Contemplative Intervention Reduces Physical

Author's personal copy Prev Sci DOI 10.1007/s11121-016-0720-x

Contemplative Intervention Reduces Physical Interventions for Children in Residential Psychiatric Treatment Joshua C. Felver 1 & Richard Jones 2 & Matthew A. Killam 2 & Christopher Kryger 3 & Kristen Race 4 & Laura Lee McIntyre 5

# Society for Prevention Research 2016

Abstract This research explored the effectiveness of a manualized contemplative intervention among children receiving intensive residential psychiatric care. Ten children with severe psychiatric disabilities received 12 sessions (30– 45 min) of BMindful Life: Schools^ (MLS) over the course of a month. Facility-reported data on the use of physical intervention (i.e., seclusions and restraints) were analyzed. Acceptability questionnaires and broad-band behavioral questionnaire data were also collected from children and their primary clinicians. Robust logistic regression analyses were conducted on person-period data for the 10 children to explore the timing of incidents resulting in the use of physical intervention. Incidents within each person-period were regressed on indicators of days of contemplative practice and days without contemplative practice. Results indicated that during the 24-h period following MLS class, relative to a comparison 24-h period, children had significantly reduced odds of receiving a physical intervention (OR = 0.3; 95 % CI 0.2, 0.5; p < 0.001). Behavioral questionnaires did not indicate significant contemplative intervention effects (ps >0.05), and MLS was found to be generally acceptable in this population and setting. These data indicate that contemplative practices acutely reduced the utilization of physical interventions. Clinicians

* Joshua C. Felver [email protected]

1

Syracuse University, Syracuse, USA

2

Alpert Medical School of Brown University, Providence, USA

3

Youth Villages Oregon, Lake Oswego, USA

4

Mindful Life, Carbondale, USA

5

University of Oregon, Eugene, USA

seeking to implement preventative strategies to reduce the necessity of physical intervention in response to dangerous behavior should consider contemplative practices. Those wishing to empirically evaluate the effectiveness of contemplative practices should consider evaluating objective measures, such as utilization of physical intervention strategies, as oppose to subjective reports. Keywords Mindfulness . Children . Residential treatment . Yoga . Seclusion and restraint Clinicians who work with children in residential treatment settings face unique challenges to providing safe and effective treatment. Although adolescents (over 13 years of age) relative to children (under 13 years of age) make up the majority of youth receiving residential treatment services overall, data suggests that children have more severe behavioral and emotional challenges than adolescents (Huefner and Vollmer 2014), including higher rates of aggression and social problems, and higher likelihoods of suicidal behavior, previous psychiatric hospitalizations, and histories of psychopharmacological treatment (Baker and Purcell 2005). Younger children in residential treatment are also more likely to exhibit dangerous aggressive behavior that necessitates physical intervention to keep themselves and others from harm, such as seclusions and restraint procedures (dosReis et al. 2010; Stewart et al. 2010). The use of seclusions and restraints with children is particularly concerning given the documented risks of these interventions, such as decreased staff morale, lower overall treatment outcomes, emotional traumatization, physical injury, and death (LeBel et al. 2010). Given the risks posed by the use of seclusion and restraint interventions with children in residential treatment facilities, there has been a call for an increased emphasis on

