J. Indian Assoc. Child Adolesc. Ment. Health 2014; 10(1):1-8. Guest Editorial

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1 1 J. Indian Assoc. Child Adolesc. Ment. Health 2014; 10(1):1-8 Guest Editorial Mindfulness based interventions for children Dr. Eesha Sharma Address for Correspondence: Dr. Eesha Sharma, Lecturer, Department of Psychiatry, King George s Medical University, Lucknow. eesha.250@gmail.com Kabat-Zinn et al introduced mindfulness, a concept and technique borrowed from Buddhist meditation practices, to the field of psychotherapy. It is defined as the the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment to moment (1). Unlike other forms of meditation that emphasize distancing oneself from the present to reach a higher state of consciousness, mindfulness stresses upon a fuller awareness of, and thus a greater involvement with, the present moment. The fuller awareness incorporates all visual, auditory, gustatory, tactile, cognitive and emotional information available to consciousness at that moment (2). Further, all occurrences are observed but not judged, i.e. they are not given labels like good or bad, healthy or sick, important or trivial, etc. (3). The seemingly complex task of being mindful requires regular practice, and it has oft been said that psychotherapists must first become adept in mindfulness themselves, before being able to effectively use it with their clients. Steven Hayes has placed mindfulness, along with acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT), under the new or third wave Cognitive Behavior Therapy. These newer therapies aim to change the meaning of psychological events (thoughts) that people experience, rather than change the events themselves (4). Instead of restructuring, mindfulness encourages a person to regard troublesome thoughts

2 as mental events that do not necessarily reflect anything about the self or reality. The premise is that cognitive, emotional and behavioral responses to unpleasant thoughts can add to emotional distress. Increased acceptance of unpleasant experiences and the experiential learning thereof are instrumental in the benefits derived from mindfulness (5). Mindfulness-based stress reduction (MBSR) (6) and mindfulness-based cognitive therapy (MBCT) (7) have been found useful in adults, in controlled studies, with depression, anxiety disorders, suicidality, obsessive-compulsive disorder, stress-related disorders, and the medically ill with chronic pain or other symptoms. Mindfulness-based skills are also important components of DBT, ACT and relapse prevention strategies for substance use (8). The effective application of mindfulness in adults has prompted researchers to use the same in children. Studies so far have covered an array of subjects, disorders, administration procedures, and outcome measures (2, 5, 9-16). The clinical-setting studies include anxiety disorders, depression, learning disability, non-syndromal behavioral problems, aggression, attention-deficit hyperactivity disorder, substance use disorder, and physical and psychological morbidity from medical illness. From preschool (3-6 years) to late adolescence (17-19 years), all age groups have been represented in studies. Techniques used with children were derived from both MBSR and MBCT. Individual and group settings have been used. Outcome measures have generally been target symptom reduction, as assessed by self-report, or teacher or parent report. Unlike research with adults, multiple studies have also looked at mindfulness-based techniques for children in non-clinical settings like school and mindfulness-based interventions for parenting and parent-child relationship. The goal in these non-clinical settings was to

3 3 promote emotional well being, to enhance cognitive processes associated with learning and to reduce behavioral problems in the home-setting and parent-child disharmony. School teachers, in the school setting, and trained professionals, in clinical settings, administered the mindfulness sessions. Published literature tends to favor the multitude applications of mindfulness. However, existing studies on use of mindfulness in children have several methodological limitations that constrain meaningful translation into clinical practice. These limitations have been discussed in two excellent review articles (5, 16). The techniques used, administration procedures, and outcome measures are heterogeneous. Sample sizes are small. There are very few studies with controlled designs. Standardized measures for mindfulness in children have not been used, thus limiting interpretation of positive outcomes. Comparison with existing evidence-based interventions is lacking. Also, it seems that almost all the published studies report positive outcomes, making one consider the possibility of publication bias. However, given the novelty of this area, it is understandable that issues like feasibility, acceptability, and safety gain priority over establishing efficacy. The existing studies, to a large extent, give positive support to these issues. Some conceptual questions arise when one reads about the use of a technique like mindfulness with children. As stated earlier, it is a seemingly complex task. One wonders whether children with their developing cognitive and emotional abilities are capable of mastering the technique. Is it possible to train children in mindfulness? What would be an

4 4 appropriate way to assess practice of mindfulness? What would be appropriate outcomes measures? A striking observation about children is that they are naturally mindful (17). Children live engrossed in the present moment, easily let go of the past, and think relatively little about the future. It is of course contentious whether this is something they consciously do, or they just have not acquired higher cognitive abilities that enable us to reflect on the past and worry about the future. Mindfulness works at the level of meta-cognition, the ability to think about thinking, a concept defined by John Flavell in the late 1970s (18). Metacognition can be broken down into two sub-components cognitive knowledge and cognitive monitoring (18,19). According to Piaget s cognitive development theory, children would be deficient in these abilities till they acquire formal operational level of thinking, i.e. by adolescence (10-11 years). However, this view is now being challenged by a number of researchers. Schraw and Moshman (19) state that although cognitive knowledge tends to improve with age, even at age of 4 years children are capable of theorizing about their own thinking and appear to use simple theories to regulate their learning. Effective reflection and regulation of the thinking process is a skill acquired around early adolescence, while monitoring and evaluation take longer, sometimes the whole adult life, to develop. In this background using mindfulness for children appears reasonable. However, dispositional mindfulness (20) is different from training to be mindful. A stepwise progress in this regard would lead us to clearer answers. Research should first focus on studying the psychological construct of mindfulness in children, followed by looking at outcomes of training normal children in mindfulness, and

