Mindfulness-Based Approaches for Children and Youth

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Mindfulness-Based Approaches for Children and Youth Carisa Perry-Parrish, PhD,a Nikeea Copeland-Linder, PhD, MPH,b Lindsey Webb, MS,c and Erica M.S. Sibinga, MD, MHSd Mindfulness meditation is a useful adjunct to behavioral and medical interventions to manage a range of symptoms, including psychological and physical responses to stress, anxiety, depression, and disruptive behavior. Mindfulness approaches can be taught to children, adolescents, and their parents to improve self-regulation, particularly in response to stress. Mindfulness may be particularly relevant for youth and families who have an increased risk for exposure to chronic stress and unique stressors associated with medical and/or social-contextual

considerations. Moreover, mindfulness parenting techniques can augment traditional behavioral approaches to improve children’s behavior through specific parent–child interactions. A growing body of empirical studies and clinical experience suggest that incorporating mindfulness practices will enable clinicians to more effectively treat youth and their families in coping optimally with a range of challenging symptoms. Curr Probl Pediatr Adolesc Health Care 2016;46:172-178

Introduction

to recognize that effective health approaches to mitigate the negative effects of toxic stress and trauma may occur any youth and their families are at risk of in the community, not only in medical settings.4 experiencing stressors that may lead to maladMindfulness has been described as “paying attention aptive coping strategies to manage negative in a particular way: on purpose, in the present moment, affective experiences. And ethnic minority youth are and nonjudgmentally.”5 In essence, mindfulness is the disproportionately exposed to a range of stressors.1 complete, nonjudgmental awareness of what is hapAlthough emotion regulation and coping may protect pening right now. Mindfulness instruction is intended youth by reducing the impact of to enhance an individual's innate negative stressors, continued expoability to be aware of what is sure to stressors may overload their Mindfulness instruction is happening internally and extercoping resources. Significant, recurnally with open curiosity and intended to enhance an rent and/or ongoing stress may conwithout judgment. Mindfulness tribute to toxic stress, in which an individual's innate ability to interventions are theorized to be aware of what is hap- target regulation of emotion individual's ability to manage or cope with stress is overwhelmed.2 Increas- pening internally and exter- and coping processes associated ingly, there are calls for broader thinkwith stress,6 and may represent a nally with open curiosity ing about how to treat toxic stress. helpful branch of psychotheraand without judgment. Pediatricians have been called to pies to address the suffering understand the complex and interexperienced by stressed youth. twined systems that are disrupted by stress,3 as well as Formal mindfulness instruction entails a range of techniques that help foster an intentional focusing of From the aDepartment of Psychiatry and Behavioral Sciences, Johns b attention on one's present-moment experience while letting Hopkins School of Medicine, Baltimore, MD; Department of Pediatrics, go of negative, self-critical judgments. This type of training Johns Hopkins School of Medicine, Baltimore, MD; cDepartment of Pediatrics, Center for child and Community Health Research, Johns aims to help individuals accept unpleasant and painful Hopkins School of Medicine, Baltimore, MD; and dDivision of General experiences without reactively attempting to change the Pediatrics and Adolescent Medicine, Center for child and Community experience. As moment-to-moment awareness through the Health Research, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD. day is the ultimate goal of mindfulness programs, there is Curr Probl Pediatr Adolesc Health Care 2016;46:172-178 also instruction of informal techniques that can be used at 1538-5442/$ - see front matter any time. As most of us would prefer to reduce or & 2016 Mosby, Inc. All rights reserved. eliminate pain and discomfort as much as possible, some http://dx.doi.org/10.1016/j.cppeds.2015.12.006

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mindfulness-based programs additionally adopt a dialectical position of balancing desire for change alongside intentional acceptance of the inevitability of suffering.7 The application of mindfulness meditation to reduce suffering has been a feature of behavioral medicine in the West for well over 30 years.8 Meditation practices complement a group of established psychological approaches to reduce stress and discomfort,9 including cognitive-behavioral therapies and relaxation techniques. Mindfulness-based stress reduction (MBSR) is one of the more well-known programs, which initially was developed for use with adults presenting with chronic pain, and other chronic and stressful conditions.8 The common thread among these other approaches is a dual emphasis on mindfulness and behavioral change as core processes to alleviate suffering. In this article, we will review the literatures pertaining to coping with stressors among youth, the role of stress exposure/experience in regulation and coping; and highlight the role of mindfulness-based therapies to improve self-regulation among youth.