Author's personal copy Prev Sci

prevention-oriented strategies to reduce the need for physical intervention, notably interventions to bolster self-regulation in children to prevent the occurrence of dangerous aggressive behavior (Huckshorn 2005; LeBel et al. 2004). An emerging body of evidence indicates that contemplative practices (e.g., mindfulness and yoga practices) are a safe and generally effective method of intervention for youth across different settings (Birdee et al. 2009; Black et al. 2009; Burke 2010; Felver et al. 2016). In a recent meta-analysis on the topic, Zoogman et al. (2015) explored the effects of mindfulness-based interventions on youth. The results highlighted that the omnibus effect size was significant (del = 0.23), comparable to effect sizes obtained from the adult mindfulness-based intervention literature (Khoury et al. 2013). Interestingly, Zoogman and colleagues also found that clinical samples seemed to benefit more from contemplative practices than non-clinical groups, suggesting that these practices may be more effective for youth exhibiting psychopathology. It is worth noting that of all the studies included in this meta-analysis, there were only four that focused on clinical subsamples of youth, of which three were comprised only of adolescents and none of which were conducted in an inpatient treatment setting, suggesting a lack of research exploring the effects of contemplative practice with younger youth in more intensive treatment settings. To date, there have been only a few studies that have examined the effects of contemplative practice on youth with significant behavioral problems. Singh and colleagues (2007) found that brief mindfulness training was an effective strategy for reducing aggressive and conduct-disordered behavior in a group of adolescents diagnosed with conduct disorder in a school setting. Barnes and colleagues (2003) found that following contemplative training (transcendental meditation), adolescents had decreased rates of school-based behavior problems that resulted in school suspensions. Only one study to date has examined the effects of contemplative practice on youth in a residential treatment facility. Spinazzola and colleagues (2011) reported qualitative results that children in a residential treatment center appeared to benefit in their ability to self-regulate as a result of practicing yoga. Taken as a whole, the current research suggests that contemplative practices are promising modalities for supporting the behavioral and emotional needs of youth, including children with severe behavioral and emotional challenges, although more highquality research is needed to better understand the utility of these interventions (Black et al. 2009; Felver et al. 2016; Greenberg and Harris 2012; Serwacki and Cook-Cottone 2012) including research conducted in inpatient treatment settings (Zoogman et al. 2015). Leading theories into the putative mechanisms behind the benefits observed following contemplative practice suggest that self-regulation (e.g., attentional-regulation and emotional-regulation) plays a central role (Bishop et al. 2004; Hayes

and Feldman 2004; Shapiro et al. 2006). Although the majority of evidence supporting the theoretical implications of selfregulation in contemplative practices has come from research with adults, there have been a few studies conducted with youth to support this theory. In one randomized control trial, children demonstrated improved behavioral performance on a task of attentional self-regulation following mindfulnessbased intervention (Felver et al. 2016). Several other mindfulness intervention studies have suggested that youth may be more able to self-regulate their problematic behavior after learning basic mindfulness practices (Felver et al. 2014; Singh et al. 2007). Taken as a whole, the existing research offers some evidence that contemplative practices bolster self-regulatory processes in youth, which may in turn result in reductions in problematic behavior. However, more research exploring the outcomes following intervention for high-risk groups is needed to advance this nascent field of scientific inquiry. The present study aimed to evaluate the effects of 1 month of a manualized contemplative intervention, BMindful Life: Schools^ (MLS; Race 2016), with problematic behavior exhibited by children in a residential psychiatric treatment center. Specifically, we intended to evaluate the quantitative relation between contemplative practice and the utilization of physical intervention procedures in response to aggressive behavior. Our a priori hypothesis was that during days of contemplative intervention (i.e., either the three calendar days per week coinciding with the MLS class or the 24-h period immediately following the MLS class), children would engage in fewer dangerous aggressive behaviors that necessitated physical intervention (e.g., seclusions and restraints). Given the limited amount of research exploring contemplative practices with this population, acceptability data was collected from children and their primary clinicians at the completion of the intervention, and a broad-band measure of child problem behavior was completed by each child’s primary clinician before and after intervention.

Method Contemplative Intervention—BMindful Life: Schools^ This project implemented the MLS intervention, a manualized contemplative intervention designed to teach youth selfregulatory and relaxation skills through secularized yoga and mindfulness practices. MLS teaches children basic mindfulness and yoga skills in a developmentally tailored format for youth, incorporating games, activities, and structured lessons. A typical MLS class lasts for approximately 30–45 min and is conducted by a trained instructor. The MLS lesson curriculum includes 12 thematic sessions (see Table 1) that are intended to be completed sequentially and include activities designed to

Author's personal copy Prev Sci Table 1

BMindful Life: Schools^ sessions

Session and theme

Description

1 – Mindful listening

Focusing attention to sensory experience of sound Focusing attention to somatic sensation of breath

2 – Mindful breathing 3 – Mindful movement 4 – Mindful eating 5 – Peace and happiness 6 – Gratitude

Focusing attention to somatic sensations of movement Focusing attention to food objects and sensations of eating Defining basic emotions and bringing attention to positive emotional states Defining and practicing gratitude and giving thanks to positive experiences

7 – How my brain works

Explaining basic brain functions related to anger and impulse control, and practicing mindfulness skills as a way of calming emotional states

