TEACHING MINDFULNESS TO MIDDLE SCHOOL STUDENTS AND

HOMELESS YOUTH IN SCHOOL CLASSROOMS

_______________

A Thesis

Presented to the

Faculty of

San Diego State University

_______________

In Partial Fulfillment

of the Requirements for the Degree

Master

of

Social Work

_______________

by

David Paul Viafora

Summer 2011

iii

Copyright © 2011

by

David Paul Viafora

All Rights Reserved

iv

DEDICATION

I would like to dedicate this work to Mia, who has continually offered her loving

support and encouragements to me in so many ways, even while facing significant challenges

in her own life. Thank you for teaching me to be more real, creative, and sensitive to the

needs of the youth. I have enjoyed learning from your ability to see the seeds of inner-

wisdom and compassion that are always present in children. Thank you for your support and

faith in my deepest aspirations, as well as all the delicious and nutritious meals you have

cooked for me during my studies – they were excellent.

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The cosmos is filled with precious gems.

I want to offer a handful of them to you this morning.

Each moment you are alive is a gem,

shining through and containing Earth and sky,

water and clouds.

It needs you to breathe gently

for the miracles to be displayed.

Suddenly you hear the birds singing,

the pines chanting,

see the flowers blooming,

the blue sky,

the white clouds,

the smile and the marvelous look

of your beloved….

Cherish this very moment.

Let go of the stream of distress

and embrace life fully in your arms.

~ Thich Nhat Hanh

Call Me by My True Names

Let us put our minds together

and see what life we can make for our children.

~ Sitting Bull, Lakota Sioux, 1877

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ABSTRACT OF THE THESIS

Teaching Mindfulness to Middle School Students and Homeless Youth in School Classrooms

by David Paul Viafora

Master of Social Work San Diego State University, 2011

The prevalence and early onset of mental and emotional health problems for children and adolescents suggest an urgent need to explore the potential of preventive intervention programs to strengthen the emotional well-being of youth and insulate them from the harmful effects of stress and other risk factors of daily life. A small but growing base of research shows that mindfulness-based interventions with children and adolescents demonstrate treatment feasibility and acceptability, with encouraging findings in emotional and cognitive well-being, and externalizing behaviors. Mindfulness is the ability to focus one's attention on internal and external experiences as they take place in the present moment, with an attitude of kindness and curiosity. Mindfulness helps individuals to be more accepting and at ease with whatever thoughts, feelings, and bodily sensations arise. When youth are able to simply observe and respond compassionately to their thoughts and impulses without being attached to or pulled by them, they can make choices that are not limited by their habitual emotional reactions. As the research base is still emerging, only a handful of studies have explored mindfulness-based interventions in educational settings; applications of mindfulness have yet to be tested with youth from disadvantaged backgrounds. No studies have empirically evaluated a mindfulness course with middle school students in a classroom setting, or with youth facing homelessness. The purpose of the current study was to evaluate the feasibility, acceptability, and effectiveness of an 8-week mindfulness course in middles school classrooms.

A quasi-experimental design with a non-equivalent comparison group of waitlisted students was used to measure student reported changes over time in the domains of acceptance and mindfulness, psychological inflexibility, and self-compassion. Two treatment groups, composed of students attending a traditional middle school (n=38) and with students attending a specialized school serving homeless youth (n=18) were assessed at pre- and post-test. Participants completed a post-course evaluation questionnaire to illustrate their satisfaction and responses to the mindfulness course and how they may have applied mindfulness skills in their daily lives. The first treatment group improved significantly in the domain of psychological acceptance and mindfulness from baseline to post-intervention and in comparison to the comparison group. Both treatment groups experienced improved changes in psychological inflexibility in relation to the comparison group, though the findings were not significant. Highly positive student evaluations and high course completion rates indicated that the mindfulness course was acceptable to both treatment groups and feasibly implemented in

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their school classrooms. Furthermore, the mindfulness skills were applied in various domains of their daily lives, and led to improved sense of well-being, reduced stress, management of difficult emotions, and improved interpersonal dynamics. The study's findings and clinical observations suggest that quality instructor training, teacher support for classroom behavior management, and class size may be important variables that impact the effectiveness of a mindfulness course for students. Future studies may be enticed by the qualitative results to more objectively explore the effects of a mindfulness course upon levels of stress, anger and aggression, overall quality of life in youth, and overall academic performance.

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TABLE OF CONTENTS

PAGE

ABSTRACT ............................................................................................................................. vi

LIST OF TABLES ................................................................................................................... xi

LIST OF FIGURES ................................................................................................................ xii

ACKNOWLEDGMENTS ..................................................................................................... xiii

CHAPTER

1 INTRODUCTION .........................................................................................................1

Purpose of Study ......................................................................................................2

Limitations of the Study...........................................................................................3

Organization of the Study ........................................................................................4

2 REVIEW OF THE LITERATURE ...............................................................................6

Adolescence and Mental Health ..............................................................................7

Mental Health Prevention and Early Intervention for Youth.................................10

Universal Prevention Programs .......................................................................12

Selective Preventive Intervention Programs ....................................................13

Indicated Preventive Intervention Programs ....................................................14

Applying Evidence-Based Practice in Review of Preventive Interventions ....................................................................................................16

Mindfulness-Based Interventions ..........................................................................16

What is Mindfulness? ......................................................................................17

Mindfulness: Practicing without Attachment to Outcome ...............................19

Historical Origins of Mindfulness Training .....................................................20

Mindfulness Instructors ...................................................................................21

Mindfulness-Based Stress Reduction (MBSR) ................................................23

Mindfulness-Based Cognitive Therapy (MBCT) ............................................24

How Mindfulness Skills Can Lead to Symptom Reduction and Behavior Change ..............................................................................................24

Exposure ....................................................................................................25

Cognitive Change.......................................................................................25

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Self-Management .......................................................................................26

Acceptance .................................................................................................26

Mindfulness with Adults: Results of Three Meta-Analyses ..................................27

Studies of Mindfulness with Children and Adolescents ........................................33

Mindfulness with Preschool Age Children ......................................................34

Mindfulness Training with Elementary Age Children .....................................36

Mindfulness Training with Middle School Age Youth ...................................39

Mindfulness Training with High School Age Youth .......................................43

Organizations Supporting Mindfulness Training for Youth in Schools and Other Settings.........................................................................................................47

Summary ................................................................................................................49

3 RESEARCH QUESTIONS AND HYPOTHESES .....................................................51

Supporting Evidence for Research Questions and Hypotheses .............................51

Research Questions and Hypotheses Presented .....................................................53

4 METHODOLOGY ......................................................................................................54

Design of the Investigation ....................................................................................54

Participants .............................................................................................................55

Mindfulness Course Instructor Experience and Training ......................................57

Measures ................................................................................................................57

Acceptance and Mindfulness ...........................................................................58

Psychological Inflexibility ...............................................................................58

Self-Compassion ..............................................................................................59

Demographics Questionnaire ...........................................................................60

Participant Evaluation and Questionnaire ........................................................60

Statistical Analyses ................................................................................................61

Limitations of the Methodology ............................................................................62

5 RESULTS ....................................................................................................................63

Participant Characteristics .....................................................................................63

Outcomes in Acceptance and Mindfulness, Psychological Inflexibility, and Self-Compassion .............................................................................................67

Participant Evaluation Questionnaire: Quantitative Results ..................................70

Qualitative Results for Participant Satisfaction and Applications of Mindfulness............................................................................................................72

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Participant Completion of the Course and Assessment Measures .........................77

6 SUMMARY, DISCUSSION, AND CONCLUSION ..................................................79

Summary of the Study ...........................................................................................79

Discussion of the Findings .....................................................................................81

Reliability of the Non-Equivalent Comparison Group ....................................81

Hypotheses One and Two ................................................................................82

Hypotheses Three and Four .............................................................................85

Hypothesis Five ...............................................................................................86

Hypothesis Six .................................................................................................87

Differences between TG1 and TG2 in Participant Evaluation Results............89

Implications for Practice ........................................................................................92

Recommendations for Further Research ................................................................94

Concluding Words .................................................................................................96

REFERENCES ........................................................................................................................98

APPENDIX

A LETTERS OF PERMISSION FROM TWO SCHOOL ADMINISTRATOR/FACULTY MEMBERS TO CONDUCT THE STUDY AT THEIR SCHOOL SITES .....................................................................................105

B LETTER OF COLLABORATION FROM THE MEDITATION INITIATIVE ......110

C INFORMED STUDENT ASSENT AND PARENT CONSENT FORMS ...............112

D COVER LETTER TO PARENTS .............................................................................118

E APPROVAL LETTER TO CONDUCT THE STUDY FROM THE INSTITUTIONAL REVIEW BOARD......................................................................120

F OVERVIEW OF MINDFULNESS COURSE: STRUCTURE, CURRICULUM CONTENT, AND INSTRUCTOR EXPERIENCE AND TRAINING ................................................................................................................123

G DEMOGRAPHICS QUESTIONNAIRE ...................................................................137

H PARTICIPANT EVALUATION QUESTIONNAIRE .............................................140

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LIST OF TABLES

PAGE

Table 1. Meta-Analyses of Mindfulness-Based Interventions with Adults .............................28

Table 2. Studies of Mindfulness-Based Interventions with Preschool and Elementary Age Youth ....................................................................................................................35

Table 3. Studies of Mindfulness-Based Interventions with Middle School Age Youth ..........40

Table 4. Studies of Mindfulness-Based Interventions with High School Age Youth .............44

Table 5. Participant Characteristics .........................................................................................64

Table 6. Age and Grades Received ..........................................................................................65

Table 7. Results for Three Scales ............................................................................................67

Table 8. Results for Participant Evaluation Questionnaire ......................................................70

Table 9. Themes and Results from Student Open-Ended Responses ......................................75

Table 10. TG2 Responses to Sentence Completion Participant Evaluations ...........................75

Table 11. TG2 Responses to Experiencing Past Eight Weeks .................................................76

Table 12. TG1 Responses to Sentence Completion Evaluations .............................................76

Table 13. TG1 Responses to Experiencing Past Eight Weeks .................................................76

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LIST OF FIGURES

PAGE

Figure 1. Results of children’s acceptance and mindfulness measure. ....................................68

Figure 2. Results of avoidance and fusion questionnaire for youth. ........................................69

Figure 3. Results for self-compassion scale for youth. ............................................................69

Figure 4. Graphs depicting TG2 student responses to selected questions from the participant evaluation questionnaire. ...........................................................................72

Figure 5. Graphs depicting TG1 responses to selected questions from the participant evaluation questionnaire. .............................................................................................73

Figure 6. Graphs of participant responses from both TG1 and TG2 to selected questions from the participant evaluation questionnaire. ............................................74

xiii

ACKNOWLEDGMENTS

While only one person’s name appears on the title page, the short truth of the matter

is that this entire research study and thesis would absolutely not have been possible without

the generous support and collaborative efforts from so many individuals. Many professors,

colleagues, and friends have contributed their time, energy, and caring attention into making

this project a reality. Thus, it is a success for everyone involved.

First, I would like to express my sincere gratitude for the opportunity to be mentored

in this project by Dr. Sally Mathiesen, my thesis committee chair. From day one, Dr.