Review of Literature Role of Stress Exposure in Youth Stressors experienced in childhood and adolescence have been linked to a number of negative mental health outcomes, including internalizing problems, externalizing behaviors, academic difficulties, and health risk behaviors.10,11 Further, a number of cross-ethnic comparison studies suggest that ethnic minority youth experience more stressors than their non-minority

peers.12 Minority youth are more likely to experience the death of a loved one, to have a family member who has been arrested or jailed, to have to take care of a loved one, and to be placed in a foster home.13 However, the effects of stress on coping and psychological functioning are important for all youth. Thus, interventions that enhance children's and adolescents' abilities to cope effectively with inevitable stress may provide a protective effect.

Effects of Mindfulness on Self-Regulation Empirical interest in the potential theoretical mechanisms of mindfulness-based treatments has grown significantly since the initial introduction of mindfulness into psychotherapy. Mindfulness has been broadly theorized to improve the self-regulation of emotions, behavior, and cognitive processes,14 emerging from increased acceptance and self-awareness, such as noticing unpleasant emotions and distress as experiences that can be accepted, rather than impulsively reacted to, ruminated over, or chronically avoided.9,15,16 This enhanced acceptance of one's internal experiences is thought to lead to reduced suffering and distress in response to stress. Mindfulness approaches emphasize approaching and accepting one's experiences, rather than chronic efforts in avoiding uncomfortable or undesired experiences.17 Our theoretical model (Fig) reflects the range of potential changes associated with mindfulness instruction, including the intertwined self-regulatory processes of improved coping, positive cognitive changes, and improved psychological functioning.6

FIG. Mindfulness instruction and improved self-regulation. Previously published in: Functional Symptoms in Pediatric Disease, Ran D. Anbar editor. 2014. Springer, New York, p. 350.

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Mindfulness-Based Therapies: Empirical Evidence

been adapted for use with children and youth. Adaptations typically involve shortening the formal mindfulness techniques when they are introduced, with a gradual increase in duration as the course progresses; Mindfulness-based stress reduction (MBSR) was develclarifying and concretizing language used for instrucoped in 1979 to reduce stress among adults with chronic tion; and providing age-appropriate mindfulness health conditions.16 The MBSR program is an 8–10 week activities.21 group program of 2.5 h per session. MBSR instructional content focuses on mindfulness meditation practice, selfThis growing body of knowledge has provided awareness of the body during gentle yoga practice, and encouraging preliminary results regarding acceptabildiscussion of barriers to the use of mindfulness practices. ity, feasibility, and benefit in pediatric samples. For Since the introduction of MBSR, several other psyexample, in high school students, mindfulness instrucchological treatments emphasizing mindfulness and tion led to reductions in elevated blood pressure.22 mindful acceptance have emerged within the behavioral Additionally, mindfulness instruction has been studied and cognitive-behavioral movement. A common theme in younger students (with age-appropriate adaptations, among these third-wave behavioral approaches was a such as belly breathing, focusing on breath, and the use new focus and legitimation of affect and emotional of “mind jars”), showing benefits in attention and experiences as a primary target for executive function.23–25 treatment. For example, Dialectical Several studies have examined Behavior Therapy (DBT) incorpoadapted for youth, showSeveral studies have exam- MBSR rates mindfulness and acceptance ing feasibility, acceptability, and ined MBSR adapted for practices to address severe emotional positive effects. Studies of MBSR 18 youth, showing feasibility, from an urban outpatient primary dysregulation. Acceptance and Commitment Therapy (ACT) acceptability, and positive care clinic have shown program acceptability, feasibility, and pofocuses on the importance of the effects. tential benefit related to improved function and context of experiential relationships and coping, and avoidance to improve psychological reductions in conflict engagement, self-awareness, flexibility.19 Mindfulness-based cognitive therapy anxiety, and stress.26–28 Also, a randomized trial of (MBCT)20 modified cognitive therapy as applied to depression in an effort to reduce risk for depressive MBSR compared with usual care for adolescents in episodes by targeting processes involved in maladaptive outpatient psychiatric treatment showed significant mood regulation. In addition to focusing on affect, these reductions in anxiety and depression and improvements mindfulness-based approaches share another common in global psychiatric functioning.29 link that distinguishes them from other cognitiveBeyond clinic-based evaluations of mindfulness, behavioral treatments. In CBT approaches, the clinician there are also school-based models for teaching mindhelps an individual change the content of one's thoughts fulness to school-age youth, with research looking at a (e.g., cognitive restructuring) and behavior (e.g., activanumber of different mindfulness programs. Randomtion). In contrast, mindfulness-based approaches focus ized control trials of school-based MBSR compared on changing the context in which those internal expewith an active control program in urban settings have riences occur. Thoughts and feelings are cast as shown improvements in psychological symptoms experiences or events rather than facts.20 Thus, these (anxiety and depression), coping, somatization, selfhostility, and reduced post-traumatic stress symptreatments based on mindfulness actively balance desire toms.30,31 Additionally, a teacher-implemented 6-week for changed experiences on one hand and mindful acceptance of the present moment on the other. mindfulness intervention in a private school was Despite decades of research in adults, studies associated with significant decreases in clinical sympof mindfulness-based interventions for use with chiltoms from baseline to follow-up for the both meditatdren and youth are still emerging. However, this ing and the non-meditating control group; in contrast, small literature provides preliminary evidence that decreased self-harm tendencies were observed for the mindfulness-based treatments are feasible and benefimindfulness condition only.32 Another study used cial for use in pediatric populations and well-accepted the Mindful Schools curriculum in an elementary by youth. A number of mindfulness programs have school with predominately ethnic minority students

