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Psychology in the Schools, Vol. 50(6), 2013 View this article online at wileyonlinelibrary.com/journal/pits

2013 Wiley Periodicals, Inc. DOI: 10.1002/pits.21695

MINDFULNESS IN SCHOOL PSYCHOLOGY: APPLICATIONS FOR INTERVENTION AND PROFESSIONAL PRACTICE JOSHUA C. FELVER, ERIN DOERNER, JEREMY JONES, NICOLE C. KAYE, AND KENNETH W. MERRELL

University of Oregon

Although the use of mindfulness is increasing in other areas of applied psychology, school psychology has yet to embrace it in practice. This article introduces school psychologists to the burgeoning field of mindfulness psychology and to the possibilities that it offers to their discipline. A background on the Western scientific study and application of mindfulness provides a theoretical foundation to those unfamiliar with the topic. We then discuss the application of mindfulness technologies to various forms of service provision in the professional practice of school psychology. The innovative and novel avenues that mindfulness psychology offers to psychological C 2013 Wiley Periodicals, Inc. science

The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will. . . . An education which should improve this faculty would be the education par excellence. William James, 1890

During the past two decades, the science of psychology has witnessed the emergence of a distinct field of research and intervention: mindfulness psychology. Discussion of mindfulness psychology has dramatically increased in peer-reviewed scientific literature (Singh, 2006), including empirical research that suggests mindfulness exercises are beneficial for children and adolescents (Burke, 2010; Garrison Institute, 2005; Zelazo & Lyons, 2005). The field of mindfulness psychology has established itself as an innovative approach to the basic and applied science of psychology. Aspects of mindfulness have been incorporated into two of the three American Psychological Associationrecognized specialties of applied psychology: clinical and counseling psychology. The development of many new research directions and interventions ensued (Baer, 2003; Brown, Ryan, & Creswell, 2007). Yet, to date, mindfulness has not been extensively researched or implemented into the third branch of professional psychology, school psychology. In this article, we seek to familiarize school psychologists with mindfulness psychology, spark interest in the topic, and encourage those in the field to consider its potential applications. First, the reader is oriented to current conceptualizations and applications of mindfulness. In the second section, we describe how mindfulness can be integrated into existing school psychology professional practice, and service provision. The conclusion then reviews challenges and limitations that may arise as school psychologists begin to introduce mindfulness into their research and practice. Because school psychology is ripe for the integration of technologies currently available in mindfulness-based intervention, it is our intention to introduce the possibilities that mindfulness psychology brings to the field.

This project was supported by National Institutes of Health grant T32 MH20012 to Elizabeth A. Stormshak, codirector of the Child and Family Center, University of Oregon. We also wish to thank Cheryl Mikkola and Jacob T. Groff for their assistance with this article. Correspondence to: Joshua Felver, University of Oregon–Child and Family Center, 195 W. 12th Avenue, Eugene, OR 97401. E-mail: [email protected]

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C ONCEPTUALIZING M INDFULNESS P SYCHOLOGY

The early stages of any new realm of science are commonly characterized by a degree of controversy and misunderstanding about what defines or constitutes the subject, and mindfulness psychology is no exception. Mindfulness is most commonly defined as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn, 1994, p. 4). Although concise, this definition lacks some of the more formal detail and explicitness of other psychological constructs. To address the need for clarity, Bishop and colleagues (2004) proposed a different working operationalization and defined mindfulness as “the self-regulation of attention so that it is maintained on immediate experience . . . an orientation that is characterized by curiosity, openness, and acceptance” (p. 232). Inherent in this definition are two key features. The first is that mindfulness relates to the self-regulation of attention, or the ability to intentionally attend to, and be vigilant of, certain stimuli while ignoring or suppressing others. The second feature has to do with the relationship with or orientation toward experience, specifically one characterized by nonjudgment, acceptance, and inquisitiveness. Although this second facet is more difficult to formally operationalize, it is no less important to the construct. Mindfulness differs from existing conceptualizations of attentional self-regulation in that the relational, inherent attitude is one of acceptance and openness to the current internal (e.g., cognitions and emotions) and external (e.g., sensory stimuli) experience. It is important to note that acceptance as it is used here is distinguished from resignation. Acceptance implies a simple acknowledgment of the reality of one’s present experience as it is, whereas resignation suggests surrender or submission. Put another way, acceptance means not wishing for a reality other than what is currently unfolding, regardless of whether that experience is pleasant or unpleasant. What is already happening is allowed to be as it is, with the understanding that this reality may be undesirable. In short, mindfulness psychology is the systematic scientific study of how self-regulated attention, applied to one’s current experience with an attitude of acceptance, affects human functioning. Before delving more deeply into the research on mindfulness as an applied science, it is useful to clarify some common misunderstandings about the construct. The first misconception is that mindfulness is a form of Eastern religion, specifically Buddhism. Although it is true that mindfulness and many of the techniques used in mindfulness interventions do have roots in Eastern religions or philosophical schools of thought, the concept (as it is discussed here) and application of mindfulness are completely secular in nature. An analogous metaphor would be to equate the practice of fasting with a form of religion. Whereas abstaining from taking food or drink is a common practice in many world religions, fasting in and of itself is not inherently religious in nature. The second misconception is that mindfulness refers to the act of meditation. The generally accepted definition of the verb meditate is “to engage in contemplation or reflection” (“Meditate,” 2005), which can include behaviors as disparate as pondering, prayer, or reminiscence. Meditation, by itself, is an elusive construct, and whereas some may refer to the practice of mindfulness as a type of meditation, such language is avoided here in favor of more specific language. A final common misconception is that mindfulness is completely synonymous with attention. As previously mentioned, mindfulness is conceptualized as a specific form of attention; however, it also incorporates the key element of being focused on the present moment with an attitude of nonjudgment. These critical features of mindfulness differentiate it from attention, although attention is admittedly in many ways a very closely related construct. Theories about the mechanisms underlying the effects of mindfulness-based interventions generally posit that mindfulness practice enables individuals to gradually learn to disidentify, or reperceive, experience from a clear, nonjudgmental stance (Shapiro, Carlson, Astin, & Freedman, 2005). Reperception then allows the content of internal experience (i.e., thoughts and consciousness) Psychology in the Schools