Mathiesen has been an incredibly solid source of encouragement and guidance. She always

seemed to know just the right balance of support to offer me; this included guiding my

direction while at the same time allowing as much space and freedom for my own creativity,

inspiration, and experience to ultimately define the project in ways that felt right for me. I

have appreciated her faith in my capacity to lead the project regarding its overall structure,

timelines, and content. I could always count on Dr. Mathiesen to brainstorm ideas with me,

problem solve certain dilemmas, or offer strong motivating words when I needed it; however,

I always felt that the project was securely held and positioned in my own two hands. Despite

living, teaching, and conducting her own research abroad, it still felt like Dr. Mathiesen was

right down the social work department hall, as she was so reliably responsive and sensitive to

my questions, celebrations, and struggles, whether academic or personally related.

I would like to wholeheartedly thank Mr. Jeff Zlotnik, founder and executive director

of The Meditation Initiative, and also my good friend. Without Jeff, this research project with

youth from schools in San Diego simply would not have been possible. Jeff’s passion and life

dedication to providing free meditation classes to children and adults of all ages in San Diego

County is remarkable, and an inspiration to me. The first time I met Jeff was at a student

meditation group at San Diego State University, and we clicked instantly. I was impressed by

Jeff’s vision and his capacity to accomplish his goals of offering free meditation classes to so

many young students, vulnerable populations, and other interested adults. Jeff recognized my

capacity to work with young people using mindfulness and meditation skills, and the rest was

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history. I felt most honored and appreciative when Jeff extended his trust to me and invited

me into some very special relationships he had formed with school administrators, classroom

teachers, and ultimately the students themselves. This allowed me the wonderful opportunity

to work with the middle school students in their natural environments and be supported by

the school systems. I have learned so much from Jeff about how to build relationships with

school personnel based on trust and a mutual desire to serve the profound needs of our youth.

I would like to express my deep appreciation to Mr. Doug Harrell, principal of King-

Chavez Preparatory Academy, and to Dana Harwood, the 7-8th grade teacher at Monarch

School. Mr. Harrell and Ms. Harwood are both huge inspirations to me because of their

undying commitment to serving youth, especially those with underprivileged backgrounds. I

have watched them creatively implement so many possibilities for their students to learn,

become inspired, know themselves better, and to see the greater potential in themselves and

in life. I felt honored to receive their wholehearted support, and I thank them deeply for

extending their trust and confidence in me to working with their students. I am happy that we

were able to collaborate together to offer the students yet another pathway toward developing

their own inner strengths and resiliency.

I owe a huge thank you to Dr. Segars, for offering so much of his time, patience, and

skill in teaching me many of the ins and outs of SPSS data analysis. I really appreciated his

coaching style of “minimal handholding”, as I gradually learned how to turn a messy heap of

information into a workable and satisfying set of data, and joyfully run the analyses by

myself. It was especially heartening for me to receive Dr. Segars help, as I know that he does

this out of his own interest and passion to empower students through skills of social work

research. All of our work together was on his own time, outside the bounds of his formal job

expectations – this spirit of generosity is often the most precious gift that we students receive.

I would like to thank my two other committee members, Dr. Unsworth and Dr. Ko for

contributing to an all-star thesis committee team, and for supporting me when I needed and

asked for their help. I have appreciated their candid and insightful feedback and suggestions,

support for the Student Research Symposiums, dedication to my continued learning and

growth, and dedication to their own endeavors of teaching, research, and personal growth

which has been a model for me and for all of their students. It makes a huge difference for us.

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I am most thankful to my parents for offering unfailing support during both happy

and healthy times as well as times that I have been sick and needed their support, patience,

and a place of refuge to heal. I am thankful for their extra pairs of eyes on my continued

progress the last few years; for frequently offering encouraging words by letter or phone

messages; for always leaving your home open to me, especially when I needed to retreat and

write the final chapters in solitude; and for the sincere interest in my education they have

shown throughout my life. Dad, thank you for your continuous offers to help edit my sloppy

English, and I’ll continue to take advantage of this gift of yours in upcoming and future

manuscripts. And Mom, thank you for the steady source of nourishment from your delicious

meals during my writing-at-home retreats, for your thoughtful care packages, and for your

caring attention in my life.

I would like to offer a huge heartfelt thank you to my teacher and all of the Brothers,

Sisters, and many lay friends from Deer Park Monastery and Plum Village who were my

original teachers and sources of inspiration in sharing mindfulness practice with the young

ones. They have taught through their own living examples of how to be in joyfully in touch

with the child or teenager within themselves first. Then, they naturally were able to show the

children and adolescents how to cultivate peace, solidity, and freshness within themselves,

how to be a refuge for themselves and their family; how to develop compassion and

understanding for plants, animals, and others humans; how to communicate and get along

better with siblings and parents; how to enjoy just being together with friends and family;

and most importantly, how to learn mindfulness while having lots of fun, games, and songs

together.

And lastly, I thank the many students who I have been fortunate enough to meet,

share the practice and learn from. I have admired their openness and courage to try out the

mindfulness techniques that were initially completely foreign to them and the culture in

which they were raised. I have appreciated their authentic expressions of desiring more

peace, less stress, and less conflict in their lives, related to school, family, or friends. And

most of all, I have appreciated the honestly of their expressions, despite what others may

think (including myself) about what they like or dislike, what helps and what does not, and

what is actually relevant and applicable to their lives and what would never work. Their

unhidden truths have been and will continue to be my best teacher.

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CHAPTER 1

INTRODUCTION

In recent years, researchers have emphasized a greater need to explore the potential of

prevention programs to strengthen the emotional well-being of children and adolescents and

insulate them from the high rates of mental and emotional health problems that are currently

prevalent in our society (Roe-Sepowitz & Thyer, 2004). Mindfulness-based interventions

with adults have proven effective not only to improve psychological functioning with clinical

populations, but also as an effective intervention to reduce stress and enhance well-being

with healthy participants (Baer, 2003; Chiessa and Serretti, 2009). While the research base of

mindfulness-based interventions with children and adolescents is still just emerging, these

programs are becoming increasingly popular and used in various settings with youth. So what

is mindfulness and why is it helpful for children? Put simply, mindfulness is learning to pay

attention to what is happening here and now, with kindness and curiosity. Most youth can

benefit greatly from learning to enhance their attention skills, to observe before reacting, and

to become more kind and compassionate towards themselves and others. If youth learn how

to cultivate a sense of ease and peace, and to access their inner wisdom and intuition, they

may be less vulnerable to negative peer influences, or less likely to escape their difficulties

with high risk behaviors. If youth can develop familiarity and attunement with their

fluctuating ranges of thoughts, feelings, and bodily sensations, they may be less susceptible

to unhealthy effects of emotional stress (Saltzman, 2008). The capacity to cultivate one's

awareness in this way and apply it in different realms of daily life may reduce daily stressors

and improve their abilities to focus on activities which are meaningful and nourishing for

them. Schools are logical settings to provide mindfulness programs to youth. Not only do

youth spend the majority of their waking hours at there, but schools have a vested interest in

strengthening the attention skills of students: evidence shows that stronger attention skills

leads to reduced stress, improved learning, and improved academic success (Napoli, Krech,

& Holley, 2005; Saltzman & Goldin, 2008). With the growing popularity and use of

mindfulness programs with youth, research in this field is needed to help schools and child

2

related professionals more accurately understand in what domains and with what populations

that these programs are helpful. Furthermore, school systems and related professionals need

to understand how these interventions can be implemented with quality to help youth in their

personal and academic goals. This study explores the application of a mindfulness program

with two populations of middle school students: those attending a traditional middle school

in a low-income, inner-city neighborhood, and those attending a school which serves

homeless youth. To gather data for the study, the investigator collaborated with two schools

and a non-profit organization, The Meditation Initiative, which provides free mindfulness

classes to local schools and other institutions.

PURPOSE OF STUDY The purpose of this study was to evaluate the feasibility, acceptability, and

effectiveness of a mindfulness course with middle school students in a classroom setting.

Research in mindfulness-based interventions has already demonstrated feasibility and

acceptability with children and adolescent populations, with encouraging results in measures

of cognitive and emotional well-being, and externalizing behaviors. However, there has been

little empirical evidence for mindfulness courses in a classroom setting. To the author's

knowledge, no studies have assessed a strictly mindfulness course with middle school

students in a classroom setting. This study contributes to the base of empirical evidence of

mindfulness based approaches with youth, assessing benefits with non-clinical adolescent

students (grades 7-8; ages 12-14) in a classroom environment. The study assessed student

reported changes from pre- to post-intervention in measures of mindfulness, psychological

inflexibility, and self-compassion.

It is also important that researchers understand the benefits and effects of mindfulness

courses with specific populations of children and adolescents. To the author's current

knowledge, no studies had assessed the effects of a mindfulness course for a population of

youth living in a homeless shelter. A second purpose of this study is to determine the

feasibility, acceptability, and usefulness of a mindfulness course with a sample of this under-

privileged population. In “The Practitioner's Guide to Acceptance and Mindfulness

Treatments for Children and Adolescents”, O'Brien, Larson, and Murrell (2008) state that “an

issue to address in the future is whether there are populations for whom acceptance and

3

mindfulness procedures work better than others. The only way to answer this question is

through a series of carefully designed studies that identify important clinical processes and

outcome variables” (p. 30). This study's research design is only moderately rigorous, but

more importantly, it takes the next step as an exploratory study to better assess the

implementation of mindfulness training with this population of youth.

The two school sites chosen for this study, several other schools in San Diego, as well

as dozens of other K-12 schools and community-based centres in the country are

implementing courses which teach students the skills of mindfulness (Garrison Institute

Report, 2005). It is important for the field to examine in what ways mindfulness courses may

benefit students, and in what ways it does not. Studies must be conducted within classrooms,

and not only in clinical settings, to understand its effectiveness when implemented in the

children or adolescent's natural environment. The study aims to validate some of the positive

preliminary anecdotal findings and empirical results of mindfulness courses in educational

settings, and to extend the evidence base by assessing this new population of students. The

study's findings may be helpful to both educators and other professionals who are interested

in or already providing mindfulness courses to youth, so they may better understand the

effectiveness for students and factors related to quality implementation.

LIMITATIONS OF THE STUDY Prior to analyzing results of the study, the investigator was aware of several

limitations that pose threats to the study's internal validity and prevent generalizing the

study's findings. This includes the small sample size, diluting effects of the treatment groups,

and use of a non-equivalent comparison group design instead of a true experiment with

random assignment. The study's sample was limited to participating students from four

classrooms of two schools. Although the total sample included 76 students, treatment group

one (TG1) had only 38 participants, treatment group two (TG2) was composed of eighteen

participants, and the comparison group (CG) had 20 participants. Due to expected drop-outs

or non-completed assessment forms during treatment, the sample size was further reduced by

the end of the study. In a chapter on research methods, Lunenburg and Irby (2008) offer

broad guidelines for sample sizes, indicating that for experimental or causal-comparative

research, it is appropriate to use at least 30 participants. Therefore, this study's sample size is

4

minimally adequate for TG1 and questionable for TG2. Furthermore, the findings of the

study cannot be generalized, as the small sample is not representative of the population of

youth in the region.