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(n ¼ 409) at two intensity levels: the first group received 15-min sessions three times per week for 5 weeks, the second group received a 15-min weekly session for an additional 7 weeks, for a total of 12 weeks.33 This naturalistic field evaluation design suggested that students across both groups improved on teacher ratings of behavior, including improved attention, self-control, participation, and respect for others.33 A third study examined the school-based, teacherdelivered Mindfulness in Schools Program curriculum.34 A non-randomized, controlled study was conducted to appraise the feasibility of the program. Schools were selected for the intervention if their teachers had prior training in the curriculum, while control schools were selected to match intervention schools on a range of social/demographic considerations (e.g., academic achievement, private vs. public status; total n ¼ 522). Results of this study indicated reduced depression and stress, and increased wellbeing.34 A randomized-controlled trial was conducted to examine the school-based MindUp program.35 Fourth or fifth grade classrooms were selected from four schools (one classroom per school) to be randomized into either the MindUp program or a control course that discussed social responsibility (n ¼ 100). The results of the study suggest that the MindUp curriculum helped to increase empathy, mindfulness, and optimism, and to decrease depression and aggression compared with the control.35 Taken together, these results are promising, yet all of these studies denote the need for ongoing research that adhere to rigorous study design to enhance the methodological evaluation of mindfulness instruction for youth (e.g., randomization, active control arm, raters blind to assignment). Fewer studies address the effects of the other mindfulness-based programs for children and youth. A small feasibility trial of mindfulness-based cognitive therapy for children (MBCT-C) found support for acceptability and reduction of internalizing (e.g., anxiety and depression) and externalizing symptoms (e.g., disruptive behavior) among a non-referred sample of preadolescents.23 Another randomized trial of MBCT-C found reductions in attention problems.36 The authors also found a strong association between attention problems and behavior problems and speculated that MBCT-C could help promote improved behavioral functioning by reducing in attention.36 Dialectical behavior therapy (DBT) is a cognitivebehavioral therapy that incorporates mindfulness to

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treat individuals with emotional dysregulation. DBT involves four major treatment modules: mindfulness; distress tolerance; emotion regulation; and social/interpersonal effectiveness. DBT has been modified for use with adolescents (DBT-A) to include an emphasis on improving parent-child interactions. Among adolescents with oppositional defiant disorder, 16 weeks of DBT-A skills training reduced self-reported and parent-reported internalizing and externalizing symptoms.37 A year-long trial of DBT-A in a small sample of adolescents with bipolar disorder demonstrated feasibility and acceptability, and indicated significant improvements in feelings of suicidality, self-harm, emotional dysregulation, and depressive symptoms.38 DBT-A was well received among adolescents with severe emotional dysregulation (e.g., significant selfharming behavior); mindfulness and distress tolerance skills were rated as particularly helpful components of the intervention by adolescents.39 DBT-A reduced behavior problems among incarcerated adolescent females with comorbid mental health and substance problems40 and decreased premature terminations from residential treatment facilities due to self-harm and psychiatric hospitalization; it also reduced the number of days spent in psychiatric hospitals among a sample of predominantly White adolescent young women.41 In addition to interventions that provide individual or group-based treatment to target individuals, there is also a growing body of mindfulness-based approaches that target parents of youth.42 An early study investigated mindfulness instruction with a small cohort of four mothers and their young children (ages 4–6 years old) with developmental disabilities; mindfulness training was associated with decreases in children's aggressive behavior and improved social skills.43 A larger study (n ¼ 432) focused on youth in middle school in integrated mindfulness practices into a well-established parenting program (strengthening families).42 Parents and youth participated in seven 2-h weekly group sessions; parents and youth met separately for 1 h and then together for the second hour. This mindfulnessenhanced parent training program was as effective as standard parent training in improving parent–youth relationship quality and improving youth behavior management.42 In summary, evidence suggests that mindfulnessbased interventions are beneficial for children, adolescents, and parents to enhance self-regulation and coping, which are aspects central to the management of psychological symptoms associated with stress.

