This course describes challenges and potential benefits of using mindfulness as a clinical intervention with children. We also discuss the results of research on mindfulness with children, now in its early stages.
Background: Mindfulness and Its Uses with Adults
Since Jon Kabat-Zinn first began teaching Mindfulness-Based Stress Reduction (MBSR) in a basement at the University of Massachusetts Medical School in 1979, there has been a boom of both clinical interest in and research on the applications of this simple practice adapted from the Buddhist tradition. According to a recent article by Margaret Cullen in the journal Mindfulness (2011, Mindfulness-Based Interventions: An Emerging Phenomenon), Kabat-Zinn’s secularized approach to the teaching of mindfulness has been the subject of literally hundreds of clinical studies that have demonstrated its clinical effectiveness in the treatment of a wide range of physical and mental health issues including the following:
• Depression, including relapse prevention
• Substance abuse
• Eating disorders
• Chronic pain
• Rheumatoid arthritis
• Heart disease
In addition mindfulness has been shown to improve immune function. (Davidson, R. et al. (2003) Alterations in brain and immune function produced by mindfulness meditation)
In fact, it turns out that mindfulness training is also good for those who are basically healthy. Chiesa and Serretti report in their review of the literature on healthy adults that mindfulness reduces stress, ruminative thinking, and trait anxiety in those of us who are basically healthy. In addition, mindfulness increases empathy and self-compassion in people with no current clinically significant physical or mental health issues. (For a review of the research, see Chiesa, A. and Serretti, A. (2009) Mindfulness-based stress reduction for stress management in healthy people: A review and meta-analysis)
Interest in Mindfulness for Children
With this strong base of evidence for adults, the past five years have seen attention begin to shift toward applications with children and adolescents as well. In this lesson we will explore mental health applications of mindfulness with children. In the next lesson, the intimately related topic is mindfulness for children in education.
There is some significant overlap of these two areas in several ways. Much of the research on mindfulness with children in education focuses on executive function. Differences or deficits in executive function are important in childhood mental health concerns as well, so the educational research has strong relevance for mental health uses of mindfulness with children. (For more on executive function and mindfulness in education with children see the lesson “School-Based Mindfulness for Children.”) In addition, many of the mindfulness interventions being developed for use with children in the classroom can also be effectively adapted for clinical groups or individual therapy with this age range. In fact, some therapeutic uses may actually take place in the school setting under the purview of school counselors and school psychologists.
Lastly, mindfulness with children in the classroom is an example of Positive Psychology Mindfulness interventions in educational contexts are typically given to all students in a class or even to a whole school. Yet most school children don’t have clinically significant mental health issues. However the use of mindfulness to enhance their executive function by improving such skills as attention, impulse control, meta-cognition, and cognitive flexibility has the potential to strengthen cognitive and emotional well-being in addition to educational benefits. Mindfulness in the classroom thus naturally falls within the arena of psychological interventions that enhance human flourishing. In addition, improved executive function during childhood may serve to prevent the development of mental health issues as adults. Clinicians are therefore encouraged to explore the lesson on School-Based Mindfulness Interventions for Children.
Issues Involved in the Application of Mindfulness Interventions with Children
Therapeutic mindfulness interventions with children represent a further extension of third-wave Cognitive Behavioral Therapy (CBT) into the domain of childhood mental health issues. (See our full listing of courses on mindfulness in mental health.) As with third-wave CBT with adults, the emphasis in mindfulness interventions with children is on processes that happen within the child rather than changing the content of the child’s experience (e.g., challenging a thought to change or reduce it thereby changing the frequency of an emotion). With mindfulness-based therapies we help the client learn to turn towards their challenging emotions with equanimity rather than helping them replace an unpleasant emotion with a pleasant one. In mindfulness-based CBT, its OK to be vulnerable. It’s not helpful to hide from or avoid painful feelings. And we work to remember that we are not alone in our suffering.
This orientation in the therapeutic alliance involves the potential for conflict between openness to emotions taught through mindfulness practice versus emotional suppression often modeled and taught by other adults in a child’s life. All of these points suggest that third-wave CBT, whether with children or adults, involves a re-emphasis on the importance of the therapeutic relationship. And within this reemphasis, it is especially important that the clinician using mindfulness-based interventions is practicing a mindful approach in their own lives.