A second limitation is that the mindfulness course included students participating in

the data collection with those with those not participating. In other words, the treatment

groups were mixed with non-participating students in each mindfulness session. The amount

of individual attention and support given to students by the instructor is important for

engaging in the exercises and learning to apply them in daily life, an aspect recognized in

other studies of mindfulness programs (Lee, 2006). The amount of instructor support offered

to students not participating in the study most likely diluted the effectiveness of treatment to

participants. This is further explained in the discussion section as it applies to different

outcomes between the treatment groups as well.

The study's research design has inherent limitations as well. This study uses a two-

group pretest-posttest design using an untreated non-equivalent comparison group. While

some threats to internal validity are minimized due to the comparison group, the groups are

still not equivalent, as randomized assignment to group was not possible. The threat of

selection bias well as different environmental factors affecting assessments still remain

(Lunenburg & Irby, 2008). For example, the class of participants not receiving treatment may

experience environmental factors (testing on different days, different teacher influences)

which are exclusive to their class and impact assessment outcomes. Furthermore, TG2 is at a

different school and experienced a later data collection period than TG1 and the CG.

Therefore, TG2 experienced altogether different schoolwide environmental factors than the

CG which further compromises the reliability of comparisons. The issues are further

discussed in the discussion section, as they relate to the study's findings.

ORGANIZATION OF THE STUDY This thesis is presented in six chapters. Chapter 1 began with the background of the

study, followed by purpose of the study, and limitations of the study. Definitions of technical

terms used in the thesis have been provided in the relevant chapters. Similarly, the theoretical

underpinnings of mindfulness-based interventions are presented in detail in Chapter 2.

5

Chapter 2 offers a review of the literature in the field of mindfulness-based

interventions and contains sections on adolescence and mental health, mental health

prevention and early intervention for youth, mindfulness-based interventions, how

mindfulness skills lead to symptom reduction and behavior change, results of three meta-

analyses, studies of mindfulness with children and adolescents, and organizations supporting

mindfulness training for youth. Chapter 3 follows the literature review by showing

supportive evidence for posing specific research questions and hypotheses which serve as a

foundation for the research study’s direction and purpose.

Chapter 4 explains the methodology used for the research study, including the

intervention design, participants recruited in the study, measures, methodological limitations,

and statistical analysis. Chapter 5 leads into the results of the study, and describes the

participant characteristics, outcomes of the three scales, quantitative and qualitative results of

the participant evaluation questionnaire, and participant completion of the course and

assessment measures.

Lastly, Chapter 6 present a summary of the study, which leads into a discussion of the

findings, followed by implications for practice, recommendations for future research, and

some concluding words.

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CHAPTER 2

REVIEW OF THE LITERATURE

This chapter provides the rationale for conducting a study to assess the feasibility,

acceptability, and beneficence of a mindfulness course with middle school students and with

youth facing homelessness. As children and adolescents face serious emotional and mental

health challenges in our society, prevention programs are increasingly needed to minimize

risk factors and increase strengths in youth. Mindfulness-based interventions are being

increasingly recognized as effective treatments to enhance psychological functioning and

well-being in both healthy and clinical populations of adults. A review of studies evaluating

applications of mindfulness with children and adolescents reveals that although the evidence

base is small, there are promising findings for effectiveness with younger populations. The

literature shows that studies have generally demonstrated treatment acceptability and

feasibility with certain populations of youth, and improvements in different measures of

cognitive and emotional well-being, however further studies need to replicate these findings

and demonstrate their effectiveness with different populations and in relevant settings. My

study aimed to build upon this past research by studying the effectiveness of a mindfulness

course with new populations of youth in their natural environment. While a few well-

designed studies have been used with elementary and high school age youth, no studies have

assessed a mindfulness course with middle school students in their school classroom, and no

studies have been conducted with homeless youth.

Chapter 2 is organized into five broad areas, each with individual sections. The

sections include: (a) adolescence and mental health, (b) mental health prevention and early

intervention for children and adolescents, (c) mindfulness-based interventions,

(d) mindfulness with adults: results of three meta-analyses, and (e) studies of mindfulness

with children and adolescents.

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ADOLESCENCE AND MENTAL HEALTH Adolescence is defined as a time which begins around 10 to 12 years old and ends

around 18 or 19 years old (Roe-Sepowitz & Thyer, 2004). The period of adolescence can be

challenging for both teens and their parents. Some of the main forces which shape the

behavior and thoughts of adolescents include peer acceptance, accepting and becoming

comfortable with physical changes in their bodies and appearance, family issues, school

environment, and making choices about their future. Adolescents experience significant

changes in their lives due to increased hormones, vacillating energy levels, physical growth

spurts, labile mood states, and relationships among peer groups become a priority. During

this period of extreme changes, the risks of developing socioemotional or mental health

problems should not be overlooked. Mental health issues can manifest in various ways, but

all impact an adolescent’s ability to meet the challenges of his or her life and successfully

mature to young adulthood.

The Surgeon General of the United States defines mental health as the “successful

performance of mental function, resulting in productive activities, fulfilling relationships

with other people, and the ability to adapt to change, and cope with adversity” (Surgeon

General’s Report on Mental Health, 1999, p. vii). Mental health problems include

disturbances in thinking, behavior, and temperament, with accompanying dysfunction or

impairments in psychological, social, and educational functioning. Mental health problems

for adolescents can lead to school failure, poor peer and family relationships, and in extreme

circumstances, suicide or homicide (Roe-Sepowitz & Thyer, 2004). Therefore, it is important

for schools, families, and mental health professionals to understand the risk factors of mental

health problems in adolescence and to support the development of effective treatment and

prevention programs.

Adolescents face enormous risks for mental health as many youth participate in high-

risk behaviors or are living in conditions which harm their full potential for development.

High-risk behaviors include activities that may bring about negative psychological, social,

and physical health effects. Besides high-risk activities and adverse living conditions,

adolescent mental health can also be affected by clinical dysfunctions. This refers to

emotional and behavioral problems that inhibit normal functioning on a daily basis (Kazdin,

1993).

8

Lifetime prevalence (LP) rates for children and adolescents with mood disorders is

high and demonstrate that mental health problems for youth are far from rare in the U.S..

Studies reveal that mental health problems for adolescents grew steadily in the 1990s. This

may have been due to more accurate reporting measures or to more significant risk factors

for youth such as homelessness or parental drug problems. In 1994, the National Health

Interview Survey on Disability showed that 12.9% or 529,000 children in the U.S. have a

reported mental/emotional problem, and roughly 1 in 10, as many as 6 million youth are

challenged with a serious emotional disturbance (Surgeon General’s Report on Mental

Health, 1999). Compared to the 1994, more recent studies suggest an upward trend in mental

problems for youth, though this may be accounted for by age differences of youth in the

survey. The Center for Disease Control and Prevention offers 12 month prevalence rates for

8 to 15-year-olds in 2001. In this age group, 13.1% of U.S. children experience any mental

disorder in one year's time. Attention Deficit Hyperactivity Disorder (ADHD) is the most

frequently occurring disorder, affecting 8.6% of youth. Next was general mood disorders at

3.7%, and more specifically, major depressive disorder at 2.7%. The CDC surveys found that

dysthymia affects 1% of youth per year, with anxiety disorders affecting 0.7% (Merikangas,

He, Brody, et al., 2010). Studies can vary widely, however, in reporting prevalence rates. For

example, O'Hare (2005) states that prevalence rates for all childhood anxiety disorders range

between 1% and 3%, as indicated by a thorough review of epidemiological research. Fraser

(2006), on the other hand, cites studies that portray anxiety disorders as the most prevalent of

all mental health problems in children and adolescents, afflicting 8-10% of all youth in the

United States. Estimates of prevalence most likely vary based on methodological differences.

Merikangas, He, Burstein, and colleagues (2010) displayed their findings of LP rates

for mental disorders of a nationally representative sample of U.S. adolescents between 13-18

years old, a slightly older age group than previously discussed. At the turn of the 21st

century, almost half of this age group (46.3%) experienced a mental disorder in his or her

lifetime. Among those youth, more than 1 in 5 (21.4%) experienced a “severe”, or seriously

debilitating disorder in his/her lifetime. A severe disorder is characterized by having both

distress and impairment in one's life, and either higher thresholds of impairment in daily

activities, or severe distress. The authors break down the prevalence rates among different

categories of mental disorders. In 2001, over one quarter (25.1%) of youth in the U.S.

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between 13 and 18 years experience an anxiety disorder in his or her lifetime; among female

youth, the rate jumps to over 30%. Almost 6% of this age group experienced a “severe” case

of anxiety disorders in his/her life. For mood disorders, the LP is 14%, with females

experiencing 18.1% over males at 10.1%. The findings also reveal a steady increase in rates

of depression among age subgroups: 13-14 year olds had a 9.4% LP rate for mood disorders;

15-16 year olds had 15.3%, and 17-18 year olds had 19.2%. This steady incline suggests that

teenagers within each age group are experiencing mood disorders for the first time. Among

mood disorders, LP rates for major depression or dysthymia is 11.2% for 13-18 year olds.

The LP rate for Attention Deficit Hyperactivity Disorder (ADHD) is 9%, with males

experiencing almost 13%. The previous two studies found that 8 to 15 year olds experience

the highest 12 month prevalence rates for ADHD, followed by mood disorders, especially

major depression, and anxiety disorders (Merikangas, He, Brody, et al., 2010); however, LP

rates for 13 to 18 year olds are highest for anxiety, followed by mood disorders, and ADHD

(Merikangas, He, Burstein, et al., 2010). This possibly suggests that ADHD is more

frequently diagnosed in younger children, while anxiety disorders and to a lesser extent mood

disorders are more often recognized in early and later adolescence.

The CDC survey showed a compounding factor to these high rates of mental health

problems for youth, revealing that only half (50.6%) of adolescents (13-18) who have mental

disorders are receiving treatment, with females being 50% less likely than males to use these

services. Among youth with mental disorders, those with anxiety disorders are the least likely

to use mental health services, as 66.8% do not receive treatment for their disorder

(Merikangas, He, Brody, et al., 2010). The Surgeon General's Report on Mental Health

(1999) suggested slightly higher rates, that 70% of youth with a mental/emotional problem

do not receive mental health treatment. Mental health problems and lack of receiving

treatment are contributing factors to the high suicide rates among adolescents. Among 15 to

19 year olds in the United States, the rate for suicide is 10.3 per 100,000, or 0.01%. The

highest rates for suicide are between the ages of 15 and 19 years old, and studies have shown

that 14% of 15 year olds have attempted suicide at some point in their life (U.S. Congress,

Office of Technology Assessment, 1991). Helping adolescents to better cope and deal with

habitual stressors of adolescence may reduce the high risks that adolescents face which

increase the likelihood of attempting suicide (Kazdin, 1993). Prevention programs targeting

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youth can help to reduce the risk factors which increase stress, and to provide protective

buffers to mitigate the effects of such stress.

The lifetime prevalence rates for adolescents documented by Merikangas, He,

Burstein, et al. (2010) are similar to those for adults, which have been found using similar

research methods. This indicates that most mental disorders begin in childhood or

adolescence, rather than adulthood. The authors document the early onset of certain classes

of mental disorders: the median age of onset for adolescents affected by anxiety disorders is

6 years; for behavior disorders, the median age of onset is 11; age 13 likewise for mood

disorders, and age 15 for substance use disorders. The authors assert that this highlights the

need for more focus on prevention and early intervention services for children and youth,

rather than putting the majority of attention and resources on treatment for youth and adults.