8 – Bottle breathing

Focusing on the calming effects of diaphragmatic breathing exercises Defining empathy and practicing focused attention to emotional states of others and self Defining attitude of kindness and the concept of present moment, and practicing attention to breathing with kindness Discussing physiological arousal (e.g., increased heart rate) as indicator of strong negative affective state and practicing mindful breathing to self-regulate these feelings Reviewing concept of kindness and practicing making kind statements to self and others

9 – Perspective taking

10 – Present moment

11 – Self-regulation

12 – Kindness

enhance attention regulation, inhibitory control, somatic awareness, and emotion regulation. Each of the twelve sessions had a similar format: review of previous session content, didactic instruction of new material, practice of several yoga/mindfulness activities related to the sessions theme and teaching, and a closing mindfulness practice. Table 2 details an example MLS session. MLS sessions were delivered three times per week during weekdays for four consecutive weeks. The MLS intervention was delivered by a facility Program Manager who was employed at the psychiatric treatment facility but did not work directly with any of the children in this study. The interventionist had 11 years of personal contemplative practice, had 4 years of teaching yoga to 12–16-year olds in residential treatment centers, and had completed an intensive 3-day training program in MLS. MLS classes were implemented during the children’s daily allotted Bgross motor activity time,^ and aside from this substitution, weekdays in which children

participated in MLS were no different than a typical day of programming. Setting This study took place at an intensive residential psychiatric treatment facility located in a metropolitan center of the Pacific Northwest. The general admission criteria to this facility included a lack of success with other psychiatric treatment programs, severe emotional and behavioral problems, being between ages 7 and 18, and full-scale scores on standardized intellectual assessment batteries over 70. This facility also accepted youth with co-occurring medical challenges and developmental disabilities. The average (mean) length of stay for all youth at this facility during the year this study took place was 117 days. During the year that this current study took place (2012), this facility provided 16,366 days of residential treatment to patients. During 2012, patients were secluded 1010 times, for an average of 84 seclusions per month and 0.06 seclusions per day of treatment; patients were restrained 2508 times, for an average of 209 seclusions per month and 0.15 restraints per day of treatment. Within the facility, this study focused on one of the two children’s units (ages 6–12 years of age) that had a maximum capacity of 12 children per unit. Children in these units participated in treatment as a group, engaging in meals, group therapy, school, and recreation as a group. Weekdays within the children’s unit included regular school hours at the facility, and weekends included community outings and family visits. Treatment for all children included psychotherapeutic counseling (i.e., group, individual, and family therapy) and standard psychiatric care (i.e., psychopharmacological management). Participants Participants were drawn from one of the two children’s units at this facility. Children and their legal guardians were approached to participate in the study; all legal guardians gave consent for their children to participate and all but one child assented to participate. Children’s primary individual mental health clinicians were also approached to participate in this study to complete questionnaires about program acceptability and effectiveness; all clinicians consented to participate (n = 5). This study received Institutional Review Board approval from the University of Oregon and from the facility’s internal research review board. Participants included 10 of the 11 children staying at the unit at the time of the study; one child’s data were excluded because he did not assent to participate in the research. The 10 participating children ranged in age from 7 to 12 years (mean 10.0 years; interquartile range 8.0–11.7 years) and were mostly (60 %) male. Ethnically, the sample was mostly White

Author's personal copy Prev Sci Table 2 Example BMindful Life: Schools^ session (Lesson 3)

Topic covered

Minutes devoted

Description

Review and brief practice

5

Explain new skill

2–3

Review content from previous classes. Children practice focusing attention to somatic sensation of breath (i.e., mindful breathing). Brief explanation of theme for class, mindful movement, which involves moving your body with careful attention.

Practice skill

5

Practice activity that builds off of the theme for the day. The activity, Bmirroring,^ involved children pairing off and taking terms mimicking the other child’s movements.

Group discussion

2–3

Group discusses importance of theme and skill and connects it to daily life. Mindful movement can be useful during busy transitions (e.g., walking down halls in schools so you don’t bump others), or for certain adult jobs (e.g., surgeons and athletes).