There are other challenges for mindfulness-based interventions with children as well. Perhaps the most obvious is that of the various developmental levels of childhood. New methods of training mindfulness to include child-friendly teaching strategies such as imagery, story telling, songs, play, art, and games are being developed and tested for different childhood age groups.
In addition, much mindfulness research relies on self-report of various kinds. Mindfulness research with adults thus already struggles with the challenge of using subjective data to measure the very private experience of being mindful. How much more difficult will it be doing mindfulness research on children, where self-report may need to come from a child who cannot speak, let alone read and write, at an adult level of sophistication when reporting their inner experience.
Lastly, the more we learn about mindfulness as a treatment for issues like childhood anxiety, impulsivity, inattentiveness, etc., the more our attention will turn to the potential preventive capacity of mindfulness interventions as well as their expression as an element of Positive Psychology by which we make the lives of mentally healthy children even happier and more fulfilling. Can then visions of societal and cultural change be far behind?
Research on Clinical Interventions with Children
While we are just in the early stages of studying mindfulness in educational settings with elementary school students, there has been even less research on clinical populations of children. In fact much of the research with children that has a clinical focus has been conducted in the context of educational institutions. In the earliest such study (Semple, R., Reid, E., and Miller, M. (2005 ) Treating anxiety with mindfulness: An open trial of mindfulness training with anxious children), the authors worked with five students identified by their teachers as demonstrating anxiety symptoms. These five students were given a 6 week group mindfulness intervention after which each child showed “improvement in at least one area – academic functioning, internalizing problems, or externalizing problems.” However the researchers did not report on anxiety issues since the students in the study did not show clinically significant levels of anxiety when evaluated as part of the initial assessment process for this study. The researchers concluded that mindfulness interventions were both feasible and promising for children.
Semple and Lee (2011) then went on to develop a manualized protocol called Mindfulness-Based Cognitive Therapy – Children (MBCT-C) that was adapted developmentally for children in conjunction with Williams, Teasdale, and Segal, the creators of MBCT for adults. (This manual has been published as Mindfulness-Based Cognitive Therapy for Anxious Children: A Manual for Treating Childhood Anxiety.) Semple and Lee along with Miller and Rosa used this protocol to conduct a randomized trial with boys and girls aged 9-13. Their intention in this study was to increase social-emotional resiliency, which they defined as reduced problems in the areas of attention and behavior as well as reduced symptoms of anxiety. Those who completed the program did show reduced attention problems, a shift that was maintained for three months post intervention. For behavior problems and anxiety symptoms no overall shift was seen, though it is of note that both these areas improved significantly for those students who showed clinical levels of anxiety pre-intervention. (Semple,, R. (2010) A randomized trial of mindfulness-based cognitive therapy for children: promoting mindful attention to enhance social-emotional resiliency in children)
A second study conducted in an educational setting also shows potentially clinically relevant results. In 2005, Napoli, Creach and Holley published the results of their study on the effects of a mindfulness intervention called the Attention Academy with 1st to 3rd graders. The subjects demonstrated better selective attention (the ability to pick and choose what to pay attention to), but were not different from controls on sustained attention (the ability to stay with a particular chosen focus of attention over a sustained time period). Those receiving the mindfulness intervention also showed less test anxiety and their teachers reported fewer ADHD type symptoms. (An ADHD behaviors measurement was used to track behaviors even though the test subjects themselves were a randomly chosen 1st to 3rd graders, and thus not a group chosen for clinical ADHD symptoms.) (Napoli, M., Creach, P., and Holley, L. (2005) Mindfulness training for elementary school students: The attention academy)
In another pilot study that blends clinical and educational contexts, Desmond studied the effects of mindfulness on six students in a special support classroom for those with learning and emotional disabilities. They concluded that their results “strongly support the positive effects of mindful awareness teaching on student cognitive, physical, and social behaviors for both learning support and emotional support students..” (Desmond, C. (2009) The effects of mindful awareness teaching practices in the “Wellness Works in Schools” program on the cognitive, physical and social works in schools program on the cognitive, physical and social behaviors of students with learning and emotional disabilities in an urban, low income middle school, p. 11)