Furthermore, the authors found that mood and substance use disorders increased significantly

in older adolescents, highlighting a need for prevention efforts during early and mid-

adolescence. In the same light, the steadiness of many anxiety and behavioral disorders

during adolescence suggest that preventive strategies in pre-adolescence or earlier may be

more effective for these disorders.

MENTAL HEALTH PREVENTION AND EARLY INTERVENTION FOR YOUTH

The field of preventing mental health problems has received greater support with the

increased awareness of school violence, breakdown in the family, and the growing numbers

of children who are diagnosed with mental health disorders. Mental health prevention

programs focus on minimizing the effects of risk factors (e.g. family stress, peer pressure)

and increasing social and emotional growth and development, in order to prevent mental

disorders or at least to minimize their effects on individuals. Prevention programs for

adolescent mental health issues have steadily increased in recent years; however, the

empirical support for such programs is still not strong (Roe-Sepowitz & Thyer, 2004).

Many of the different types of dysfunction experienced in adolescence, such as

attention-deficit disorder, conduct disorder, and depression, may bring about consequences

which continue throughout one’s lifetime. This continuity of dysfunctional behavior further

warrants the need for earlier intervention. Earlier treatment and prevention in childhood and

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adolescence may not only help youth with their current situations, but also offer preventative

benefits for early later adolescence and early adulthood (Kazdin, 1993). The case for

prevention and early intervention services grows even stronger in light of the prevalence of

youth with severe emotional and behavior disorders (one in every 4 to 5 youth) which

severely impair an adolescent's daily functioning (Merikangas, He, Burstein, et al., 2010).

This rate is higher than the most frequently occurring physical ailments in adolescents, such

as asthma or diabetes, although mental disorders do not receive nearly the degree of national

health attention. Current estimates of the yearly economic cost upon American youth and

their families total nearly 250 billion dollars per year. These findings reveal that mental

health in America is no longer simply an individual or familial concern, but a national public

health issue. More research is necessary to examine the risk factors for emerging mental

disorders in adolescence, and the predictive factors for whether they will continue or

extinguish as youth mature into adulthood (Merikangas, He, Burstein, et al., 2010). Just as

importantly, more research is needed to understand which protective factors can strengthen

adolescents to prevent the onset of mental issues or mitigate their effects during adolescence,

and what types of preventative programs can successfully foster these protective factors in

adolescents.

Youth from all background types are vulnerable to mental health problems, and some

factors can increase the risk. Rutter (1979) demonstrated that some of the factors which raise

the risk of psychiatric disorders in children include low economic status, marital discord,

placement of children into foster care, and overcrowding or large family size, among others.

Each of these aspects adds stress to an adolescent’s life, and has shown to increase the risk of

psychological, behavioral, and educational problems. When risk factors are minimized,

prevented, or altered, the chance that an adolescent will develop mental health problems is

reduced. However, few of the many risk factors which are possible in an adolescent’s life can

be completely eliminated. There will be a certain amount of risk factors present in the life of

any adolescent.

Social workers and school systems can address these risk factors through offering

prevention programs to embrace and transform their negative effects. Programs for

adolescent mental health problems can be created for general populations, specific risk

groups, as well as for certain groups of youth who reveal early signs and symptoms of poor

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mental health (Roe-Sepowitz & Thyer, 2004). The author will describe different categories of

prevention programs, and will briefly review the literature and evidence base of prevention

programs designed for adolescent populations. This overview is broadly guided by the

research review of prevention programs conducted by Roe-Sepowitz & Thyer (2004).

Universal Prevention Programs The aim of universal prevention programs is to broaden and strengthen the protective

factors that defend against risk factors in an entire population, such as a school or

community. The development of many protective factors such as acquiring skills on how to

be assertive, or managing feelings of anger can be helpful for the entire population of teens.

Two types of universal prevention programs discussed here focus on social-cognitive skill-

building, and violence/ victimization and anger prevention (Roe-Sepowitz & Thyer, 2004).

These programs meet the standards of the American Psychological Association’s Division 12

(Clinical Psychology) Task Force on Promotion and Dissemination of Psychological

Procedures, as to whether an intervention is designated as well-established in effectiveness.

This calls for a minimum of two well-designed between-group experiments that demonstrate

the intervention's effectiveness (Division 12 Task Force, 1995).

Responding in Peaceful and Positive Ways (RIPP) focuses on social and cognitive

skills to empower youth in nonviolent conflict resolution and increase positive

communication. The model is based on learning theory, with programs typically lasting 25

sessions (Greenberg, Domitrovich, & Bumbarger, 2001). Students learn to employ anger

management skills and self-evaluation strategies that they can use in their daily life. It

includes exercises such as role playing, identifying feelings, peer mediation, working with

prejudices, team building, and relaxation techniques. The main steps involve stopping,

calming down, recognizing the problem and feelings around the situation, choosing among

nonviolent opportunities, acting based on best choices, looking back, and then evaluating

what happened (Farrell, Meyer, & White, 2001). Results of the RIPP program show that

students had less violence-related injuries, positive changes in self-esteem, and greater peer

mediation for resolving disputes. The treatment group of students also had less behavioral

problems and suspension than the control group (Roe-Sepowitz & Thyer, 2004).

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The Bullying Prevention Program has the goal of reducing and preventing bullying

and victimization in both elementary and middle school environments. The school staff is

able to implement and offer the program to the entire student population in a school.

Classroom interventions establish rules and guidelines to stop and prevent bullying behavior,

and individual interventions can include discussions with students who bully, victims, and

their parents. In one study by Olweus (1989), bullying and victimization rates dropped by

more than half, four months after the program was initiated in the school. Others studies

reported that the program improved social climates in the participating classrooms and

schools. The student participants reported that they had better attitudes toward school and

schoolwork, had more wholesome relationships, and were more disciplined at school (Roe-

Sepowitz & Thyer, 2004).

Selective Preventive Intervention Programs Selective preventive intervention programs are tailored for individuals who have

higher risks for developing emotional and behavioral problems, whether due to biological or

environmental risk factors. Programs are developed to improve coping skills and integrate

supportive elements of an individual’s life in order to prevent mental health problems from

occurring. Positive Adolescent Choices Training (PACT) is a selective preventive

intervention program designed to reduce aggression in youth, ages 12-18. It focuses on

developing their social adjustment skills, enhancing communication skills, and learning anger

management techniques. The program was designed for at-risk students, and tries to reduce

the chances that they become victimized or initiate violence. Classroom teachers select the

student participants based on their levels of poor social skills, aggressive behaviors, and

history of violent behavior. The intervention is provided in groups of 10 members at most.

Two quasi-experimental studies by Hammond and Yung (1991) and Hammond and Yung

(1993) found that students reported improvements in social skills, negotiation skills,

problem-solving and communication skills, improved anger management, as well as less

aggressive and violent behavior (Roe-Sepowitz & Thyer, 2004).

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Indicated Preventive Intervention Programs Indicated preventive interventions target high-risk youth who have signs or symptoms

of a mental health problem or who have a biological predisposition which makes them more

likely to develop a mental disorder, but who do not meet the DSM criteria for a disorder.

Depression and anxiety are two mental health issues which will be addressed by this section

of indicated preventive interventions. Two such programs for adolescent depression which

also meet the task forces' criteria for effective and well established evidence-based practices

include Coping with Stress (CWS) and the Penn Prevention Program (PPP).

The CWS course was created by Clarke, Lewinsohn, and Hops (1990) to help

adolescents with high levels of depressive symptoms. Teens learn to cultivate adaptive

coping skills during the course of 15 group sessions of 45 minutes each. Using group

exercises, role playing, and cartoons, the adolescents learn cognitive restructuring techniques

to recognize and transform negative thought patterns. School psychologists or school

counselors are trained to offer the group courses, usually in after school programs. In a

randomized clinical trial, Clarke et al. (1995) discovered that at 12 month follow-up

assessment, teens in the treatment group had significantly less incidences of major depressive

disorder or dysthymia than the control group.

The Penn Prevention Program has the goal of transforming cognitive distortions and

enhancing coping strategies for teens that show risk of developing depression. Participants

reported high levels of family conflict, and also high levels of depressive symptoms. Over the

course of twelve 90-minute sessions, participants learn new problems solving skills and

coping strategies, including problem interpretation. The group course is facilitated through

direct instruction and homework activities. Results of a quasi-experimental study showed that

participants in the PPP treatment group had decreased levels of depressive symptoms at post-

treatment and at a 6 month follow-up assessment (Jaycox, Reivich, Gillham, & Seligman,

1994).

Anxiety disorders are mental health problems including generalized anxiety,

separation anxiety, panic disorder, agoraphobia, and social phobia, among others.

Adolescents suffering from anxiety can experience hindered cognitive and social functioning.

Risk factors for anxiety disorders in adolescents can include poor coping mechanisms,

parents' negative behavior, and negative life events, among others (Roe-Sepowitz & Thyer,

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2004). Stress Inoculation Training (SIT) is a school-based preventive program which helps

students to manage and decrease difficult emotions, including anxiety, and other stress-

induced difficulties in youth (Hains, 1992). SIT also meets the Division 12 Task Force’s

standards for effective evidence-based practices (Division 12 Task Force, 1995). Over the

course of 13 sessions, students participate in progressive muscle relaxation techniques,

assertiveness training, and use a stress diary. These activities are used to teach cognitive

restructuring, anxiety coping skills, and problem-solving strategies. In the study by Hains,

15- to 17-year-old males showed reduced levels of anxiety symptoms after completing the

program. Karpe, Kumaraiah, Mishra, and Sheshadri (1994) conducted another study in which

adolescent boys ages 13 to 16 experienced a large drop in number of angry outbursts and

levels of stress. Kiselica, Baker, Thomas, and Reedy (1994) used SIT with 9th grade male

and female students. Compared to the control group, the participants receiving SIT had

significantly better outcomes for anxiety and stress-related symptoms at post test and 4 week

follow-up. The results indicate that SIT may be an effective preventive intervention for

anxiety management and psycho-social adjustment techniques for adolescents.

The Queensland Early Intervention and Prevention of Anxiety Project (QEIPAP) is

another school based program, designed to prevent the development of anxiety problems in

youth ages 7 to 14. It combines pscyhoeducational training with cognitive-behavioral

exercises in both child and family-based group interventions. The program teaches students

how to use different coping strategies (e.g. cognitive, behavioral, and psychological), in the

midst of stressful or anxiety-arousing circumstances. In a randomized control trial,

researchers found that the treatment program students displayed reduced rates of anxiety, and

fewer symptoms than those in the control group (Dadds, Spence, Holland, Barrett, &

Laurens, 1997). In a two-year follow-up, Dadds et al. (1999) found that students in the

treatment group continued to experience lower levels of anxiety than those in the control

group. Although the QEIPAP program has only been empirically evaluated in this one study,

the study design was so rigorous and the study done so well that the program was included as

a promising preventive intervention for adolescent anxiety problems in the review of

prevention programs by Roe-Sepowitz & Thyer (2004).

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Applying Evidence-Based Practice in Review of Preventive Interventions

In the field of psychosocial preventive interventions, there are relatively few

programs that meet the standards of being “evidence-based” or “established” treatments.