Yoga practice

20

Relaxation activity

2–3

Closing

2–3

Group practices focusing attention to somatic experience via a series of guided movement activities including gentle stretching. This activity is delivered as a game for children, such as by standing in a circle and copying the physical stance or Bpose^ of the person next to you, thus teaching both a mindfulness skill (i.e., attention to somatic experience) and also behavioral self-regulation (i.e., child must wait until the pose comes around the circle to them before they move). Guided relaxation to end class. Children lie on their backs on the floor, and sequentially focus attention to body parts (e.g., head, chest, legs) with the instruction to imagine the body part as very heavy and sinking into the mat. Class ends with children practice focusing attention to somatic sensation of breath (i.e., mindful breathing).

(n = 5), with other children identifying as Hispanic Latino(a) (n = 1), Asian (n = 1), and belonging to more than one ethnicity (n = 3). Their DSM-IV primary diagnoses at intake included post-traumatic stress disorder (n = 3), mood disorder not otherwise specified (n = 2), depressive disorder (n = 2), attention-deficit/hyperactive disorder (n = 2), and disruptive behavior disorder (n = 1). Their Children’s Global Assessment Scale at intake ranged from 25 to 40 (mean 34.6). The length of stay at this residential psychiatric facility for these 10 children ranged from 3 to 10 months (mean 181 days; interquartile range 142–201 days).

Measures Facility-Collected Behavioral and Psychiatric Data Data collected by the psychiatric residential facility were collected and analyzed as part of this research. These data included the primary dependent variable of incident occurrences that resulted in seclusions and restraints, including the child’s name, time, date, and type of physical intervention (i.e., restraint or seclusion). Seclusion and restraint procedures were implemented only when children were an active danger to

themselves or other (i.e., exhibiting severe aggressive behavior). Staff were thoroughly trained in consistently implementing these seclusion and restraint procedures, which included intensive pre-employment training by an international behavior management training organization focused on crisis prevention and de-escalation (Crisis Prevention Institute), protocol refresher courses every 6 months, debriefing and discussion during team meetings, and individual supervision. Seclusion and restraint data were uniformly reported by milieu staff per facility and state regulations as part of their typical job functioning. These staff were not informed about the current research project and were in essence blinded to the research as a whole, although depending on the staff’s schedule, some did know that children were doing a yoga class as part of their gross motor programming at the facility. Data also included intake diagnostic information reported from the facilities attending child psychiatrists, and facility intake and discharge dates.

Children’s Intervention Rating Profile Children’s acceptability was measured using an adapted version of the Children’s Intervention Rating Profile (CIRP; Witt and


Elliott 1985), an eight-item measure using a five-point Likert-type scale, in which children responded to how much they agreed or disagreed with statements about the fairness and acceptability of MLS. Previously reported internal consistency reliability estimates of the CIRP range from 0.75 to 0.89 (Witt and Elliott 1985). Children were also asked open-ended questions about MLS (e.g., BWhat I liked best about MLS?^). Behavior Intervention Rating Scale Acceptability was also measured from the children’s primary clinician using an adapted version of the Behavior Intervention Rating Scale (BIRS; Elliott and Treuting 1991), a 24-item measure using a five-point Likert-type scale, in which clinicians agreed or disagreed with statements about the acceptability, effectiveness, and how quickly an intervention can produce change in children (i.e., rate of change). The reported internal consistency for the full scale of the BIRS is 0.97, and the internal consistency for the three subscales ranged from 0.87 to 0.97 (Elliott and Treuting 1991). Clinicians were also asked openended questions about MLS (e.g., BDo you feel that MLS was effective for this student? Why or why not?^). Intervention Fidelity Checklist To monitor the validity of MLS intervention implementation, the interventionist completed a brief fidelity checklist at the completion of each lesson to document which lesson components were completed that day. The interventionist was also instructed to take program implementation notes during each lesson as a way of collecting additional qualitative information. Table 3 details an example MLS session fidelity checklist. Table 3 Example BMindful Life: Schools^ intervention fidelity checklist (Lesson 3) Directions: Check off if you have completed the component for this lesson. Component Review (discuss): (1) Mindful listening, (2) mindful/belly breathing Practice (review): (1) Mindful listening, (2) mindful/belly breathing Explain new skill: Mindful movement Practice mindful movement: Mirroring Game Explain importance of Mindful movement Yoga lesson (please circle which one you did): -pass the clap -The Wave: Sundance -Morph Guided Relaxation: Body Part Visualization—Feeling Heavy Closing: mindful bodies and mindful listening Notes:

Yes No

Teacher Report Form As a secondary outcome, to assess for general child behavioral problems and psychopathology, children’s primary clinicians completed the teacher version of the Achenbach System of Empirically Based Assessment, the Teacher Report Form (TRF; Achenbach 2009). The TRF is a widely used measure of child psychopathology, and its scales have demonstrated adequate test-retest validity (r range from 0.71 to 0.95) and acceptable internal consistency (Cronbach’s alpha range from 0.71 to 0.95). Research Design Given the small number of participants in our study, and the heterogeneity and acuity of the psychiatric disabilities of the children, a repeated measures logistic regression analytic strategy was devised to compare children’s behavior during periods of contemplative practice to periods of no-practice (conceptually similar to a single-case A-B-A-B analytic strategy (Kennedy 2005)). The facility’s data regarding the occurrence of physical interventions (i.e., holds and seclusions) were recoded in reference to the 24-h time period following the beginning of the MLS class for that week. The day of the week was also included in this design in order to account for the possibility of this confounding variable. MLS acceptability data was examined post-intervention. Open-ended questions were also reviewed independently by the first and sixth authors, and a consensus opinion on significant themes was reached after discussion. Child problem behavior as measured by clinician TRF was compared pre- and post-MLS.

Statistical Methods To test the hypothesis that contemplative practice was associated with fewer seclusions and restraints, robust logistic regression analyses were utilized (Agresti 2002; Singer and Willett 2003). The data were prepared as a person-period data set, whereby the 10 children provided 7680 person-hours of observation. Occurrences of seclusions and restraints within a personperiod were regressed on an indicator variable identifying days of contemplative practice (MLS day) from nonpractice days (non-MLS day). Robust variance estimates were obtained controlling for clustering within person. Parameter estimates were obtained with Stata software (Stata Corp. 2015). Clinician and child acceptability data were analyzed quantitatively by calculating and interpreting the mean responses to post-MLS questionnaires, and qualitatively by reviewing and discussing open-ended questions. Clinician-completed questionnaires of child problem behavior (i.e., TRF) were analyzed using a simple paired-sample statistical analysis, using both parametric and non-parametric approaches, obtained with SPSS software (IBM Corp. 2015).


Results

Acceptability Questionnaires

Physical Intervention Incident Data

Clinician Report Overall, on the BIRS five-point Likert-style scale (with descriptive anchors of 1 BStrongly Disagree,^ 3 BNeutral,^ and 5 BStrongly Agree^), clinicians endorsed generally neutral opinions regarding the overall acceptability of MLS in this population (total score mean = 3.0, SD = 0.6), as well as on the three subscales of acceptability (mean = 3.3, SD = 0.6), effectiveness (mean = 2.5, SD = 0.7), and rate of change (mean = 2.1, SD = 0.6). Internal consistency for the BIRS total score was strong (alpha = 0.9), with the subscales of acceptability, effectiveness, and rate of change all falling in the acceptable range (alphas = 0.9, 0.9, and 0.7, respectively). Clinicians were also asked three open-ended questions about the use of MLS for this population and with their particular child patients. Clinicians did not report any immediate concerns about the use of MLS in general prior to implementation. When asked if they felt MLS was effective for their particular patients, clinicians often reported that MLS seemed to be beneficial for their patients functioning (e.g., BThe client was greatly helped with yoga^ and BThis client benefited from slowing down and listening to their body^); however, they believe shorter session delivered more frequently would have been more useful (e.g., BThe sessions for the study were too long in time but this intervention would be beneficial if done over and over in short spurts during downtime or transitions.^ One clinician reported that the practices were directly linked to an iatrogenic response (i.e., BTheir PTSD symptomatology increased when the child was in the quiet environment—the lack of external distraction enabled the child to continuously think invasive thoughts regarding past trauma and we saw a spike in behavior^); however conversely, a different clinician reported the practices were supportive of the patient’s treatment for past traumatic experiences (i.e., BI believe that this child benefited from learning different relaxation techniques and learning to focus on quiet thought. This child was completing trauma work…and MLS built on these skills that child already learned and mastered^). All clinicians reported that they would recommend the use of MLS to other clinicians in similar settings (e.g., BYes. It is an effective technique that can