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Table 1 Summary of Common Mindfulness Techniques Intervention Mindfulness-Based Stress Reduction Mindfulness-Based Cognitive Therapy Soles of the Feet

Acceptance and Commitment Therapy

Format

Description

8 weeks, daily homework, weekly group meetings to teach mindfulness techniques and discuss application 8 weeks, daily homework, weekly psychoeducational group meetings to discuss precursors to psychopathology 5 structured 45-minute sessions to teach awareness of emotional precursors to aggressive behavior and technique to shift attention to a neutral stimulus Individual or group sessions of varying lengths, uses experiential thought exercises, relies heavily on metaphors

Teaches mindful breathing, body awareness, and stretching; focuses on integrating mindfulness into everyday life Blends CBT and MBSR to address precursors to psychopathology Teaches simple self-regulation strategy to interrupt escalating emotional problems that lead to aggression Works to increase psychological flexibility relevant to internal and external experience, concurrently uses behavioral strategies to promote change

Note. CBT = Cognitive behavioral therapy; MBSR = Mindfulness-Based Stress Reduction.

and external experience (i.e., somatic sensations) to be observed with clarity and objectivity, which in turn affects other critical psychological processes linked to salutary treatment effects (e.g., selfregulation, values clarification, cognitive–behavioral flexibility, experiential exposure). This idea is similarly echoed in other conceptualizations of mechanisms underlying mindfulness interventions, such as cognitive defusion (Hayes, Strosahl, & Wilson, 1999) and deautomatization (Safran & Segal, 2005). Put another way, mindfulness-based practices are postulated to create a fundamental shift in awareness from the content of experience to the objective observation of experience, which in turn affects other related psychological processes. C URRENT M INDFULNESS I NTERVENTIONS There are several incarnations of mindfulness-based interventions, each focused on a different population or using different treatment modalities. Table 1 summarizes four commonly used mindfulness interventions. Although a detailed description of these interventions is beyond the scope of this paper, it is worth pointing out several notable features of these programs, which are discussed as potential starting places for incorporating mindfulness into school psychology practice (for a comprehensive review and description, see Baer, 2003, 2006). Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990) is perhaps the most frequently used and studied method of mindfulness training. MBSR is an intensive, 8-week group intervention designed to teach and promote the use of mindfulness in everyday life. Individuals learn three core mindfulness techniques: mindful breathing (concentrating on the sensation of breathing while, at the same time, remaining open to other bodily sensations, thought processes, and emotions), the body-scan exercise (progressively applying awareness to different parts of the body), and mindful stretching (a series of slow stretches or yogic poses). A variant of MBSR, Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2005) fuses traditional cognitive therapy and mindfulness concepts. MBCT teaches individuals to become mindfully aware of response patterns that contribute to impairment and pathology and then learn to use cognitive–behavioral techniques to address and combat these patterns. It is worth noting that both of the aforementioned programs are quite intensive; individuals meet once Psychology in the Schools

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a week for 2.5 hours of group instruction and discussion and are required to practice daily for about 45 minutes. During the past 30 years, MBSR has been studied in numerous controlled and observational studies with a variety of clinical and nonclinical samples in different settings (e.g., hospitals, community mental health centers), with evidence suggesting that MBSR may be an effective intervention for conditions such as stress (Shapiro, Schwartz, & Bonner, 2007), anxiety (Miller, Fletcher, & Kabat-Zinn, 2005), major depression (Teasdale, Segal, & Williams, 1995), chronic pain (Kabat-Zinn, Lipworth, & Burney, 1985) and fibromyalgia (Kaplan, Goldenberg & Galvin-Nadeau, 1993). A meta-analysis of the health benefits of MBSR reported an average treatment effect size of .49 (Grossman, Niemann, Schmidt, & Walach, 2004). Soles of the Feet (SOF; Singh, Wahler, Atkins, Myers, & The Mindfulness Research Group, 2007) is a simple mindfulness-training program consisting of five 30-minute sessions during which individuals learn to redirect attention from an emotionally arousing internal or external experience to the emotionally neutral soles of the feet. Individuals are taught a three-step routine: first, to pause and take notice of the situation; then, to focus awareness on their emotionally arousing cognitions (without trying to change them; that is, with acceptance); and finally, to shift concentration to the somatic sensations of their feet. By intentionally redirecting and holding their awareness on their feet, participants actively decrease their emotional arousal, eventually calm down, and then consciously choose a response to the situation that is nonaggressive. SOF has demonstrated effectiveness in decreasing aggressive and problematic behavior in multiple single-subject studies published in peer-reviewed journals, including adults with intellectual disabilities in forensic facilities (Singh et al., 2011), adolescents with autism spectrum disorders in home and school settings (Singh et al., 2010), and adults with severe and persistent mental illness in inpatient psychiatric hospitals (Singh, Lancioni, Winton et al., 1998). Acceptance and Commitment Therapy (ACT; Hayes et al., 1999) is a psychotherapeutic technique stemming primarily from the behavior analytic tradition. ACT combines behavioral change strategies designed to orient and direct people toward valued goals and objectives, with mindfulness strategies intended to promote acceptance, contact with the present moment, and ability to relate to one’s experience from a decontextualized perspective (i.e., perceiving experience as it simply is rather than as one verbally understands it to be). ACT does not directly incorporate “traditional” mindfulness practices (e.g., breathing meditation or yoga) into its methodology but instead includes its own mindfulness exercises and its own conceptualization of mindfulness that are independent of practices derived from Eastern religions. Interestingly, there are a great number of similarities between ACT theory and Buddhist philosophy, despite their independent origins, suggesting convergent validity relevant to the core secular construct of mindfulness (Fletcher & Hayes, 2005). A meta-analysis of 18 randomized controlled trials of ACT conducted primarily in mental health treatment settings reported an average treatment effect size of .42 relative to control conditions (Powers, Zum Vörde Sive Vörding, & Emmelkamp, 2005). Two important points should be made about mindfulness-based interventions in general. The first is that the growth of interest in mindfulness psychology and intervention is due in large part to significant treatment effects in clinical trials. In a recently published meta-analysis of 39 peerreviewed studies on the effects of mindfulness-based therapy on anxiety and mood symptoms in clinical and nonclinical samples, researchers found effect sizes in the moderate to large range, with Hedge’s g values between .59 and .97 (Hofmann, Sawyer, Witt, & Oh, 2010). Two other meta-analysis studies have shown similar results for the effectiveness of mindfulness-based intervention on various measures of physical and psychological well-being for a variety of populations, with effect sizes ranging from moderate to high (Baer, 2003; Grossman et al., 2004). The second point is that although the aforementioned results were obtained from studies conducted primarily with adult populations, all the interventions have been successfully adapted for children and adolescents (Burke, 2010). These Psychology in the Schools