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Recommendations for Future Research and Clinical Care

mindfulness instruction is evaluated. In this article, we reviewed clinic-based and school-based instruction, as well as interventions targeting parents of youth. Other Mindfulness meditation instruction has been shown exciting avenues for future research could target other to improve mental health and qualimportant social figures in the lives ity of life. Mindfulness instruction of children and youth, including Mindfulness instruction leads to reduced stress and teachers. There are several proenhanced self-regulation, which leads to reduced stress and grams under investigation that procan be thought of as the interenhanced self-regulation, vide mindfulness instruction to twined processes of psychological which can be thought of as teachers; this 44model may provide functioning, cognitive functioning, sustainability. Finally, future and coping (Fig). In particular, the intertwined processes of research needs to continue to probe psychological functioning, for the potential mechanisms of mindfulness reduces psychological symptoms, such as anxiety, and cognitive functioning, and change associated with mindfulimproves emotion regulation; ness instruction. Assuming that coping. improves attention and the ability mindfulness instruction does lead to focus; and reduces maladaptive to positive changes for youth, it coping and rumination. These outcomes have been will be important to identify which emotional and associated with increased calm, improved relationpsychological processes are changed, and how they ships, and reduced stress and anxiety. There is a great are improved. deal of enthusiasm among many who study mindfulMindfulness techniques represent a group of comness instruction for youth and are hopeful for the plementary treatments that are beneficial for children benefits that mindfulness practices presenting with a range of behavmay yield. However, as noted ioral, emotional, and somatic above, there is still a need for symptoms, as mindfulness instrucThe application of implerigorous scientific evaluation of tion supports a positive change in mindfulness interventions for chil- mentation science to efforts the relationship to one's experiendren and youth. to disseminate mindfulness ces. When considering integrating There are several promising direc- instruction will play a critical mindfulness techniques into the tions for the future of mindfulnesscare of youth and their parents, it based interventions for children and role in the success of deliv- is essential to identify mindfulness youth. Chief among the possibilities ering high-quality mindful- instructors with rigorous training is the continued goal of improving and excellent experience, and ness programming. the methods for evaluating mindfulongoing support for their practice. ness instructions to ensure that chilIn the right hands, mindfulness dren and youth have access to optimal clinical care that meditation instruction has extraordinary potential for is evidence-based. Mindfulness interventions need to benefit. demonstrate the same level of clinical and psychological value as other evidence-based treatments, and dissemReferences ination of these interventions needs to ensure fidelity. As 1. American Psychological Association, Task Force on Resilwith other efforts to disseminate treatments that have ience and Strength in Black Children and Adolescents. demonstrated efficacy, it will be crucial to determine Resilience in African American Children and Adolescents: how mindfulness-based treatment can survive the transA Vision for Optimal Development. Washington, DC. fer from optimal delivery in rigorous studies to more http://www.apa.org/pi/families/resources/resiliencerpt.pdf; 2008. Accessed 24.01.15. typical settings of care, such as community mental 2. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. health centers. The application of implementation sciNew York, NY: Springer, 1984. ence to efforts to disseminate mindfulness instruction 3. Johnson SB, Riley AW, Granger DA, Riis J. The science of will play a critical role in the success of delivering highearly life toxic stress for pediatric practice and advocacy. quality mindfulness programming. A second goal is to Pediatrics 2013;131(2):319–27. http://dx.doi.org/10.1542/ continue to expand the social contexts in which peds.2012-0469.

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