However, evidence-based practice does not imply selecting interventions that are only

supported by multiple randomized control trials (Roe-Sepowitz & Thyer, 2004). Evidence-

based practice is a process by which human service practitioners can track down and

critically evaluate the best available clinical evidence to answer a specific question related to

service delivery. Then it is necessary for practitioners to integrate their appraisal of the

research evidence with their own clinical expertise and the circumstances of their clients in

order to select the best intervention for one’s client (Thyer, 2004). For a certain area of

practice, there may be only a few quasi-experimental studies with a limited number of

subjects, or even single subject research studies, which are available as evidence. But even

these can provide valuable preliminary insights as to what may work best in strengthening

the mental and emotional health of an adolescent, depending on the youth's background,

culture, needs, as well as the circumstances of the problem at hand. Adolescent mental health

professionals should be knowledgeable about the range of treatment services available such

as the ones previously described, as well as other psychosocial prevention programs which

have some level of empirical support (Roe-Sepowitz & Thyer, 2004). Applying and

evaluating the success of prevention programs that have already been tested is the final step

of evidence-based practice, as this continuously builds the empirical base and knowledge of

what works, what does not, and in what situations. Continuously testing these preventive

intervention approaches and applying them based on what is shown to be effective is a more

ethical approach to serving the mental health needs of adolescents than relying on sources

based on tradition, authority, or easy availability (Roe-Sepowitz & Thyer, 2004; Thyer,

2004).

MINDFULNESS-BASED INTERVENTIONS The following sections attempt to present a thorough description and understanding

of what are mindfulness-based interventions. This includes the conceptual definitions and

explanations of mindfulness practice, the essential aims of mindfulness practice, historical

17

origins, key concepts related to mindfulness instructors, and an explanation of the two main

interventions based on mindfulness.

What is Mindfulness? “Many of us wish we had learned Mindfulness when we were younger, and want to offer these skills to children well before they begin suffering from the stresses of daily life, or are diagnosed with a serious mental or physical illness... So let's do what we can now to immunize our children against the stresses of modern life, and the related diagnoses, and give them the skills that will benefit them throughout their lives” (Saltzman, 2008, p. 15).

Many authors and teachers of mindfulness-based interventions assert that mindfulness

practice can be helpful for both those who have acute illnesses and stress-related difficulties,

as well as for healthy participants. With its applicability to individuals with a broad range of

levels of health and well-being, it may be seen as both a prevention and treatment program.

Jon Kabat-Zinn (2003), an initiator of empirically testing mindfulness based applications,

offers an operational working definition of mindfulness as “the awareness that emerges

through paying attention on purpose, in the present moment, and nonjudgmentally to the

unfolding of experience moment by moment” (p.145). From the point of view of mindfulness

interventions with children and adolescents, Thompson and Gauntlett-Gilbert (2008) describe

the intentions of mindfulness practice in their clinical review:

“When individuals deliberately stay in the present moment, they can respond to current events with a full awareness of their automatic tendencies, but can make choices that are not necessarily constrained by these. A greater non-judgmental awareness of one’s own impulses and thought patterns should result in a decreased emotional reactivity and vulnerability” (p. 396).

The literature suggests that mindfulness skills can be developed through a vast array of

meditation exercises. This can include attending to internal experiences in each moment,

such as bodily sensations, emotions, or mental formations; it also includes attention to

sensations coming from the external environment, such as through sight and sound. Whether

attending to internal or external phenomena, the essence of mindfulness is observing through

nonjudgmental awareness and acceptance. Awareness of bodily sensations, emotions, or

thoughts are simply recognized and not evaluated as “good or bad, true or false, healthy or

sick, or trivial or important” (Baer, 2003, p. 125). Through mere recognition and acceptance

18

of thoughts and feelings, the practitioner may more deeply understand and embrace the

impermanent and selfless nature of such internal or external phenomena.

While this description of mindfulness practice may seem simple and mundane, some

of the renowned mindfulness meditation teachers emphasize the empowering qualities of

mindfulness. Nhat Hanh (1973) states that mindfulness helps one focus attention on and

know what one is doing. He states that usually, “Our energies are dispersed here and there.

Our body and our mind are not in harmony... When the lamp of awareness is lit, our whole

being lights up, and each passing thought and emotion is also lit up. Self-confidence is

reestablished, the shadows of illusion no longer overwhelm us, and our concentration

develops to its fullest” (p.26). Mindfulness can be taken into every day life. One can do the

same daily activities as before – washing dishes, putting on clothes, sweeping – but with

mindfulness, one is truly aware one's thoughts, speech, and actions. Nhat Hanh explains that

a daily practice of mindfulness can shine light of attention on the objects of one's attention,

including daily activities. Over time, mindfulness will steadily grow stronger to produce the

capacity of deeper concentration; this in turn may develop into personal insights. Kabat-Zinn

(2003) adds that mindfulness is also referred to as “insight” meditation, which is a “deep,

penetrative nonconceptual seeing into the nature of mind and world” (p. 146). This insight

requires diligent and persistent inquiry into life phenomena.

In understanding mindfulness meditation, it is helpful to explore the use of the words

“meditation” and “practice”, as both are often used in the mindfulness programs and

meditative traditions. Whereas mindfulness involves paying attention to life in the present

moment in a nonjudgmental way, mediation is more broadly conceptualized as “a family of

complex emotional and attentional regulatory strategies developed for various ends,

including the cultivation of well-being and emotional balance” (Lutz, Slagter, Dunne, &

Davidson, 2008). Mindfulness can therefore be understood as either a certain form or a

foundational component of meditation. The “practice” of meditation or mindfulness refers to

the actual involvement and participation in the techniques. It does not refer to the meaning of

“rehearsal”, for some later time. The “practice” and the “performance” are one and the same

as they unfold in the present moment (Kabat-Zinn, 2003).

Mindfulness practice can take many forms along a spectrum: from formal practices

that can be done for varying lengths of time and with regularity, to informal practices that

19

attempt to cultivate awareness spontaneously in all aspects of daily living. Despite the

structured form of many exercises, mindfulness meditation is confined to the mechanics of

particular techniques. While these formal practices may be important and essential, they are

also merely stepping stones and tools to cultivate attention in specific ways – the structured

practices are not the end-goals in themselves.

Mindfulness: Practicing without Attachment to Outcome

From the very beginning, those learning mindfulness practice are reminded that the

practice is not about arriving at a fixed destination, solving one's problems, or fixing

something. Rather, the intention of practice is to allow oneself to be present just as one is in

the very present moment, and to be aware of what is going on within and around oneself. As

a practitioner learns to wake up more fully to his vast range of internal and external

experiences, he may discover that reality is often distorted by habitual reactions of thoughts,

feelings, and perceptions that go unexamined (Kabat-Zinn, 2003). Thus, there is inherent

paradox in mindfulness practice. One begins mindfulness practice in order to be free of, or at

least to minimize one's suffering and pain, whether emotional or physical. But the practice

invites one to be wholeheartedly present to that which is already there, and to release the

frequent urge to avoid, get rid of, or change the unpleasant sensations that are present. It is at

this moment, when one accepts and allows space for such sensations to occur without trying

to avoid one's experience of them, when transformation can occur. The resistance to pain and

the range of aversive thoughts and feelings towards the sensations themselves can begin to

diminish, thus inviting a more loving embrace for what one is actually experiencing and

feeling in the moment.

Kabat-Zinn (2003) describes the challenges of teaching the practice to patients at the

Stress Reduction Clinic, advising them to momentarily let go of their expectations and

wishes of participating in the program and whatever reason they initially came for. He invites

them to drop their desires to relax in deep relaxation, to drop their desire to feel better, and to

just sink in to their actual experiences in the present moment as best as they can in each

continuing moment. This capacity to sink in to each moment develops and deepens over

time, provided that it is nurtured by an ongoing commitment and diligent efforts to practicing

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in each and any moment. The paradox of successfully embodying and mastering mindfulness

practice is the sustained effort of a lifetime, and also of no time at all, as the practice pertains

only to engaging life in the present moment, in its simplicity and fullness. This paradox or

koan may be grasped through delving into the practice in each moment, for days, months,

and even years.

Historical Origins of Mindfulness Training Historically, mindfulness has been known as the heart of Buddhist meditation, and is

a core element of the Buddha's comprehensive set of teachings. His set of teachings is

referred to as dharma, which has multiple translations, such as lawfulness as in “the laws of

physics” or in Chinese notions, “the way things are”. Kabat-Zinn (2003) shares that dharma

is a sort of “universal generative grammar, an innate set of empirically testable rules that

govern and describe the generation of the inward, first-person experiences of suffering and

happiness in human beings. In that sense, dharma is, at its core, truly universal, not Buddhist”

(p. 145). Dharma is not an ideology, belief system, nor a philosophy, but rather, a

comprehensible and phenomenological outline of the workings of the mind, the suffering that

arises from the mind and its potential dissipation. It is based on highly attuned and refined

practices designed to cultivate wholesome activities in the mind and heart through mindful

awareness. Kabat-Zinn (2003) notes that in Asian languages, the words for mind and heart

are the same – therefore “mindfulness” is not merely a cognitive exercise, but includes

qualities of affection, compassion, and a spirit of openheartedness and friendly presence.

On the one hand, mindfulness is simply about being attentive, which is a universal

quality and necessity in human life; thus, it is not particular to Buddhism per se. As a natural

human faculty, everyone is mindful to a greater or lesser extent. Buddhist traditions,

however, have cultivated methods to effectively refine this capacity of attention and use it

beneficially in the areas of one's life. While Buddhist lineages have systematically developed

and articulated methods of cultivating mindfulness over the past 2500 years, other ancient

and modern spiritual traditions also engage mindfulness at the heart of their practice, which

can also offer valuable methods for training the mind. In the various Buddhist traditions in

the world, the practice of mindfulness is always integrated into a broader practice-oriented

ethical framework which guides the practitioner towards compassion, or non-harming. This

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ethical and conceptual framework contains a skillful understanding of how unexamined

thoughts and actions can cause or contribute to the suffering of oneself and others. The

Buddhist view also includes a path towards the transformation of that suffering through

consistent meditative practices to calm and concentrate the mind, free the heart, and clarify

attention and action (Kabat-Zinn, 2003).

In the past four decades or so, the West has become a new dwelling and fresh soil for

all of the Buddhist traditions to newly inhabit and take root. This includes the Theravada

tradition in Southeast Asia (Thailand, Burma, Vietnam, and Cambodia), the Mahayana, or

Zen schools of Vietnam, Japan, China, and Korea; and the Vajrayana tradition of Tibetan

Buddhism located in Tibet, Mongolia, Nepal, Bhutan, Ladakh, and parts of India. The

practice in these traditions have been assumed now by several generations of Westerners who

have incorporated and adapted the teachings in their own daily lives and communities in

culturally appropriate ways. This may be only the beginning of a cultural shift in the West.

For now, the richness of the Buddhist traditions provide vast resources for personal growth,

training in mindfulness practice, and dialogue, which can help fuel the development of a

league of highly skillful and accomplished teachers of mindfulness. These teachers may

come from and be involved in a range of professional disciplines, and who are committed to

offering genuine and effective mindfulness training in various sectors of our society, whether

that be in secular on non-secular form (Kabat-Zinn, 2003).