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FIGURE 1. Mindfulness-based service delivery in a three-tiered educational support system.

adaptations have been spurred by emerging evidence demonstrating the clinical effectiveness of mindfulness-based interventions for school-age populations (Greco, Barnett, Blomquist, & Gevers, 2008; Lee, Semple, Rosa, & Miller, 2008; Semple, Lee, Rosa, & Miller, 2002) and in educational settings (Napoli, Krech, & Holley, 2001; Saltzman & Goldin, 2009; Singh, Lancioni, Joy et al., 1998). Although mindfulness-based intervention with children and adolescents is still an emerging area of research, data to date support the effectiveness of this modality and justify future novel and adapted interventions. The next section describes how mindfulness-based interventions, such as those previously described, could be incorporated into school psychology practice. Ideally, school psychologists will explore the possibilities that the technology of mindfulness can offer to their practice and the new avenues for intervention and applied research. I NTEGRATING M INDFULNESS

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D IRECT S CHOOL P SYCHOLOGY P RACTICE

School psychology is a dynamic branch of applied professional psychology concerned with the development, mental health, and education of children and adolescents (Merrell, Ervin, & Gimpel, 2003). School psychology practice often takes on many disparate forms and can manifest in a wide variety of services for various populations (e.g., students, teachers, parents). This review focuses primarily on how mindfulness psychology could be infused into direct service provision to help students maintain focus and clarity. We have adopted the familiar three-tiered model of service delivery to organize examples of how this integration could take shape (see Figure 1). Briefly, in a three-tiered model framework, provision of supports is divided based on the needs of the entire population. Universal, or Tier 1, supports are provided to all students and are aimed at the prevention of behavior problems. Targeted, or Tier 2, interventions specifically focus on those students who require a greater level of support, and they typically adhere to a small group structure consisting of a set of students with a comparable level of need (Crone, Horner, & Hawken, 2004). Intensive, or Tier 3, intervention strategies are appropriate only for those students who display the most extreme difficulties (Sugai & Horner, 2008; Walker et al., 2008), and they are typically individualized to meet the youths’ complicated needs. Psychology in the Schools

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Mindfulness practice and intervention can take various forms, depending on the needs of the individuals and the contexts in which these persons function. As a direct intervention for students, the intensity and method of integration would be tailored to meet the needs of the student or students under consideration. As a Tier 1 intervention, mindfulness could be incorporated with a preexisting intervention, such as a social–emotional learning (SEL) curriculum, or as a standalone universal intervention to develop mindful awareness among an entire student body. At the Tier 2 level, mindfulness interventions could be delivered in a small-group context to students with targeted needs of support. As a Tier 3 intervention, mindfulness may be used as a concentrated intervention for individual students with specific high-level needs. The task of integrating mindfulness in such a fashion would fall within the purview of school psychology professional practice, as school psychologists are increasingly becoming trained in how to effect systems-level change by introducing novel interventions (Curtis, Castillo, & Cohen, 2008), such as those incorporating mindfulness psychology. Tier 1: Universal Interventions Mindfulness Incorporated Into SEL. Using programs that promote SEL is one way to address primary prevention. The Collaborative for Academic, Social, and Emotional Learning describes SEL in terms of five groups of interrelated core social and emotional competencies: self-awareness (accurately assessing one’s feelings), self-management (regulating one’s emotions to handle stress, controlling impulses, and persevering in addressing challenges), social awareness (being able to take the perspective of and empathize with others), relationship skills, and responsible decision making (Devaney, O’Brien, Keister, Resnik, & Weissberg, 2006). Mindfulness practice aligns with many of the same theoretical concepts of SEL. Indeed, there is theoretical and empirical support that mindfulness interventions explicitly target and promote many of these same competencies, including self-regulation (Jha, Krompinger, & Baime, 2007; Morris, Felver-Gant, & Dishion, 2011; Saltzman & Goldin, 2009), self-awareness (Allen, Blashki, & Gullone, 2006; Wall, 2008), and emotionregulation (Arch & Craske, 2006; Chambers, Gullone, Allen, 2009). As such, mindfulness could be easily integrated into an existing SEL framework to bolster core social and emotional competencies. Integrating explicit mindfulness training and practice into an existing universal intervention, such as schoolwide SEL programs, could enhance the intervention’s effectiveness and also promote generalization of skills. Although enhancing SEL programs with mindfulness components has not been specifically studied, there is evidence to suggest that integrating other protocols with a mindfulness component can yield highly effective results. For example, Coatsworth, Duncan, Greenberg, and Nix (2010) conducted a randomized clinical trial of a widely implemented group-based parent training curriculum, the Strengthening Families Program (SFP; Molgaard, Kumpfer, & Fleming, 2006) augmented with mindfulness-training called the Mindfulness-Enhanced Strengthening Families Program (MSFP). The MSFP was modified by infusing mindfulness activities into parent sessions and changing some of the language to emphasize mindfulness. Participants consisted of 65 families recruited from rural school districts, randomly assigned to either the original SFP program, MFSP, or a wait-list control condition. Families were mostly European American (98%) and consisted of mother–child dyads, except for 13 families, in which both mothers and fathers participated. The mean age of children was 11.7 years (38% female). Multiple regression analyses (α = .05) of pre- and post-intervention self-report questionnaires of parenting practices and relationship quality found that MFSP produced comparable treatment effects to SFP on child management practices and stronger treatment effects relative to SFP on parent–youth relationship quality. Similarly, mindfulness could be integrated into an existing SEL curriculum, potentially enhancing the effectiveness of the intervention as a whole. Psychology in the Schools