Liehr and Diaz recruited 18 children from a summer camp for minority children for a study of the effects of mindfulness on depression and anxiety. Half were given a mindfulness intervention while the others attended classes in health education. Results showed that mindfulness reduced depression symptoms, but not anxiety symptoms, in the mindfulness group relative to the health education group. (Liehr, P. and Diaz, N. (2010) A pilot study examining the effect of mindfulness on depression and anxiety for minority children)
An Australian study by Joyce et al. involving a school-based mindfulness program for 10-12 year olds focused on mental health issues. The researchers found that after mindfulness training, students scored lower on psychological assessment tools designed to identify those with mental health issues at clinical levels. One test was a general assessment tool used to screen for a variety of diagnostic categories while the other was designed to detect depression. There was an overall 35% drop in students who tested within the borderline or clinical range for mental health issues while the drop was 16% when depression alone was the focus of the assessment. (Joyce, A., et al. (2010) Exploring a mindfulness meditation program on the mental health of upper primary children: A pilot study)
Coholic, Eys, and Lougheed in Canada have designed a program integrating mindfulness with visual arts. In their preliminary qualitative research using this protocol with 8-14 year old children in the foster care system or referred to them by child protective agencies, they examined reports both from the participants and their parents/guardians. They found that the children experienced a decrease in emotional reactivity while the reports also depicted them as happier, more confident and more willing to talk about their emotions. The authors of this study, which was essentially a feasibility study, found that the program was both acceptable to and suitable for participants while showing promise as an effective intervention. (Coholic, D., Eys, M., and Lougheed, S. (2012) Investigating the effectiveness of an arts-based and mindfulness-based group program for the improvement of resilience in children in need)
By contrast, a study by White of a once-a-week, hour-long, 8-week intervention of mindful yoga for 4th and 5th grade girls recruited from a local school yielded ambiguous results. Both control and yoga groups demonstrated increased self-esteem and self-regulation while the yoga group reported higher levels of stress but also better ability to deal with stress. The authors suggest that this may be because their subjects were more aware of stress and therefore, while they tended to report more stress, they were better able to cope with it as well. (White, L. (2012) Reducing stress in school-age girls through mindful yoga)
Self-Esteem vs. Mindfulness-based Self-Compassion
This last study raises the issue of self esteem in childhood. Self-esteem is another area that has both clinical and educational significance. Self-esteem was important in education from the 60s through the 90s, when it began to come under some question. The practice of mindfulness-based self-compassion has been developed and studied by Kristin Neff at the U. of Texas as an alternative to self-esteem. Mindfulness-based self-compassion involves the cultivation of three elements: mindfulness, kindness towards oneself, and what Neff calls common humanity, the recognition that others also experience similar difficulties and challenges to the ones we ourselves experience. In 2009, Neff and Vonk compared self-compassion to self-esteem in two studies with adults. They found that both constructs were equally strong in predicting happiness, optimism, and positive affect. However self-compassion was more strongly associated with “stable feelings of self-worth” while self-esteem was more clearly associated with “social comparison, public self-consciousness, self-rumination, anger, and the need for cognitive closure.” Perhaps especially noteworthy was the clear association between self-esteem and narcissism, something not found with self-compassion. Although this research was done with adults, given that mindfulness research on executive function with children tends to follow results with adults, there is reason to believe that self-compassion work, grounded so strongly, as it is, in mindfulness practice, would also have similar results in children. (Neff, K. and Vonk, R. (2009) Self-compassion versus global self-esteem: Two different ways of relating to oneself). (For an article which offers exercises for children in the development of self-compassion, see Persinger, J. (2011) An alternative to self-esteem: Fostering self-compassion in youth p. 4ff)
Website for Diane Coholic, developer of an art-based approach to teaching mindfulness.
Diane Coholic’s work described in an article can be found at Tollinsky, N. (2009) Arts-based work groups help children.
An overview of executive function from the perspective of academic skills can be found on the Great Schools website.
Susan Kaiser Greeneland, The Mindful Child, Free Press, 2010.
Thich Nhat Hanh, Chan Chau Nghiem, and Wietzke Vriezen, Planting Seeds: Practicing Mindfulness with Children , Parallax Press, 2011.
Thich Nhat Hanh and Wietzke Vriezen, Mindful Movements: Ten Exercises for Well-Being, Parallax Press, 2008.
Sarah Wood Vallely, Sensational Meditation for Children: Child-Friendly Meditation Techniques Base on the Five Senses, Satya International, Inc., 2008.
Christoper Willard, Child’s Mind: Mindfulness Practices to Help Our Children Be More Focused, Calm, and Relaxed , Parallax Press, 2010.
Diane Coholic, Art Activities for Children in Need, Jessica Kingsley Publishers, 2010