Mindfulness Instructors From the point of view of Kabat Zinn (2003) and other leading teachers, one cannot

teach mindfulness from an outside perspective of the practice; that is, instructors of

mindfulness must genuinely practice it in his or her own life. Mindfulness meditation is not a

technique that can be picked up briefly at a weekend workshop and then shared with others to

teach on occasion. Rather, an ongoing effort is required to sustain and authentically transmit

the practice to others. Ultimately, one can teach mindfulness only through a “deep

experience-based confidence” (p.150) in the transformative capacity of the practice, which is

combined with an equally profound sense of humility in offering it to others. At the Center

for Mindfulness in Medicine, Health Care, and Society, a guiding principle for teachers is

never to ask more of their patients / students than a teacher would ask of him or herself, in

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terms of following a daily practice. Another guiding truth is that both “instructors” and

“students” or “patients” are all students of the practice and of life; as such, learning and

growing in this practice is a process and engagement that can span a lifetime. In a similar

fashion, Saltzman (2008) emphasizes in her training manual for teaching mindfulness to

children and adolescents: “While I can offer experience, language and suggestions,

ultimately your teaching must come from the depths of your own practice; you must be able

to hold whatever comes up” (p. 9). In the manual, she offers guidelines and criteria for

individuals to assess whether they are ready to begin teaching youth.

Kabat Zinn (2003) warns about the pitfalls of mindfulness programs when the

teachers themselves are not accomplished mindfulness practitioners. Unless the instructor has

a solid foundation of personal practice, then the teachings will not be able to offer the kind of

energy, genuineness, and relevance that is required for a program to truly benefit the

participants. Kabat-Zinn rhetorically asks, “Can one ask someone else to look deeply into his

or her own mind and body and the nature of who he or she is in a systematic and disciplined

way if one is unwilling (or too busy or not interested enough) to engage in this great and

challenging adventure oneself, or at least to a degree that one is asking it of one's patients or

clients?” (p. 150). It is essential that a mindfulness teacher can answer questions to

participants based on the wisdom of his or her own life experiences, and how the practice has

helped to transform afflictions. Teachers cannot simply teach by the books through

conceptual knowledge, as a paradoxical essence of mindfulness is about transcending the

limitations of conceptual thinking, while also knowing when to skillfully use one's faculties

of thought and discernment. Without a teacher's living embodiment of the practice, at least to

some depth and degree, a mindfulness program risks becoming only an imitation, a mimicry

of mindfulness. It will be empty of the living energies of wisdom, joy, and compassion which

are necessary for personal transformation to take place; instead they may only resemble some

of the superficially similar methods found in relaxation techniques, cognitive-behavioral

methods, and behavioral-monitoring exercises. Kabat Zinn (2003) states that it is essential to

understand the multifaceted layers of mindfulness practice, especially those aspects that are

inherently different from most other clinical interventions. This includes primarily the

paradox of practicing without a goal. The “emphasis on nonattachment to outcome is a

radical departure from most clinical interventions” (p.148); this is important for clinical

23

interventions to embody and for the scientific paradigm to grasp when studying these

applications.

Mindfulness-Based Stress Reduction (MBSR) In a conceptual review of mindfulness training as a clinical intervention, Baer (2003)

reviews four intervention which are based in or integrate mindfulness practice. Of these,

MBSR, designed by Kabat-Zinn (1990) is the most widely studied and reputable program for

mindfulness training, and is considered a model program for other medical centers,

psychotherapy clinics, and other physical and emotional health related organizations to

develop their own programs. It is an 8- to10-week course for groups of about 30 participants

who receive instruction and engage in mindfulness exercises for 2 to 2.5 hour sessions each

week. Participants learn methods of mindfulness meditation, engage in discussion about the

relevance of the practice to their lives and experiences, and have weekly homework

assignments. There are several core mindfulness practices which are taught. The body scan is

a 30 to 45 minute exercise in which the participant lies down, follows his/her breathing, and

attends carefully to sensations of different body parts in a systematic way. During the

practice of sitting meditation, participants sit in a relaxed, upright, and attentive posture while

focusing attention on a given bodily or mental experience, which may include sensations of

breathing, bodily sensations, or the ebb and flow of feelings and mental states, or a

combination of them (such as placing attention on one's breath and feelings at the same

time). Sitting meditation may also combine breath awareness with concentrations on specific

feeling states, such as focusing loving kindness or compassion on oneself, parts of oneself, or

others; this is also practiced in a systematic way. In hatha yoga postures or mindful

movements, participants are trained to observe bodily sensations while moving and stretching

the body. Participants also learn to be attentive to present moment experiences during routine

activities such as eating, listening, walking, and standing. Both during and after the course,

participants are encouraged to maintain a formal daily practice of 45 minutes using these

skills. They are also instructed to spontaneously practice being aware of physical sensations

and mental states in the present moment during their daily life. Participants are instructed to

nonjudgmentally observe bodily sensations, emotions, or thoughts as they arise; this includes

recognizing and accepting the content of thoughts and feelings without being overwhelmed

24

by or lost in them. When attention wanders into daydreaming about the future or regretting

about the past, the participant simply recognizes the content of the distraction, and then

redirects attention back to experiences in the present moment. Participants are invited to

watch the flow of thoughts and emotions, as if one were sitting on the bank of a river and

watching the water flow by naturally (Baer, 2003; Kabat-Zinn, 1994).

Mindfulness-Based Cognitive Therapy (MBCT) Mindfulness-based cognitive therapy (MBCT) (Teasdale, Segal, & Williams, 1995) is

a manualized 8-week program that is rooted in the MBSR model. The innovators of this

approach assert that the methods of selective attentional control, which is inherent in

mindfulness practice can help prevent relapse for those suffering from episodes of major

depression. This approach integrates aspects of cognitive therapy with mindfulness in an

attempt to prevent negative thinking from turning into harmful ruminative patterns. The

founders of both MBCT and of the modified version for children, Mindfulness-Based

Cognitive Therapy for Children (MBCT-C) (Semple, Reid, & Miller, 2005) propose that

impaired attention abilities are primary symptoms of anxiety; thus, enhancing self-

management of attention may reduce anxiety and associated symptoms. Like CBT,

mindfulness practice can help participants to recognize difficult feelings such as anxiety,

illuminate misperceptions and maladaptive thoughts, reduce avoidant behaviors, and improve

self-management skills in relation to forming new coping skills. Unlike CBT, mindfulness

training focuses on developing a more accepting and embracing relationship with one's

mental formations, whereas CBT focuses on producing more positive or adaptive thoughts.

Dialectical Behavior Therapy (Linehan, 1993), and Acceptance and Commitment

Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) both significantly incorporate elements of

mindfulness training, though it is not the primary approach. Studies based on these

interventions will not be included in the following evidence-based review.

How Mindfulness Skills Can Lead to Symptom Reduction and Behavior Change

This section explains the core processes by which mindfulness practice helps to

alleviate mental health symptoms and fosters adaptive qualities in participants. This review

25

has been largely guided by Baer’s (2003) description of the transformational mechanisms of

mindfulness-based interventions.

EXPOSURE The capacity of recognizing and accepting painful sensations in a nonjudgmental and

less reactionary way is known to reduce the levels of distress which accompany the initial

pain (Baer, 2003). In his work with patients suffering from chronic pain, Kabat-Zinn (1982)

explains that prolonged exposure to raw sensations of pain, while maintaining stillness and

focus during sitting or lying meditation, can lead to desensitization and an overall decrease in

the amount of painful emotional responses as well. Even if the painful bodily sensations do

not decrease, the emotional distress resulting from such sensations may dissipate. In later

work with patients experiencing anxiety related symptoms, Kabat-Zinn and colleagues

(1992) describe a similar process: as patients non-judgmentally observe their difficult

emotions during sitting or lying meditation, and do not try to avoid or reject them, but rather

accept them as they are, the emotional reactivity which follows such anxiety symptoms may

be reduced.

COGNITIVE CHANGE Several authors and teachers of mindfulness state that mindfulness practice can foster

healthy ways of relating to one's thoughts, and also to alter thought patterns (Baer, 2003).

Kabat-Zinn (1994) explains that through the process of watching the thoughts without being

absorbed by them and without necessarily trying to change them, the thought patterns change

already. They change not by being intentionally replaced by other more positive thoughts,

but because the relationship to the thoughts is different. It invites more space into the

relationship with the thoughts and can liberate one from the prison of thinking. The thoughts

can be recognized as just thoughts, which do not necessarily reflect the truth. Teasdale et al.

(1995) explain that through MBCT, formerly depressed patients can disrupt ruminative

thinking by decentering and non-judgmentally observing one's thoughts. They can then

mindfully direct their attention away from the thinking to other experiences in the present

moment, namely walking, breathing, and environmental stimuli. Another advantage of

mindfulness is that it can be practiced at any time, whether during treatment, or later when

26

the depressive symptoms are not manifesting as heavily. This allows the individual to use

mindfulness as a preventive measure to disrupt ruminative patterns and depressogenic

thinking at very early stages. In other words, mindfulness of thinking can be applied at any

time or place, and to all thoughts.

SELF-MANAGEMENT Several authors offer examples of improved self-management skills (Baer, 2003).

Kabat-Zinn (1982) notes that as participants develop greater awareness of and can more

easily accept their stress responses and pain sensations as they occur in the present moment,

it is easier for them to proactively engage in other coping methods, even ones that are not

offered in the mindfulness class. Teasdale et al. (1995) relate that mindfulness training can

help clients recognize the early signs of potential relapse for a depressive episode. With this

enhanced awareness at early stages, individuals may be able to use previously learned

strategies that are more effective in preventing the problem before it gets too large to handle.

Kristeller and Hallet (1999) skillfully point out that for individuals with a binge eating

disorder, increased awareness may help in recognizing satiety cues, as well as initial urges to

binge. The authors found that mindfulness and satiety cues were likely mediating variables

for an increased sense of control in overeating. In her work with individuals with borderline

personality disorder, Linehan (1993) states that mindfully concentrating on one task at a time

in the present moment can help those who have difficulty with task completion. This implies

that when individuals can mindfully return attention to each task without giving in to

distraction, they may more easily succeed in other endeavors unrelated to mindfulness

exercises.

ACCEPTANCE In all of the mindfulness programs reviewed by Baer (2003), acceptance of feelings,

thoughts, and bodily sensations, whether they are pleasant, unpleasant, or neutral, is a key

component of mindfulness training. Kabat-Zinn (1994) states that one aspect of mindfulness

is simply giving oneself “permission to allow this moment to be exactly as it is, and allow

yourself to be exactly as you are” (p. 13). He states that through accepting and embracing

what is actually here and now, one can begin moving forward, and take steps in the right

27

direction. In Baer's (2003) review of studies using mindfulness training, all of the treatment

programs emphasize initial acceptance and recognition of bodily sensations, feelings, and

mental activity, whether they are pleasant, unpleasant, or neutral, rather than avoiding or

changing them. A founding teacher of Acceptance and Commitment Therapy (ACT), Hayes

(1994) also encourages accepting experiences and lessening defenses. He explains that

psychotherapeutic interventions can often overemphasize changing or reducing unpleasant

feelings and experiences, without cultivating a strong foundation of acceptance. For example,

those who tend to experience intense feeling states, such as panic attacks, may form

maladaptive behaviors in trying to avoid and prevent attacks. Such maladaptive behaviors

can be more harmful to the client than the attacks themselves. Teaching acceptance that such

unpleasant feeling states can occur from time to time, but are relatively brief and can be

tolerated, can mitigate the amount of fear and maladaptive behaviors associated with the

initial problem.