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Pairing SEL programs with mindfulness technology is a natural fit, and although evidence supporting the social–emotional benefits of mindfulness intervention is still emerging (Semple et al., 2002), there is a strong theoretical rationale for the fusion of these two domains of practice. Mindfulness as a Stand-Alone Prevention Practice. Mindfulness could also be implemented in schools as a stand-alone prevention effort. An increasing number of schools are incorporating mindfulness practices, often by using mindfulness education programs such as InnerKids, the Impact Foundation, and the Lineage Project (Suttie, 2002). Researchers have just begun to scientifically examine the effects of some of these programs. One study of a mindfulness intervention conducted in a school setting (Napoli et al., 2001) examined how participation in a 24-week mindfulness training affected the attention of first-, second-, and third-grade participants. The training was designed to increase students’ ability to focus and pay attention in school. A total of 227 students (47% female) were randomly assigned to either treatment (mindfulness training) or control (no training) conditions. Mindfulness exercises were taught bimonthly during physical education and included breath work, a body-scan visual application, and body-movement tasks. Students were measured before and after the treatment group’s completion of mindfulness training on a teacher-report questionnaire of student problem behaviors and attention, a student self-report questionnaire of test anxiety, and a student behavioral assessment of selective and sustained attention. Paired-sample t tests between groups (α = .05) indicated that students had significantly fewer teacher-reported behavior problems, decreased self-reported test anxiety, and increased accuracy and reaction time in tasks of selective attention following mindfulness training. Positive effects have also been demonstrated with middle school populations. In one such study, the Mindfulness Education (ME) curriculum was implemented with middle school students over the course of 10 weeks (Schonert-Reichl & Lawlor, 2008). A total of 12 teachers were assigned to intervention (teacher ME training and classroom ME implementation) or wait-list control conditions in accordance with school district policies regarding professional development, resulting in a total sample of 246 students (56% intervention condition; mean age, 11.4 years; 48% female). The ME class was taught for 40 minutes, once a week, as a normal classroom activity by general education teachers trained during a 1-day intensive session and ongoing bi-weekly consultation; exercises were practiced by students briefly throughout the week to encourage generalization of skills. Students were measured pre- and post-intervention on self-report questionnaires of optimism, positive and negative affect, and self-concept, as well as teacher report questionnaires of social and emotional competence. Analyses of change scores comparing treatment effects between the intervention group and a wait-list control found that the treatment group had significantly greater optimism (p < .05) and positive emotions (p < .10), as well as significant treatment effects on social–emotional competence relative to controls (p < .05, η2 = .273). These studies suggest that mindfulness intervention can be integrated directly into a school setting as a universal intervention. Further, interventions were reportedly found to be acceptable and feasible by both school staff and students. Taken as a whole, there is encouraging evidence to support the further exploration of mindfulness interventions at a universal level in schools. Tier 2: Targeted Interventions Students with similar psychological and educational difficulties are frequently assigned to small-group interventions to meet their specific targeted needs, often in the context of Tier 2 targeted interventions. Mindfulness-based interventions are commonly delivered in small-group contexts that are increasingly used with children and adolescents. They have been researched among samples of children and adolescents with similar challenges, such as anxiety (Semple, Reid, & Miller, 2006; Semple et al., 2002), chronic pain (McGrath, 2003; Thompson & Gauntlett-Gilbert, 2007), attention Psychology in the Schools

