically to fine-tune such thought and behavioral patterns. Linked to this cognitive and behavioral rigidity, three core interrelated and evolving cognitive theories characteristic of ASD have emerged (Rajendran and Mitchell 2007). These include deficits in (1) theory of mind (ToM), or the ability to infer the mental state of others; (2) central coherence, or the preferential focus on a stimuli’s global whole rather than local parts; and (3) executive functioning, or the ability to plan ahead, make decisions, and inhibit impulsive behaviors. First, ToM, or the ability to represent and understand others’ mental states, such as goals, emotions, and beliefs (Bauminger-Zviely et al. 2013; Bauminger and Kasari 1999), is compromised in ASD and affects individuals’ capacities, as desired, to behave in socially normative ways (Baron-Cohen 1997; Baron-Cohen et al. 1985). Specific evidence has suggested that individuals with ASD, while not universal, may lack a fully representational, and thus delayed, ToM, rather than a fully absent one, as represented by their greater difficulty with secondary ToM than primary ToM (Baron-Cohen 1989). Consistently, ToM capacities, conceptualized as a cognitive module developmentally linked to verbal mental capacity, may develop differentially across individuals with ASD according to a spectrum (Baron-Cohen et al. 1999). Evidence of deficits in ToM stems mainly from deficits seen in the Strange Stories test, in which individuals with ASD have difficulty explaining the potential motives behind peoples’ strange behaviors (Happé 1994), and, more generally, have difficulty using context-appropriate mental state terms (Jolliffe and Baron-Cohen 1999a, 1999b), as well as the Reading the Mind in the Eyes Task, in which individuals with ASD have difficulty interpreting the mental states of others based on images of their eyes (Baron-Cohen et al. 1997), which was since reproduced with vocalizations (Rutherford et al. 2002). Mindfulness training, by sensitizing to context and perspective, may help individuals with ASD more readily tune in to contextual cues and understand others’ perspectives. Specifically, it may increase ToM by training attention to the subtle variations in story details, eye and facial expressions, and vocalization characteristics that represent shifts in emotions and mental states. In addition, and more broadly, viewed as a variation of mindlessness, such ToM deficits may be vastly improved through such increased social cognitive flexibility training (Bock et al. 2015). This is supported by studies showing that formal ToM training, in the form of structured sessions focused on listening to others, assessing social situations and recognizing others’ intentions and emotions while focusing on such concepts as perception, limitations, and fantasy versus reality—established corollaries of mindfulness training of varying degrees removed—significantly improved ASD individuals’ ToM (Begeer et al. 2011). Second, individuals with ASD exhibit weak central coherence (WCC), or a cognitive style, while heterogeneous (López et al. 2008), Whivh prioritizes attention to acute detail rather than the global whole (Frith and Happé 1994; Happe 2005). The first evidence of WCC emerged from studies demonstrating that individuals with ASD were better able than neurotypical individuals to locate a small target shape in a drawing of a larger shape composed of potentially confusing lines, such as in the Embedded Figures Task (Jolliffe and Baron-Cohen 1997; Shah and Frith 1983). Since WCC has been demonstrated in various studies and potentially causally linked to the cognitively complex ability to handle hierarchical relations between global and local levels (reduced hierarchization), one of the many potential explanations is the reduced ability of ASD individuals to generalize, i.e., generalize newly learned behaviors to a novel environment due to their narrower concepts and sharper, more delineated boundaries (reduced generalization) (de Marchena et al. 2016). Such differences may reflect issues related to the control of the spread of visual attention, predictions of which are that (1) individuals with ASD have a visual attention which is spatially overly focused and (2) individuals with ASD have difficulty broadening their attention. Such WCC may be improved through mindfulness training by helping individuals not only see boundaries as fluid and constantly changing (‘boundary extension’), but also by shifting back and forth more readily between widening and narrowing their attention. Rather than automatically paying excessive attention to detail, participants are trained to shift perspectives, including that of the “big picture”, in addition to theirs—thus building the ability to see through a centrally coherent lens in addition to the default. As a corollary, participants trained in such mindfulness techniques view both internal and external experiences as passing events in a wider field of awareness—thereby building central coherence. Third, individuals with ASD exhibit deficits in executive functioning (EF), an umbrella term for the domain-general cognitive functions of working memory, planning ahead, behavioral inhibition, and initiating, sustaining and shifting attention, alongside the associated flexibility of thought and action (Demetriou et al. 2018; Hill 2004; Landa and Goldberg 2005). Among many, deficits in EF manifest