MINDFULNESS WITH ADULTS: RESULTS OF THREE META-ANALYSES

In the last two decades, various studies have shown the benefits of offering

mindfulness training to adults, and the research base seems to be growing exponentially. In

the last decade, three different meta-analyses and clinical reviews were conducted with

mindfulness-based interventions with adults. The first two meta-analyses included studies

with mostly clinical populations, whereas the third review evaluated reports of mindfulness

with healthy participants. Table 1 displays a summary of the findings for each review.

Baer (2003) performed the first meta-analysis, analyzing 21 studies which evaluated

the efficacy of mindfulness-based interventions with individuals experiencing a range of

mental and physical illnesses. Using meta-analytic techniques to quantify and compare

findings, Baer’s analysis suggests that “mindfulness-based interventions may help to

alleviate a variety of mental health problems and improve psychological functioning”

(p. 139). Studies were included in the meta-analysis review if they were published in English

and compared a mindfulness training treatment group to a comparison group that was not

trained. Participants in the studies were grouped into four categories: chronic pain patients,

patients with other Axis I disorders (anxiety, eating, and major depressive disorders), patients

28

Tab

le 1

. Met

a-A

naly

ses o

f Min

dful

ness

-Bas

ed In

terv

entio

ns w

ith A

dults

Stu

dy

Age

N

S

ampl

e S

izes

Tr

eatm

ent

Pro

gram

S

tudy

D

esig

n P

artic

ipan

t C

hara

cter

istic

s O

utco

mes

C

oncl

usio

n

Bae

r (2

003)

A

dults

; 38

-50

year

s;

mea

n 45

ye

ars

21

stud

ies

16 to

14

2 M

BS

R,

MB

CT,

or

mod

ified

ve

rsio

n

9 pr

e-po

st; 9

be

twee

n gr

oup

with

TA

U.

Axi

s I d

isor

ders

, ot

her m

edic

al

prob

lem

s, m

ixed

po

p, n

oncl

inic

al;

Ran

ge 0

-46%

m

ale;

eth

nici

ty

rare

ly re

porte

d

- Ave

rage

med

ium

-siz

ed e

ffect

s at

pos

t-tre

atm

ent

(d=0

.59)

and

follo

w-u

p (d

=0.5

9).

- Chr

onic

pai

n pa

tient

s: re

duce

d pa

in, m

edic

al a

nd

psyc

holo

gica

l sym

ptom

s;

- Non

clin

ical

pop

s: b

ette

r psy

chol

ogic

al s

ympt

oms

and

empa

thy

- Can

cer p

atie

nts:

redu

ced

stre

ss a

nd m

ood

dist

urba

nces

- I

mpr

oved

fybr

omya

lgia

sym

ptom

s - A

xis

I dis

orde

rs: i

mpr

oved

anx

iety

and

dep

ress

ion,

bi

nge

eatin

g, re

duce

d ra

tes

of d

epre

ssiv

e re

laps

e.

Min

dful

ness

inte

rven

tions

al

levi

ate

varie

ty o

f men

tal

heal

th p

robl

ems

and

impr

ove

psyc

holo

gica

l fu

nctio

ning

; hig

h co

mpl

etio

n ra

tes,

stro

ng

mai

nten

ance

ove

r tim

e.

Gro

ssm

an,

Nie

wm

ann,

S

chm

idt,

& W

alac

h (2

004)

Not

st

ated

20

st

udie

s,

1605

su

bjec

ts

Not

st

ated

M

BS

R

10

RC

Ts,

3 qu

asi-

expe

r.

Fibr

omya

lgia

, ca

ncer

, cor

onar

y ar

tery

dis

ease

s,

depr

essi

on,

chro

nic

pain

, an

xiet

y, b

inge

ea

ting,

psy

chia

tric

patie

nts;

3 p

rison

po

pula

tions

, 3

nonc

linic

al s

ampl

es -M

enta

l hea

lth v

aria

bles

: med

ium

stre

ngth

effe

ct s

ize

(d=0

.54,

p<.

0001

), w

ith h

omog

enou

s di

strib

utio

n.

- Phy

sica

l hea

lth o

utco

mes

: med

ium

stre

ngth

effe

ct

size

(d=0

.53,

p=.

0004

), ho

mog

enou

s di

strib

utio

n.

- Psy

chol

ogic

al im

prov

emen

ts: q

ualit

y of

life

, de

pres

sion

, anx

iety

, cop

ing

styl

e an

d ot

her a

ffect

ive

dim

ensi

ons

of d

isab

ility

. - P

hysi

cal h

ealth

impr

ovem

ents

: med

ical

sym

ptom

s,

sens

ory

pain

, phy

sica

l im

pairm

ent,

and

func

tiona

l qu

ality

-of-l

ife

MB

SR

use

ful i

nter

vent

ion

for b

road

rang

e of

dis

orde

rs

and

prob

lem

s.

Enh

ance

s co

ping

with

di

stre

ss a

nd d

isab

ility

and

se

rious

dis

orde

rs a

nd

stre

ss.

Chi

essa

&

Ser

retti

(2

009)

Not

st

ated

10

st

udie

s 12

to

162

MB

SR

9 be

twee

n gr

oup

stud

ies,

7

RC

T

Hea

lthy

subj

ects

: U

nive

rsity

, nur

sing

, an

d m

edic

al

stud

ents

; nur

ses,

he

alth

car

e pr

ofes

sion

als,

th

erap

ists

, U

nive

rsity

facu

lty,

preg

nant

wom

en;

ethn

icity

not

sta

ted

- MB

SR

sig

nific

ant n

onsp

ecifi

c ef

fect

on

redu

ctio

n st

ress

(d=0

.74,

p<.

001)

and

com

pare

d to

con

trols

(d

=1.3

9, p

<.00

1)

- MB

SR

sig

nific

antly

enh

ance

spi

ritua

lity

leve

ls

(d=0

.82,

p<.

001)

and

in c

ompa

rison

to in

activ

e co

ntro

l (d=

0.96

, p<.

001)

- M

BS

R s

uper

ior t

o re

laxa

tion

prog

ram

in re

duci

ng

rum

inat

ive

thin

king

- I

mpr

oved

psy

ch s

ympt

oms

(anx

iety

, em

path

y, s

elf-

com

pass

ion)

.

MB

SR

redu

ces

stre

ss in

he

alth

y su

bjec

ts, w

ith o

ther

ps

ych

bene

fits.

S

carc

ity o

f dat

a an

d m

etho

d lim

itatio

ns p

recl

ude

stro

ng c

oncl

usio

ns.

29

with other medical problems (fibromyalgia, psoriasis, and cancer), mixed populations of

patients (e.g. psychotherapy and medical patients), and finally nonclinical populations (e.g.

students, volunteers). The mean age of the participants ranged from 38-50 years in each of

the studies, with a total mean of 45 years. Most studies involved MBSR as an 8-10 week

group intervention, or a modified version. Two studies evaluated MBCT, which used

mindfulness training as a primary treatment approach, although it did incorporate cognitive

based strategies. Baer did not review studies of DBT or ACT, as none examined the

mindfulness component specifically apart from other treatment approaches used. The

efficacy of mindfulness as a contributing treatment approach to these multifaceted treatment

programs has yet to be evaluated (Baer, 2003).

Across the 21 studies, Baer (2003) found that post-treatment effect sizes ranged

between 0.15 and 1.65. The overall mean of these effect sizes was 0.74 (SD = 0.39). Effect

sizes at follow-up evaluations ranged between 0.08 and 1.35, with an overall mean of 0.59

(SD = 0.41). Baer's review of studies suggests that mindfulness-based interventions have

medium-effect sizes (on average), with some studies showing an effect size in the large

range. Baer notes that these findings should be received cautiously, as many of the studies in

her review have methodological weaknesses which should prevent strong conclusions from

being drawn about effectiveness of mindfulness-based interventions across the variety of

mental and physical illnesses. She adds that in order to draw stronger conclusions, the field

needs further studies with more rigorous study designs (RCTs) that compare mindfulness

training to other well-established interventions.

Despite the methodological weaknesses in many of the studies, Baer's findings

acknowledge that mindfulness training may be effective in the treatment of several disorders.

For example, studies of chronic pain patients found significant improvements in ratings of

pain, other medical symptoms, and psychological well-being (Kabat-Zinn, 1982; Kabat-Zinn,

Lipworth, & Burney, 1985; Kabat-Zinn, Lipworth, Burney, & Sellers, 1987; Randolph,

Caldera, Tacone, & Greak, 1999). In addition, many of these improvements remained at

follow-up assessments. One study measured the effects of MBSR on patients with a binge

eating disorder, and found statistically significant improvements across various measures of

mood and eating (Kristeller & Hallett, 1999). The review of studies also indicates that

participants who enter into mindfulness-based treatments will finish them, and many of them

30

will continue practicing after program completion. In the Division 12 Task Force on

Promotion and Dissemination of Psychological Procedures (1995), MBSR meets the criteria

for being “probably efficacious” as a treatment program. This designation is deserving as five

studies of MBSR using group designs and random assignment have demonstrated that the

treatment is more effective than a treatment as usual (TAU) or waiting list comparison group.

Baer's (2003) review suggested that MBCT was closely approaching “probably

efficacious” in preventing relapse for major depression. A rigorous study by Teasdale and

colleagues (2000) demonstrated that MBCT was more effective than TAU with a large

sample of formerly depressed participants. Since Baer's review however, Ma and Teasdale

(2004) conducted a study with a similar research design and found similar results in reducing

rates of depressive relapse. The investigators determined that based on positive results from

two RCTs showing treatment effectiveness compared to TAU, MBCT would qualify as a

“probably efficacious” treatment for the prevention of recurring depressive episodes.

Soon after Baer's (2003) meta-analysis was published, Grossman and colleagues

(2004) found similar results in a comprehensive clinical review and meta-analysis of studies

pertaining only to MBSR. The authors found consistent improvements and moderately strong

effect sizes in various measures of mental health (e.g. coping style, depression, anxiety), and

also improvements in physical well-being (e.g. sensory pain, medical symptoms, functional

quality of life estimates). They found 64 empirical health-related studies of either MBSR or

other group intervention programs that applied mindfulness training as the core component.

Twenty reports were ultimately included after meeting selection criteria related to quality and

relevance of data, comprising a total of 1605 subjects. The study only evaluated the presence

of short term effects related to pre- to post-intervention change, as opposed to Baer's review

which also included mean effect size of follow-up evaluations. As the review's purpose was

to evaluate the effect of mindfulness training on health measures, all outcome measures of

the studies were divided into either “physical health” or “mental health” categories. Mental

health scales included measures of psychological well-being and symptomatology,

depression, sleep, perceptions of quality of life, anxiety, and affective perception of pain.

Scales measuring physical health status included medical symptoms, physical pain, physical

impairment, and physical component of quality of life.