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deficit hyperactivity disorder (ADHD; Harrison, Manocha, & Rubia, 2004; Jensen & Kenny, 2004; Peck, Kehle, Bray, & Theodore, 2011; Zylowska et al., 2007), depression (Biegel, Brown, Shapiro, & Schubert, 2009), depression relapse (Allen et al., 2006), and externalizing behaviors (Napoli et al., 2001; Wall, 2008), and often in a K–12 school environment (Schoeberlein & Koffler, 1990). Targeted school-age populations that could benefit from participation include students challenged with internalizing disorders, externalizing behaviors, learning disabilities, problems with executive functioning, and ADHD. The intervention could be implemented in an educational context by a school psychologist with foundational training in mindfulness intervention and small-group service provision. Internalizing Disorders. Semple and colleagues (2006) conducted a feasibility and acceptability trial of an adapted version of MBCT, mindfulness-based cognitive therapy for children (MBCT-C; Semple et al., 2002). MBCT-C is a manualized group intervention for youth in late childhood and early adolescence that takes into account the developmental level of the clients and has been used in school settings (Semple et al., 2006). MBCT-C was developed specifically to increase social– emotional resiliency by helping children become more aware of their cognitions, emotions, and body sensations as discrete entities and apply behavioral strategies designed to promote self-regulation by increasing mindfulness (Semple, 2010). A pilot trial of MBCT-C was implemented with five 7- to 8-year-old children with anxiety symptoms. These children participated in a 6-week intervention (45 minutes per week) delivered in a school setting by teachers experienced in teaching mindfulness. Teacher report and direct observations by the school psychologist indicated an improvement in academic functioning, reduction of problem behaviors, and a reduction in internalizing symptoms. This work also demonstrated that it is feasible to implement MBCT-C within the school environment, because it was reported to be acceptable to both students and staff. A randomized controlled trial of MBCT-C with 25 children, recruited from a university-based reading clinic, between ages 9 and 13 years from mostly low-income, inner-city households, was conducted as a follow-up to the previous study (Semple et al., 2002). The MBCT-C intervention consisted of 12 weeks of 90-minute group sessions, during which developmentally appropriate mindfulness activities were practiced and discussed. Children were assigned to either intervention or wait-list control groups; data were collected before and after the intervention group completed treatment. Questionnaire data included broad-band parent report of emotional and behavioral problems, and child self-report of anxiety symptoms. Between-group repeated-measures analyses of variance (ANOVAs) showed that children in the mindfulness-based intervention group had statistically significant reductions in attention problems. Combining intervention and wait-list control conditions, paired sample t tests of changes from pretest to posttest found statistically significant reductions in anxiety and problem behavior scores. Also, children who presented with clinically elevated levels of attention problems (n = 5) and anxiety (n = 6) at the beginning of the study exhibited statistically significant reductions in both anxiety symptoms and behavior problems at the conclusion of the intervention, and many of these same children did not have clinically significant levels of psychopathology following treatment (n = 1 for attention problems, n = 3 for anxiety). Another randomized controlled trial of a mindfulness-based intervention with adolescents was conducted by Biegel and colleagues (2009) with 102 adolescents age 14 to 18 years who were receiving services at an outpatient psychiatric center. The adolescents in the intervention condition received 8 weeks of a developmentally adapted MBSR program; the randomized wait-list control group received treatment as usual. Participants were assessed before and after the MBSR intervention group completed treatment with clinical evaluations of psychiatric diagnoses and symptoms, and adolescent self-report questionnaires of mental health. Using a mixed modeling analytic approach, in which individual characteristics (e.g., repeated assessment of psychopathological symptoms) were Psychology in the Schools

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nested within group assignment (e.g., MBSR), intervention results demonstrated that the adolescents in the treatment condition reported statistically significant reductions in symptoms of anxiety, depression, and somatic distress, as well as significant increases in self-esteem and sleep quality. Further, at the 3-month follow-up, clinicians blinded to treatment conditions assessed these youth and reported that those who had participated in the intervention had statistically significant improvements in global assessment of functioning scores compared with those in the control condition. The aforementioned studies demonstrate the utility of adapted mindfulness interventions for children with internalizing problems and the possibility of similar intervention occurring in a Tier 2 context in a school. Executive Functioning. Executive functioning (EF), or the superordinate system that controls and manages other cognitive processes, is fundamental to self-regulation (Blair & Diamond, 2008) and critical to academic ability (Blair, 2002; Blair & Razza, 2007). Emerging neurophysiological evidence suggests that mindfulness training in adults improves aspects of EF, including attentional regulation (Jha et al., 2007; Zylowska et al., 2007) and metacognition (Teasdale et al., 2002). To explore the effects of mindfulness-based intervention on children’s EF, Flook and colleagues (2010) conducted a randomized controlled trial. Sixty-four second- and third-grade children (mean age, 8.2 years; 55% female) were randomly assigned to either a mindfulness-based intervention treatment condition or an active control group (silent reading). Both conditions took place during two 30minute mindfulness-based sessions per week for 8 weeks in an elementary school. Children were assessed before and after the 8-week period with a measure of EF behaviors by their teachers and parents. Multivariate analyses of covariance were conducted, where baseline EF scores, condition, and the baseline by condition interaction were entered as covariates and posttest EF scores entered as the dependent variable. Results demonstrated a statistically significant interaction term for both teachers and parents, meaning that participants with lower initial EF improved significantly following mindfulness training compared with controls. Further, teacher and parent reports indicated that the students in the mindfulness-based intervention group had statistically significant improvements in a subcomponent of the EF scale, which measured behavioral self-regulation at school and at home, lending evidence that mindfulness-based interventions can generalize across multiple settings. Externalizing Behaviors. Two studies to date have demonstrated mindfulness intervention effects on small groups of children in respect to externalizing behaviors. Bögels, Hoogstad, van Dun, de Scutter, and Restifo (2008) used a youth adaptation of MBCT in a community mental health setting for a feasibility study among 14 adolescents (aged 11–18 years) with externalizing disorders. The majority of parents also participated in MBCT groups concurrently. Adolescents’ internalizing and externalizing behaviors were measured before and after MBCT by self-report and parent report. Analyses of data indicated statistically significant postintervention improvements in externalizing behavior. In an open trial of MBCT-C on an ethnically diverse nonclinical sample of twenty-five 9- to 12-year-olds (Lee et al., 2008), parents were administered a child problem behavior questionnaire before and after completion of the intervention. Dependent samples t tests indicated a statistically significant reduction in parent-reported total problem behaviors and externalizing behaviors. These two studies suggest the utility of group-administered mindfulness intervention for youth with externalizing behavior. Learning Disabilities. A feasibility study by Beauchemin, Hutchins, and Patterson (2008) used a mindfulness-based intervention in a specialized school setting with 34 students between the ages of 13 and 18 who had learning disabilities. The intervention was led by classroom teachers and involved 5 to 10 minutes of a mindfulness practice at the beginning of each period for 5 weeks. Unlike most of the mindfulness interventions discussed in this article, which use qualified mindfulness practitioners to teach the mindfulness intervention, this study involved teachers with just 3 hours of training in mindfulness. Using paired-sample t tests, results of the study demonstrated statistically significant Psychology in the Schools