Incidents of both holds and seclusions were combined in this data set. The 10 children provided 7680 person-hours of observation from the period August 1, 2012 and September 1, 2012 (32 days), 2880 on MLS days and 4800 on non-MLS days. During this 1-month time period, a total of 82 seclusions and restraints were recorded (10.6 per 1000 person-hours). The intra-cluster correlation for seclusions and events in this sample was high (ICC = 0.21). Results of the logistic regression model are reported in Table 4. Considering first MLS days defined as the calendar day coinciding with MLS classes, 58 seclusions and restraints were reported on non-MLS days (12.1 per 1000 personhours), and 24 seclusions and restraints on MLS days (8.3 per 1000 person-hours). Robust logistic regression confirms this lower rate was more different than what would be expected by chance, with a seclusion and restraint OR of 0.7 (95 % CI 0.5, 0.9; p = 0.02). Considering MLS days defined as the 24-h period following MLS class, we observed 4450 person-hours on MLS days and 3230 on non-MLS days. During this period, 56 seclusions and restraints were reported on non-MLS days (17.3 per 1000 person-hours) and 26 seclusions and restraints on MLS days (5.8 per 1000 person-hours). As with the previous analysis of calendar days, robust logistic regression of the 24-h period following MLS class confirms this lower rate was more different than what would be expected by chance, with a seclusion and restraint odds ratio of OR = 0.3 (95 % CI 0.2, 0.5; p < 0.001). The effect based on the 24-h time period of exposure from MLS class was still significant when including the day of the week as a covariate in the model (OR = 0.3; 95 % CI 0.2, 0.4; p < .001). This effect was somewhat attenuated when the analysis was restricted to only those days of the week (i.e., 4/7 days) when MLS was ever offered across the 4 weeks that this study occurred (OR = 0.6; 95 % CI 0.3, 1.2; p = 0.13).

Table 4

Seclusion and restraint rate comparison on MLS days and non-MLS days MLS days

Days defined as calendar days with MLS class Days defined as 24 h from MLS class

Non‐MLS days

Number of S&R

Person‐hours (PH)

S&R rate

Number of S&R

Person-hours (PH)

S&R rate

OR

95 % CI

24

2880

8.3

58

4800

12.1

0.7

(0.5, 0.9)

26

4450

5.8

56

3230

17.3

0.3

(0.2, 0.5)

MLS is BMindful Life: Schools^ and BS&R^ is seclusions and restraints. Seclusion and restraint rates are per 1000 person-hours (PH) OR odds ratio estimated from robust logistic regression with variance estimates adjusted for clustering on individual, CI confidence interval


ground and relax^) and several reported that their patient was continuing to use the practices after the completion of sessions (e.g., B(The patient) has continued to use afterwards^). Child Report Overall, on the adapted CIRP five-point Likertstyle scale (with descriptive anchors of 1 BStrongly Disagree,^ 3 BNeutral,^ and 5 BStrongly Agree^), children endorsed generally neutral opinions regarding their acceptability of MLS in this population (total score mean = 3.7, SD = 0.6), as well as on the three subscales including acceptability (mean = 3.3, SD = 0.6), effectiveness (mean = 2.5, SD = 0.7), and rate of change (mean = 2.1, SD = 0.6). Internal consistency for the adapted CIRP scale was in the acceptable range (alpha = 0.8). Table 5 details student item responses to the adapted CIRP scale. Children were also asked two open-ended questions about the use of MLS. When asked BWhat should be changed about MLS?^, 7 of the 11 children replied that Bnothing^ should be modified, and 1 child reported that the sessions should be shorter. When asked about their favorite element of MLS, four students reported that it supported their abilities to regulate their emotions (e.g., BHelped me not be so anxious^ and BCould calm down when upset^) and four students endorsed specific program activities (e.g., B(listening to the) tone bar^). Fidelity Overall, the MLS program was implemented with high fidelity across most of the sessions. The instructor reported that she was able to complete every session’s components on 6 of the 12 classes, greater than 90 % of the components on 8 of the 12 classes, and greater than 80 % of the components on 10 of the 12 classes (grand average component completion across all sessions = 87.6 %). During two of the 12 classes, the instructor reported qualitatively that the children’s disruptive behavior affected her ability to complete all of the session’s components. Taken as a whole, these data indicate that MLS program was able to be implemented with acceptable fidelity in this