themselves as difficulty inhibiting the interfering influence of one input modality on another (Adams and Jarrold 2012), deficits in tests of intentionality, to which the cognitively complex ability to handle multiple embedded rules are inherent (Poljac and Bekkering 2012), and deficits in attention flexibility inherent to executive memory and metacognition (Wallace et al. 2016). The Western-influenced construct of mindfulness Author's personal copy Adv Neurodev Disord specifically encourages attention shifting flexibility. This capacity to promote multiple perspectives and shift attentional foci may as such naturally improve both EF and cognitive performance, in particular in individuals with a diagnosed attention problem, often comorbid with ASD (Carson et al. 2001; Stevens et al. 2016). Indeed, mindfulness-based programs improve EF (van de Weijer-Bergsma et al. 2012; Zylowska et al. 2008) in ways that are strongly applicable to and promising for individuals with ASD. Furthermore, mindfulness training designed to enhance attention to variability may be extended to one’s internal environment. A core feature of ASD is the difficulty affected individuals experience with regard to interpreting, regulating, and expressing and coping with their emotions (Mazefsky 2015; Mazefsky and White 2014; Poquérusse et al. 2018). Mindfulness training may help individuals identify emotions by teaching them to be more in tune to the inner changes that characterize an emotion, whether physical, such as the blushing cheeks or racing heart of an activated sympathetic nervous system, or cognitive, such as arising thought patterns that may exacerbate negative emotions. This in turns allows individuals to (1) better identify, label, process, and express arising emotions, while (2) better understanding the triggers that precipitate emotional reactivity. In addition, since difficulties in ASD are frequently caused or expedited by sensory overload, which is often acute and overwhelming (Atkinson 2015; Belek 2018), mindfulness training may teach individuals to listen and accordingly attend to sensory symptoms at still subtle and manageable intensity levels (Watford and Stafford 2015). More generally, attention to the constant flux of experience through mindfulness may allow individuals to realize that as new roles in life are adopted and external circumstances change, moods and emotions change accordingly—the active noticing and distinguishing of which helps reduce emotional reactivity, increasing overall wellbeing (Singh et al. 2011). Building on the above, mindfulness may just as powerfully benefit individuals with ASD indirectly through the deliberate actions they are trained and encouraged to engage in, for which a state of baseline mindfulness is not only a prerequisite, but also a feedforward effect. For example, many forms of therapy that span music, arts, and sports engage individuals in a way that reduces stress and increases overall well-being (Fogleman 2012). These activities require individuals to be present, focused, active, in tune to kinesthetic, visual or musical variability, and in tune to different lenses, such as the different perspectives and messages conveyed through art. Music therapy for example brings individuals into the present moment by training and cultivating their attention to variability of pitch, tone, and rhythm, among others; in addition, it helps with emotional atonement by allowing for emotional expression through musical rhythms which match and reflect emotions (Gebauer et al. 2014; Tan and Khetrapal 2016). Such mindfulness-fostering effects are broad ranging, and similarly inherent to visual, artistic, or kinesthetic forms of expressive therapy. Finally, mindfulness training may help individuals with ASD by being applied to their social environment. On a personal level, mindfulness training helps by improving the wellbeing of caretakers themselves, with obvious and direct repercussions on individuals with ASD (Keenan-Mount et al. 2016). Children with ASD whose parents have high levels of mindfulness experience lower levels of behavior problems, stress, and depressive symptoms (Beer et al. 2013). Following a mindful parenting training, ASD children had fewer episodes of aggressions, non-compliance, and self-injury; the training also improved parent-children interactions and parents’ satisfaction with their parenting skills (Singh et al. 2006, 2014). Similar mindfulness training of relatives and caretakers, having been shown to slow disease progression and improve psychological well-being in response to a broad range of neurological challenges, is far-reaching (Haller et al. 2017; Pagnini et al. 2015). On a practical level, caretakers who are trained to be mindful pay more attention to nuances in the individuals with ASD with whom they work. This enables them to more readily recognize, target, and attend to patterns in their patients, helping implement subtle but high impact changes. In addition, free of normative social constructs and able to see boundaries as flexible and dynamic, mindful caretakers may more readily generate non-traditional and sustainable solutions for ASD. These range from deliberately choosing medical language to promoting social integration and finding creative ways of incorporating sensory integration therapy (Grandin and Panek 2013). Indeed, by seeing past the limitations, imprecision, and