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reductions in self-rated anxiety, significant improvements in self- and teacher-rated social skills, significant improvements in teacher-rated academic achievement, and significantly lower levels of teacher-rated problem behavior. This work provides preliminary support for the applicability of mindfulness interventions with students who have learning disabilities. Attention Deficit Hyperactivity Disorder. A feasibility study by Zylowska and colleagues (2007) involved an 8-week mindfulness-based intervention that included adolescents (n = 8; mean age, 15.6 years) and adults (n = 24; mean age, 48.5 years) with either a confirmed diagnosis of ADHD or elevated symptoms. The within-participant pre–post intervention included weekly (2.5 hours per week) community-based sessions and home-based practice (5- to 15-minute sitting meditation). Results indicated statistically significant improvements in self-reported ADHD symptoms and significant changes on neurocognitive measures. The authors further noted that many adolescents who wanted to participate could not because the study was held off school grounds, suggesting that schools are a desirable location to conduct mindfulness-based interventions because they are more easily accessible to members of the community. Tier 3: Intensive Interventions Individuals who need high-level support often require individualized services to fit the specific demands of their condition. As previously discussed, mindfulness interventions have been developed and incorporated into psychotherapeutic interventions, generally in small-group contexts, but also with individual clients (Baer, 2003). Although the provision of individual psychotherapeutic intervention is often outside the range of services provided by school psychologists, the school psychology profession does prepare clinicians who have the training and capacity to serve in this function. The following section describes how school psychologists can provide intensive, individual-level services to meet the needs of students in educational settings by using modified versions of commonly used mindfulness interventions. Acceptance and Commitment Therapy for Student Avoidance Behavior. As previously mentioned, ACT is considered to be a mindfulness-based intervention, although it operates within a cognitive–behavioral theoretical orientation. Because of the simple behavioral methods used in treatment, ACT is well suited for use with child and adolescent populations (Twohig, Hayes, & Berlin, 2008). ACT uses metaphors, stories, and experiential exercise, techniques that are common in other forms of child-centered intervention. One of the primary objectives of ACT is to help individuals behave in ways that are consistent with their personal values while at the same time accept their current experience. In this way, ACT deters avoidance of unpleasant internal or external stimuli, otherwise known as experiential avoidance. Individuals learn acceptance strategies to help them be less reactive to unpleasant experiences, which in turn enables thoughtful response that is in line with their own best interests. Targeting experiential avoidance in this way has demonstrated preliminary success among school-age populations. In one study, 14 adolescents (mean age, 17.0 years; 78% female) with chronic pain used ACT methods to focus on accepting their debilitating health conditions (Wicksell, Melin, & Olsson, 2006). Data were collected on adolescent functional ability and school attendance via self-report at pre-intervention, post-intervention, and 3 and 6 months following treatment. Repeated measures ANOVAs (α = .05) detailed that at posttreatment and the 6-month follow-up, adolescents’ daily functioning had improved, their school attendance improved, and they reported fewer pain symptoms. This study demonstrates the effectiveness of ACT for targeting experiential avoidance among an adolescent population. School refusal is an example of experiential avoidance that could be addressed by using ACT in an educational environment. As many as 5% of school-age children present with school refusal Psychology in the Schools

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(Burke & Silverman, 1987). This common difficulty is associated with a series of short- and long-term impairments in domains such as psychopathology, employment, and academic failure (Bernstein, Hektner, Borchardt, & McMillan, 2001; Flakierska-Praquin, Lindström, & Gillberg, 1997). School refusal is commonly rooted in avoidance of a perceived negative aspect of school, which then causes youth to behave in ways that will result in school expulsion (Evans, 2000). Given the prevalence, known functional causes, and serious implications of school refusal, school personnel would do well to adopt an ACT-based strategy to target the experiential avoidance that underlies this pressing problem. Soles of the Feet. School-age youth with aggressive behavior present one of the most urgent concerns in our educational environment today (Sugai, Sprague, Horner, & Walker, 2003). Although numerous treatment packages are available to address aggressive behavior in children and adolescents, many are costly in terms of the amount of time and resources required to implement them. SOF (Singh et al., 2007) is a simple, mindfulness-based intervention that can be pointed toward aggressive behavior in schools, and it requires minimal resources to implement (Singh et al., 2011). Using a single-subject, multiple-baseline research design, Singh, Lancioni, Joy, and colleagues (1998) implemented SOF with 3 adolescents diagnosed with conduct disorder. These individuals had high rates of aggressive behavior and were at immediate risk for being expelled from school. The adolescents met at the school for three 15-minute sessions per week, for a total of 4 weeks. Study results indicated that all 3 adolescents decreased their aggressive behavior to a level that enabled them to remain in school. Furthermore, intervention effects obtained from this study continued for 6 to 9 months following mindfulness training. Clearly, a simple mindfulness-based intervention can redirect even the highest needs students in an educational context. In part because of the success of this initial implementation, this article’s first author and colleagues began working on a school-based adaptation of SOF to decrease problem behavior and increase time spent on task for individuals and entire classrooms (Felver-Gant, Singh, Frank, & McEachern, 2010). The adaptation is designed to be implemented with minimal training or consultation. Using a single-subject, multiple-baseline research design, 3 elementary school students completed the adapted version of SOF in a public school; preliminary data from this work suggest that SOF can help decrease student disruptive behavior and increase academic engagement, and it was highly acceptable to both teachers and students (Felver-Gant, Groff, Morris, & Wilson, 2011; Felver, Frank, & McEachern, in press). S UMMARY