5 5 subsequently application in the clinical population. Since meta-cognition is a developmental task, another significant issue would be to see whether the occurrence of a psychiatric disorder hinders it, and if so what implications this would have for mindfulness training. Target symptom reduction, assessed by symptom rating scales, has been the most commonly used outcome measure. While this does mean clinical benefit, the practice of mindfulness itself needs to be assessed for apt causal attribution. Since meta-cognition is not an observable phenomenon, its assessment must rely on self-report. Questionnaires for adults (21) incorporate items that are based on the various components of mindfulness, such as awareness and acceptance. These items have to be rated on likert scales. Another lesser-used method is to ask subjects to narrate subjective experiences of being mindful (19). This technique evidently relies heavily on verbal ability. With children both these types of assessments could be complicated (22). Therefore, mindfulness assessment methods in children are an area wanting in research. Psychotherapy with children is challenging. The need for constant innovation and individualization of treatment is far greater than with adults. Mindfulness is a technique that gives a novel perspective on psychiatric disorders. While it has empirical evidence for use in adults, systematic research is still deficient in child and adolescent disorders. However, several positive studies do garner support for pursuing research in this area. References 1. Kabat-Zinn J. Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice. 2003;10:

6 6 2. Napoli M, Krech PR & Holley LC. Mindfulness training for elementary school students: The attention academy. Journal of Applied School Psychology. 2005;21(1): Marlatt GA & Kristeller JL. Mindfulness and meditation. In WR Miller (Ed.), Integrating spirituality into treatment. Washington, DC: American Psychological Association. 1999: Hayes SC, Luoma JB, Bond FW, et al. Acceptance and commitment therapy: model, processes, and outcomes. Behavior Research and Therapy. 2006;44: Burke CA. Mindfulness-based approaches with children and adolescents: A preliminary review of current research in an emergent field. Journal of Child and Family Studies. 2010;19(2): Kabat-Zinn J. An out-patient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry. 1982;4: Teasdale JD, Segal ZV, Williams JMG, et al. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology. 2000;68: Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice. 2003;10:

7 7 9. Liehr P & Diaz N. A pilot study examining the effect of mindfulness on depression and anxiety for minority children. Archives of Psychiatric Nursing. 2010;24(1): Dumas JE. Mindfulness-based parent training: Strategies to lessen the grip of automaticity in families with disruptive children. Journal of Clinical Child and Adolescent Psychology. 2005;34(4): Duncan LG, Coatsworth JD & Greenberg MT. A model of mindful parenting: Implications for parent-child relationships and prevention research. Clinical Child and Family Psychology Review. 2009;12: Flook L, Smalley SL, Kitil MJ, et al. Effects of mindful awareness practices on executive functions in elementary school children. Journal of Applied School Psychology. 2010;26: Lee J, Semple RJ, Rosa D, et al. Mindfulness-based cognitive therapy for children: Results of a pilot study. Journal of Cognitive Psychotherapy: An International Quarterly. 2008;22(1): Semple RJ, Reid EFG, & Miller L. Treating anxiety with mindfulness: Am open trial of mindfulness training for anxious children. Journal of Cognitive Psychotherapy: An International Quarterly. 2005;19(4): Singh NN, Lancioni GE, Karazsia BT, et al. Mindfulness-based treatment of aggression in individuals with mild intellectual disabilities: A waiting list control study. Mindfulness. 2013;4:

8 16. Harnett PH & Dawe S. Review: The contribution of mindfulness-based therapies for children and families and proposed conceptual integration. Child and Adolescent Mental Health. 2012;17(4): Hooker KE & Fodor IE. Teaching mindfulness to children. Gestalt Review. 2008;12(1): Flavell JH. Meta-cognition and cognitive monitoring: A new area of cognitive developmental enquiry. American Psychologist. 1979;34(10): Schraw G & Moshman D. Metacognitive theories. Educational Psychology Review. 1995;7(4): Barnhofer T, Duggan DS & Griffith JW. Dispositional mindfulness moderates the relation between neuroticism and depressive symptoms. Personality and Individual Differences. 2011;51(8): Baer RA, Smith GT, Hopkins J, et al. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13: Chambers CT & Johnston C. Developmental differences in children s use of rating scales. Journal of Pediatric Psychology. 2002;27(1): Dr. Eesha Sharma, Lecturer, Department of Psychiatry, King George s Medical University, Lucknow. 8