questionability of medical language (Davis 1979), caretakers shift from thinking in absolutes to thinking in terms of possibilities and potential. For example, in settings spanning the clinic to the classroom (Langer 1997), conditional language may be used to empower all individuals, aged and with ASD alike, to exceed normative expectations (Pagnini et al. 2016). Globally, mindfulness training defined as increased attention to variability, by fluidly considering individuals in light of the multidimensional bell curves of human-centric traits rather than strictly within the scope of hard threshold-defined clinical constructs, both logistically and philosophically improves our approach to ASD while promoting neurodiversity. Future Research Directions Mindfulness training of individuals with ASD and their caretakers is a powerful and promising way of increasing the wellbeing of individuals with ASD. Indeed, we believe that the synoptic perspective provided by this conceptual paper lays forth an under-explored focus area, bridging and highlighting Author's personal copy Adv Neurodev Disord the promise of Western-influenced mindfulness and cognitive theories of ASD. Integrating mindfulness training into ASD therapies not only treats the non-algorithmic mind in addition to the biological brain, but also provides a rapid, cost-effective, and sustainable complement to ongoingly developed molecular treatments. This said, future research is warranted in order to create the most effective ASD-centric mindfulness programs and understand how it can be more seamlessly implemented across a diversity of clinical and non-clinical settings, incorporated into or alongside other therapeutic interventions. Of particular salience are the following emerging questions: What are the precise mechanisms underlying the effects of mindfulness training on individuals with ASD, in terms of the core features of ToM, central coherence, and EF, but also other more or less related aspects of ASD such as emotion regulation and sensory hypersensitivity? How can the benefits of cognitive flexibility-inducing mindfulness training best be reconciled with the characteristic need for structure and rigidity inherent to ASD? In light of the strong heterogeneity of ASD and its defining features and presentations, how do mindfulness interventions affect syndromic vs non-syndromic autism, in addition to the different ‘autisms’ in the form of ASD cognitive subtypes (Cantio et al. 2016) and/or endophenotypes (Constantino 2018)? For example, are there certain genetic backgrounds that might be differentially responsive to mindfulness interventions? Do mindfulness interventions affect males and females with ASD to the same extent, and in the same manner? In terms of the defining features of ASD, what, if any, might be the intra- and intercellular genetic, epigenetic, brain anatomical and functional, and physiological correlates of the benefits of ASD (e.g., on amygdala functioning, sensory sensitivity, or circadian rhythms, among others)? How could this inform the discovery of biomarkers reflective and/or predictive of the benefits of mindfulness on ASD? How can mindfulness programs be best developed to train the multiple layers of actors within an individual with ASD’s social environment—from family members and caretakers to policy makers and law enforcement professionals—in order to best interact with, engage, and care for individuals with ASD? For example, how might mindfulness training increase the accuracy of diagnoses (minimizing both false negatives and false positives)? Is there an ideal time period during which to implement mindfulness interventions to maximize their benefits (either through an acute intervention and/or with the idea of developing sustainable habits)? In light of the rising evidence of the broader autism phenotype (Gerdts and Bernier 2011; Green et al. 2020), how might such mindfulness training affect the very cognitive faculties such as ToM, central coherence, and EF among individuals with ASD’s social entourage, genetically related and not, in such a way as to improve their own well-being as well as that of individuals with ASD? Moving beyond ASD to the broader landscape of neurodevelopmental disabilities as a whole, how might such mindfulness interventions benefit neuropsychiatric disorders of related genetic and psychological/cognitive etiology, including, for example, schizophrenia and attention deficit hyperactivity disorder (Gudmundsson et al. 2019)? How might this shed light on their distinct and overlapping etiologies and inform ways to enable such affected individuals to live better? Given that the concerted effort of clinical specialists, families themselves and broad societal players are key to understanding and improving the well-being of individuals with ASD, we believe that improving individual and caretaker mindfulness training, in addition to further research on underlying mechanisms, will be crucial to the collaborative initiative to better address the ASD challenge of the twenty-first century. Authors’ Contributions JP conceived of the article and wrote the paper in collaboration with FP and EL. Compliance with Ethical Standards Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationship that could be construed as a potential conflict of interest. References Adams, N. C., & Jarrold, C. (2012). 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