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C ONCLUSIONS

This overview of mindfulness psychology has described how techniques and interventions derived from this new field of study may be integrated into the professional practice of school psychology. Their effectiveness with a variety of populations in a multitude of contexts has made mindfulness-based interventions a popular method of psychological service delivery. The utility of mindfulness in the specialty of school psychology is not limited to simply a few novel tricks to add to the existing armamentarium of intervention techniques. Rather, it has the potential to improve many existing professional practices. Given the host of challenges and difficulties at play in today’s schools, mindfulness psychology offers an avenue of scientific inquiry that has promise for enhancing psychosocial well-being, decreasing stress, and providing supports for those who need them most. Implications for Practice While considering the use of mindfulness-based interventions with children and adolescents, it is necessary to take into account the developmental level of the student group in question. As in other domains of intervention science with youth, children and adolescents cannot be expected to Psychology in the Schools

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respond to a simplistic “child friendly” version of adult materials—specific tailored accommodations must be made. Thompson and Gauntlett-Gilbert (2007) describe several of these considerations for using mindfulness practices with youth, including reducing the length of time for sustained practice (recommended at 1 minute for every year of age (Greenland, 2010), incorporating multiple sensory modalities into practice activities (e.g., hearing, tasting, touching), relying on metaphors to communicate difficult concepts during discussion, and spending longer periods of time explaining key concepts. Recommendations such as these should be taken into careful consideration to ensure that mindfulness interventions are implemented with the appropriate developmental considerations for maximum effectiveness. An important variable for school psychologists to consider is monitoring stakeholders’ (e.g., students’, teachers’, and parents’) willingness to engage with and use an intervention. Acceptancebased strategies, such as ACT, could potentially be used to reduce student resistance to engaging with intervention services. Addressing emotional, psychological, social, and intellectual barriers involves reducing skepticism and increasing psychological flexibility, potentially through mindfulness-based training efforts (Varra, Hayes, Roget, & Fisher, 2002). In a study of the effect of acceptance-based treatment on willingness to use services (i.e., buy-in), 59 drug and alcohol counselors (mean age, 56.7 years; 58% female; 34% ethnic minority) were randomly assigned to either a 1-day ACT training or 1-day educational control group, followed by a 1-day training in pharmacotherapy and evidence-based treatment (both conditions). ACT training was hypothesized to reduce psychological barriers to implementing psychopharmacological interventions, an evidence-based practice with a high level of stigma and judgment attached to it by many psychotherapists (Varra et al., 2002). Data were collected pre-intervention, post-intervention, and 3 months following training on counselor self-reported willingness and reported use of psychopharmacology and evidence-supported psychotherapy. Statistical analysis showed that counselors in the ACT intervention group were more likely than controls to implement psychopharmacological evidence-based intervention, despite both groups having had an equally high level of resistance to this treatment approach at initial assessment (p < .05). Similarly, mindfulness-based practices, such as ACT, could be used with students or teachers who resist engaging with intervention practices in the classroom. This is not to suggest a form of coercion, but rather, the advantage of increasing one’s readiness to be accepting and developing one’s psychological flexibility. As such, individuals may be more willing to engage with a form of intervention they would otherwise have been unwilling to consider, given their judgment or unconscious resistance. Mindfulness- and acceptance-based strategies are meant to open doors to possible alternative behaviors or ways of functioning, which could allow individuals to consider courses of actions that they may not otherwise pursue. This potential new direction offers promising possibilities for school psychologist consultative services in that increasing buy-in and use of effective intervention strategies is currently one of the most challenging issues in professional practice. Assimilating mindfulness psychology into school psychology practice may involve some limitations. Sensitivity to the secular nature of public education in the United States must be taken into account. Although this consideration continues to change dramatically with the increasing number of mainstream applications of mindfulness intervention (e.g., yoga, MBSR), mindfulness still invokes a strong connotation of Eastern religion. Those who are interested in integrating mindfulness psychology into their public-education-based practices may want to clarify the secular nature of the practices at the outset and provide specific definitions of the activities. For example, describing an intervention simply as “mindfulness meditation” is not specific and could connote a religious undertone to some individuals, whereas unambiguous labels such as “acceptance-focused,” “exercises in attention and self-regulation,” and “incorporates secular practices in breathing meditation and yoga” are more accurate and may be met with less initial resistance. The point is not to disguise a Psychology in the Schools