Table 5 Mean student responses to adapted Children’s Intervention Rating Profile (CIRP)

population of children housed in an acute residential treatment facility. Behavioral Questionnaires Each child’s primary clinician-completed questionnaires before and after the MLS program was implemented. Due to the small sample size, data were analyzed both parametrically and non-parametrically. On the Teacher Report Form, there were no statistically significant differences following MLS on the Total Problems, Internalizing Problems, or Externalizing Problems composite scales (all ps >0.05). Internal consistency for these scales was acceptable at both time points (Cronbach’s alpha range from 0.79 to 0.95).

Discussion Physical interventions in response to dangerous child behavior are considered procedures of last resort given the high risk of child injury and other harm. Results obtained from this study suggest that youth with severe psychiatric difficulties benefitted from contemplative practice by requiring fewer physical interventions during days in which they engaged with contemplative practice. Specifically, for these children receiving intensive residential psychiatric care, the odds of being restrained or secluded following contemplative practice were significantly smaller than a comparable time period without such practice. This finding was significant regardless of whether the day was defined as a calendar day, or the 24-h period immediately following practice, and did not seem to be influenced by the day of the week. Although these data indicate that contemplative interventions may hold promise for the prevention of dangerous behaviors that necessitate physical intervention, these results should be interpreted with caution given the quasi-experimental study design and clinically heterogeneous small sample size.

Item

Mean response (SD)

1. Mindful Life: Schools is fair 2. Doing Mindful Life: Schools is too hard 3. Doing Mindful Life: Schools might cause problems with my friends 4. There are better ways to deal with feelings than Mindful Life: Schools 5. Mindful Life: Schools would be good to use with other students 6. I liked doing Mindful Life: Schools 7. I think Mindful Life: Schools will help me do better in school 8. I think Mindful Life: Schools helps me get along better with other people

4.2 (1.6) 2.1 (1.7) 2.6 (1.5) 3.2 (1.7) 4.0 (1.5) 3.6 (1.6) 3.6 (1.6) 3.6 (1.5)

Student responses to CIRP items anchored as: 1 = BI do not agree^ and 6 = BI agree^. Items #2, #3, and #4 were reverse coded for the purposes of calculating an average CIRP score


Implications There are several clinical implications of this research. First, these data suggest that the benefits of contemplative practice among children with severe emotional and behavioral challenges may be short lived, as there appeared to be a difference in our sample between the period of time following contemplative intervention relative to the period of time without. As such, clinicians wishing to implement these practices may wish to utilize them on a more frequent schedule to maximize benefits. Clinicians should also consider the utility of contemplative practices as an acute prevention strategy for known time periods associated with higher rates of severe behavioral problems (e.g., before or after family visits, following staffing transitions, major readjustments to psychopharmacological treatments). In this way, contemplative practice could be considered an antecedent behavioral prevention strategy to prevent the occurrence of problem behavior, which may be particularly beneficial to supporting self-regulatory abilities for children in residential treatment facilities to prevent the necessity of physical restraint procedures (Huckshorn 2005). Second, this research suggests that behavioral data, such as rates of physical intervention, may be a better indicator of intervention effectiveness than traditional questionnaire administration. Facilities providing intensive psychiatric services are increasingly being required to demonstrate to stakeholders that services are effective. Our data suggest that questionnaire data of behavioral problems was not sensitive to capturing changes in this sample of children; however, careful analysis of acute physical intervention data support significant and meaningful benefits of contemplative practice. Psychiatric treatment facilities serving youth are thus encouraged to carefully analyze the data collected in response to intervention in order to modify services to best meet the needs of their clientele. Third, data obtained would suggest that contemplative practices were generally acceptable in this intensive psychiatric care setting. Administrators and clinicians employed in such facilities are thus encouraged to consider implementing similar interventions given these results. Findings from our research also contribute to the emerging body of research and theory of contemplative interventions for youth. Given the paucity of research examining the effects of contemplative practices with clinical samples of children (Zoogman et al. 2015), this research is notable for being one of the few studies to examine the effectiveness of practice on a clinical subsample of children, and the first quantitative research study that we are aware of to document the benefits of practice to youth within a residential psychiatric treatment facility. Future clinical research projects are warranted to replicate and confirm these results; however, this research provides exciting evidence that children with severe psychiatric disabilities may benefit from contemplative practice. Theoretically, this research also contributes to evidence that