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mindfulness intervention as something it is not or to deceive individuals into accepting or participating in something that they normally would not choose to do. As with any intervention, one must be precise and careful when choosing words to describe a practice that someone may be unfamiliar with, and it is the ethical responsibility of the interventionist to be as transparent and detailed as possible. Mindfulness-based interventions are secular and appropriate for use in public institutions; those wishing to incorporate these practices into their work in schools must be clear and forthcoming about the practices they intend to use. Another pressing issue is that those who wish to integrate mindfulness into their practice should seek personal training and preparation in mindfulness. Although this concern has not yet been specifically addressed by empirical research, all those who have developed the most common forms of mindfulness interventions, including all interventions mentioned in this article, advise that one must have a personal practice and intimate familiarity with mindfulness interventions to effectively implement the technology. Debate continues about what constitutes adequate personal experiences in this domain, but it is a reasonable assumption that at least some competence should be achieved before trying to deliver a mindfulness intervention to others. It is likely that one would not, for example, receive quality instruction in how to play the guitar from a teacher who has never plucked a string. Future Research Mobilized by strong empirical evidence of the salutary effects of mindfulness intervention, research and practice have numerous future directions to explore. Direct service provision to students is the most obvious route to integrating mindfulness training into school psychology. Mindfulness interventions may help ameliorate the emotional and behavioral difficulties that often impede the educational progress of many students in today’s classrooms. Less obvious, but no less important, is to study how to incorporate mindfulness psychology indirectly into school psychology practice, particularly given the stress and strain on today’s educational personnel, including school psychologists. Although not empirically evaluated with school psychologists, mindfulness interventions have been found to be effective for reducing stress among professionals with high rates of burn out, such as mental health counselors (Shapiro, Brown, & Biegel, 2010), teachers (Winzelberg & Luskin, 1996), and medical school students (Shapiro et al., 2007). Future efforts in mindfulnessbased intervention should explore the potentially useful area of providing stress reduction services to school psychologists and related school-based personnel to reduce burn out and improve overall functioning. Equally compelling as the prospects for intervention are the new avenues for research in the emerging field of mindfulness psychology. The psychometric measurement of mindfulness is one domain in need of additional investigation. Psychologists studying mindfulness with adult populations have developed numerous self-report scales, each purportedly tapping into the construct, albeit with differing items and varying conceptualizations of the construct. Aiming to develop a more technically sophisticated and comprehensive tool, Baer, Smith, Hopkins, Krietemeyer, and Toney (2006) collected data using the most popular existing scales and then conducted a series of exploratory and confirmatory factor analyses to probe the underlying factorial dimensions of mindfulness. Results from their work yielded a psychometrically sound measure that includes five unique dimensions of mindfulness (Five Facet Mindfulness Questionnaire; Baer et al., 2006), and it is now the most frequently used psychometric tool to assess levels of mindfulness in intervention and research. Similarly, with respect to the measurement of mindfulness with children and adolescents, numerous unique scales (Coyne, Cheron, & Ehrenreich, 2008) reflect differing conceptualizations of the measurement of mindfulness, making it difficult to compare measurement outcomes. Future research could easily subject these scales to methodology similar to that used by Baer and colleagues Psychology in the Schools

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(2006) to develop a more psychometrically sound and theoretically comprehensive questionnaire, thus permitting more accurate measurement and comparison among treatment studies. Exploring the mechanistic underpinnings of mindfulness intervention, particularly with regard to understanding the relation between mindfulness intervention and attention, is another pressing issue in mindfulness research. Although attention is hypothesized to be a possible mediating pathway to intervention effects (Shapiro et al., 2005), researchers have yet to come to a consensus on how mindfulness intervention affects attention or its subsystems. Emerging evidence is indicating that mindfulness directly affects higher order processes related to the executive control of attention in adults (Jha et al., 2007) and in children (Morris et al., 1995; Saltzman & Goldin, 2009). Future research is needed to continue to explore the relationship between attention and mindfulness intervention, including testing for any mediational relations that may exist and that could potentially elucidate the mechanisms underlying treatment effects. The specialty of school psychology is ripe for the integration of mindfulness psychology. New directions in research and intervention are readily available to anyone willing to explore this compelling, albeit nascent, realm of Western scientific inquiry. It will be fascinating to witness how the field implements mindfulness interventions for the betterment of youth and those who have devoted their lives to educating children and adolescents. R EFERENCES Allen, N., Blashki, G., & Gullone, E. (2006). Mindfulness-based psychotherapies: A review of conceptual foundations, empirical evidence and practical considerations. Australian and New Zealand Journal of Psychiatry, 40, 285 – 294. doi:10.1111/j.1440-1614.2006.01794.x Arch, J. J., & Craske, M. G. (2006). Mechanisms of mindfulness: Emotion regulation following a focused breathing induction. Behavior Research and Therapy, 44, 1849 – 1858. doi:10.1016/j.brat.2005.12.007 Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125 – 143. doi:10.1093/clipsy/bpg015 Baer, R. (Ed.). (2006). Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications. San Diego, CA: Elsevier. Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27 – 45. doi:10.1177/1073191105283504 Beauchemin, J., Hutchins, T., & Patterson, F. (2008). Mindfulness meditation may lessen anxiety, promote social skills, and improve academic performance among adolescents with learning disabilities. Complementary Health Practice Review, 13, 34 – 45. doi:10.1177/1533210107311624 Bernstein, G. A., Hektner, J. M., Borchardt, C. M., & McMillan, M. H. (2001). Treatment of school refusal: One-year follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 206 – 213. doi:10.1097/00004583200102000-00015 Biegel, G. M., Brown, K. W., Shapiro, S. L., & Schubert, C. M. (2009). Mindfulness-based stress reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 77(5), 855 – 866. doi:10.1037/a0016241 Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., . . . Devans, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology Science and Practice, 11, 230 – 241. doi:10.1093/clipsy.bph077 Blair, C. (2002). School readiness: Integrating cognition and emotion in a neurobiological conceptualization of children’s functioning at school entry. American Psychologist, 57, 111 – 127. doi:10.1037/0003-066X.57.2.111 Blair, C., & Diamond, A. (2008). Biological processes in prevention and intervention: The promotion of self-regulation as a means of preventing school failure. Development and Psychopathology, 20, 899 – 911. doi:10.1017/S0954579408000436 Blair, C., & Razza, R. P. (2007). Relating effortful control, executive function, and false belief understanding to emerging math and literacy ability in kindergarten. Child Development, 78, 647 – 663. doi:10.1111/j.1467-8624.2007.01019.x Bögels, S., Hoogstad, B., van Dun, L., de Schutter, S., & Restifo, K. (2008). Mindfulness training for adolescents with externalizing disorders and their parents. Behavioural and Cognitive Psychotherapy, 36, 193 – 209. doi:10.1017/S1352465808004190 Brown, K. W., Ryan, R. M., & Creswell, J. D. (2007). Mindfulness: Theoretical foundations and evidence for its salutary effects. Psychological Inquiry, 18, 211 – 237. doi:10.1080/10478400701598298 Burke, A. E., & Silverman, W. K. (1987). The prescriptive treatment of school refusal. Clinical Psychology Review, 7, 353 – 362. doi:10.1016/0272-7358(87)90016-X Psychology in the Schools

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Psychology in the Schools

DOI: 10.1002/pits