one of the primary benefits to contemplative practice is in an enhanced ability to self-regulate (Bishop et al. 2004; Felver et al. in press), as children in our study engaged in fewer incidences of dangerous behavior that would have necessitated a seclusion or restraint. It is possible that the enhanced selfregulatory ability may have been the result of an enhanced Btop-down^ cognitive control of behavior or a Bbottom-up^ activation of the parasympathetic nervous system (Chiesa et al. 2013; Tang et al. 2015), and future research should consider exploring these potential mechanisms. Acceptability measures of the contemplative practices employed indicate a generally neutral opinion of these procedures for both clinicians and children. Qualitative responses suggest that both groups had no major reservations about the contemplative practices employed, with the noted exception of it possibly exacerbating traumatic symptomology among some patients. Similarly, clinicians did not report any significant changes to internalizing or externalizing behaviors among children. This was an unexpected finding, particularly in light of the reduced rates of physical intervention for children during days of practice, the clinician report that they would recommend these practices for use with other children, and also because both clinicians and children themselves qualitatively noted that they felt more able to regulate their emotions and behavior in response to contemplative practice. It could be that the benefits of contemplative practice are not as readily apparent and are thus not sensitive to questionnaire reports of effectiveness, even though there could be actual meaningful changes to behavior occurring. Limitations There were three primary limitations to this study. First, we studied a small sample size of 10 diagnostically heterogeneous children, and as such further research is needed to replicate these findings in larger samples and caution should be taken when interpreting these results. However, the small sample size is mitigated in the primary analysis because we obtained significant effects and because we used a large number of observations (7680 person-hours). When considering that the intra-cluster coefficient for the analyses was 0.21, we calculate an effective sample size of 48. The small sample size is more of a concern when considering the results obtained from the behavioral questionnaire. It could be that our study was underpowered and there is a possibility that our findings are false positives. For these reasons, our findings require replication in another setting prior to drawing firm conclusions. Second, we measured intervention fidelity by having the interventionist self-report on her own implementation. It could be that the interventionist was biased to rate herself as highly adherent when in fact she was not. Self-reporting fidelity is one of the least objective


forms of fidelity monitoring, indeed there is often low agreement between self-report and observational methods (Borrelli 2011), and as such our fidelity data should be interpreted with caution and future replication research should employ more stringent fidelity monitoring procedures. Third, data was collected by the facility employees, and as such they may have been biased by their knowledge of the MLS implementation. We believe that it is highly unlikely that the milieu staff who implemented and reported on seclusions and restraints would have been influenced given that they were blind to this research occurring at all, and plausible that the clinician’s may have been influenced by their knowledge of the study taking place; however, it is possible that either may have been influenced by an expectancy bias given the common perception that yoga as a calming practice. Future Directions Overall, these results provide an extension of the nascent body of research indicating the promise of contemplative practice for youth in general, and for children with severe emotional and behavioral problems in particular. Given the severe challenges faced by youth who require residential psychiatric services, and the high risk of physical intervention approaches to challenging behavior, the results obtained in this study offer promising directions for preventing dangerous problem behavior. It is worth noting that this was a highly heterogeneous diagnostic sample, and that even with this variability significant results were obtained. Future clinical research should consider replicating and extending these results to further explore these explicate these findings among this severely disabled population. Contemplative practices should be considered a viable and potentially robust method for preventing the use of physical intervention in children, and future research should continue to explore the utility of implementing such strategies to support the functioning of some of the most vulnerable and impaired individuals receiving psychiatric treatment in our society. Compliance with Ethical Standards Funding This work was supported by the University of Oregon’s Hope Baney Fund Award granted to the first and sixth authors. Conflict of Interest The 5th author is the creator of the BMindful Life: Schools^ curricula and is the founder and director of the BMindful Life^ organization. The authors declare that they have no other conflict of interest. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional (i.e., University of Oregon) research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent/assent was obtained from all individual participants included in the study.

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