31

The authors conducted two separate meta-analyses. The first included studies only

with control groups, and compared the experimental group with the control group. In this

analysis of 13 studies, data for mental health measures revealed a medium strength mean

effect size of d = 0.54 (p < 0.0001). Results for physical health measures was similar to the

mental health category, yielding a mean effect size of d = 0.53 (p = 0.0004). The second

meta-analysis includes results of pre- to post-intervention change for both sets of outcome

measures in a total of 19 studies. The mean effect sizes were relatively similar to the results

of the controlled studies, with d = 0.50 for the mental health category, and d = 0.42 for the

physical health category.

Based on the findings, the authors concluded that MBSR is a useful intervention for a

wide spectrum of chronic disorders and problems. Moreover, the consistently strong effect

sizes among a diverse range of mental and physical health constructs and sample populations

suggest that mindfulness training may “enhance general features of coping with distress and

disability in everyday life, as well as under more extraordinary conditions of serious disorder

or stress” (Grossman et al., 2004, p. 39). The authors optimistically state that as mindfulness-

based interventions are relatively brief, cost-effective, and have demonstrated strong results

thus far, they may have the capacity to help many people learn to successfully cope with

stress and chronic disease. The authors emphasize the need for large scale and

methodologically sound research designs with well defined participant populations in order

to more thoroughly test these conclusions (Grossman et al., 2004). Further studies may

ascertain how effective mindfulness training is with diverse populations, in what specific

formats, and across what other measures of psychological and physical well-being.

While the former two clinical reviews offer meta-analyses for the efficacy of

mindfulness training for a range of physical and mental health issues, another more recent

meta-analysis by Chiessa and Serreti (2009) reviewed the evidence of MBSR specifically in

healthy participants, and with particular attention on stress reduction and spirituality

enhancement. The authors assert that ongoing stress can lead to ruminative thinking that can

sap energy and exacerbate the initial stress itself. They note that consistently high stress can

weaken resilience factors such as hope and the capacity to forgive, and may lead to physical

and mental health problems. As mindfulness training teaches individuals to develop a more

flexible state of awareness through non-judgmentally observing thoughts, feelings, and

32

external phenomenon without reacting impulsively to them, MBSR may be an empowering

tool for nonclinical individuals to cultivate balanced levels of stress in their daily lives.

Chiesa and Serretti (2009) found over 150 articles related to mindfulness and

meditation and 10 were chosen for review based on the inclusion criteria. Aggregated data

from 7 different studies that compared MBSR to a waitlisted group found that MBSR had a

significant nonspecific effect on reducing levels of stress (Jain et al., 2007; Klatt, Buckworth,

& Malarkey, 2008; Rosenzweig, Reibel, Greeson, Hojat, & Brainard, 2003; Shapiro, Astin,

Bishop, & Cordova, 2005; Shapiro, Brown, & Biegel, 2007; Shapiro, Schwartz, & Bonner,

1998; Vieten & Astin, 2008). One study comparing MBSR with a control group intervention

showed that MBSR could have a specific positive effect (p = 0.001) (Shapiro et al., 2007).

The review includes two studies focusing on university students, one of which found that an

MBSR course significantly reduced high stress levels in undergraduate students from pre to

post-intervention. Significant improvements also occurred for the students in measures of

anxiety, depression, obsessive compulsive symptoms, somatization, and interpersonal

sensitivity (Astin, 1997). The second study also found a significant reduction in stress levels

from MBSR, this time with female nursing students (Beddoe & Murphy, 2004). Both studies

with students found that MBSR significantly increased the participants' capacity for empathy.

On a similar note, an MBSR course with therapists in training found significant increases in

self-compassion (Shapiro et al., 2007). The review also concludes that MBSR was associated

with a significant increase in spirituality values, though it was not found to be superior to a

comparison treatment group. Two studies in the review found that MBSR participants

experienced a significant decrease in ruminative thinking (Jain et al., 2007; Shapiro et al.,

2007). In two randomized control trials comparing group-based MBSR with a waitlisted

group, significant improvements were documented on state and trait anxiety levels in

treatment group participants (Shapiro et al., 1998; Shapiro et al., 2007).

Chiessa and Serreti (2009) conclude that the reviewed studies consistently

demonstrate that MBSR has both a nonspecific and potentially a specific effect on reducing

stress in healthy participants. The authors add that MBSR is associated with many other

aspects of well-being, related to decreased anxiety, and increased empathy and self-

compassion. Furthermore, MBSR may be a superior intervention to relaxation training as it

may reduce ruminative thinking in addition to stress levels. The review was limited by a

33

paucity of studies of MBSR with healthy subjects. Further research of MBSR with healthy

subjects should incorporate stronger study designs with more heterogeneous samples which

can reveal the magnitude of both short and long term effectiveness, and better establish the

specific effects of mindfulness training.

STUDIES OF MINDFULNESS WITH CHILDREN AND ADOLESCENTS

Mindfulness-based approaches with adults is becoming increasingly popular, and the

empirical evidence supporting its effectiveness is relatively strong. In an overview of

mindfulness-based interventions with children and adolescents, Thompson and Gauntlett-

Gilbert (2008) state that while applications of mindfulness trainings with children and youth

have shown feasibility and acceptability, empirical testing with this population is just

beginning. From their own and others’ applications of mindfulness training with youth, the

authors note that “mindfulness techniques can potentially teach greater self-awareness,

impulse control and decreased emotional reactivity to difficult events” (p. 395-396). Burke

(2009) conducted the only empirical review thus far of current research in this emerging field

reviewing 15 studies of MBSR and MBCT-C related programs, including both clinical and

non-clinical populations. She concludes that there is “a reasonable base of support for the

feasibility and acceptability of mindfulness-based approaches, that include core mindfulness

mediation practices, with children and adolescents” (p. 10). Her review includes programs

that use mindfulness meditation only as a core component of the intervention. Burke notes,

however, that the research base is limited by a paucity of strong empirical evidence to

support the efficacy of interventions with the younger population. While mindfulness-based

interventions have also been incorporated into other more rigorous child and adolescent

studies, it has been included as part of a larger treatment approach, and the relative

contributions of mindfulness in wider treatment programs have not yet been explored

(Thompson & Gauntlett-Gilbert, 2008).

The author used Burke's (2009) empirical review to broadly guide the following

critical analysis and overview of studies completed thus far of mindfulness training with

children and adolescents. The aim was to provide an overview of studies that offer empirical

and anecdotal support for the feasibility, acceptability, and effectiveness of mindfulness

34

training with youth. Studies were included only if mindfulness meditation was a core

program component; the review does not include programs with other forms of concentration

meditations such as transcendental meditation. While MBSR and MBCT-C are the most

predominantly used mindfulness-based interventions, these programs also vary in

implementation, especially among varying levels of child development, but also by each

program's unique delivery. Studies are categorized by the school age of youth participants in

sections and in tables: preschool age children, elementary school age youth, middle school,

and high school. Within each category, studies with the most rigorous study designs and that

use mindfulness as the primary intervention are analyzed first. Table 2 summarizes studies of

the first two groups of preschool and elementary school age children (five studies).

Mindfulness with Preschool Age Children The Mindful Awareness Research Center (MARC) at UCLA has performed several

pilot studies on mindfulness-based approaches with children and adolescents. MARC

collaborated with the Inner Kids Foundation, to conduct a study of an 8-week mindful

awareness practices (MAPs) intervention at the UCLA early childhood center. The Inner

Kids Foundation has taught mindful awareness programs in both prosperous and under-

served schools and neighborhoods in Los Angeles since 2000 (Greenland, n.d.). The MAPS

intervention, based on the MBSR model, was appropriately age modified for 44 non-clinical

children (ages 4 to 5) to take part in this randomized control trial. The intervention lasted

eight weeks and consisted of 30 minute sessions, twice a week. Both parents and teachers

completed questionnaires before and after the program to assess the children's levels of

executive functioning, temperament, and social behavior. Teacher reports of children in the

MAPs group at post-treatment showed significant improvements in some aspects of

executive functioning, such as increased working memory and planning/organizing, which

also contributed to greater Global Executive Control and Emergent Meta-cognition. Further

analyses indicated that MAPs may have a stronger effect on children who have executive

function difficulties. However, no significant improvements were found in parent ratings or

other outcome measures. Although the samples size was rather small and used measures with

non-blind raters with potential bias, the study used validated assessment measures and the

35

Tab

le 2

. Stu

dies

of M

indf

ulne

ss-B

ased

Inte

rven

tions

with

Pre

scho

ol a

nd E

lem

enta

ry A

ge Y

outh

Stu

dy

Age

/ G

rade

N

Tr

eatm

ent

Pro

gram

R

esea

rch

Des

ign

Par

ticip

ant

Cha

ract

eris

tics

Set

ting

Dep

ende

nt V

aria

bles

O

utco

mes

Floo

k et

al.

(201

0)

4-5

year

s,

pres

choo

l

44

MA

Ps;

30

min

, 2 x

w

eekl

y; 8

w

eeks

RC

T; P

re-p

ost

Non

-clin

ical

; un

know

n et

hnic

ity

Ear

ly

child

hood

ce

ntre

Exe

cutiv

e fu

nctio

ning

, te

mpe

ram

ent,

and

soci

al s

kills

(p

aren

t and

teac

her r

epor

t)

Impr

oved

teac

her r

epor

ted

exec

utiv

e fu

nctio

ning

onl

y

Nap

oli e

t al.

(200

5)

Gra

des

1-

3 19

4 A

ttent

ion

Aca

dem

y P

rogr

am;

biw

eekl

y, 2

4 w

eeks

RC

T; P

re-

post

; Con

trol

grou

p: Q

uiet

ac

tiviti

es/

read

ing

Non

-clin

ical

; et

hnic

ity u

nkno

wn

Ele

men

tary

S

choo

l O

ppos

ition

al b

ehav

ior,

atte

ntio

n sk

ills,

test

anx

iety

, an

d so

cial

ski

lls (a

ll se

lf-re

port)

; AD

HD

sym

ptom

s (te

ache

r rep

ort)

Incr

ease

d se

lect

ive

atte

ntio

n,

decr

ease

d te

st a

nxie

ty a

nd

teac

her r

epor

ted

AD

HD

sy

mpt

oms

Sal

tzm

an a

nd

Gol

din

(200

8)

Gra

des

4-

6 39

M

odifi

ed

MB

SR

; 8

wee

kly

sess

ions

Pre

-pos

t; w

ait

list c

ontro

l gr

oup

Chi

ldre

n an

d pa

rent

s in

par

alle

l m

indf

ulne

ss

cour

ses;

mos

tly

whi

te, m

iddl

e cl

ass

Sta

nfor

d U

nive

rsity

A

nxie

ty, d

epre

ssio

n, s

elf-

com

pass

ion,

atte

ntio

n sk

ills,

se

lf-co

mpa

ssio

n

83%

com

plet

ion

rate

; Im

prov

emen

ts in

atte

ntio

n co

ntro

l, em

otio

nal r

eact

ivity

, se

lf-co

mpa

ssio

n

Sem

ple

et a

l. (2

005)

7-

8 ye

ars

5 M

BC

T-C

; 45

min

, 6 w

eeks

, w

eekl

y

With

in

subj

ects

, pre

-po

st

Anx

ious

chi

ldre

n;

ethn

icity

unk

now

n E

lem

enta

ry

scho

ol

Anx

iety

(sel

f-rep

ort);

in

tern

aliz

ing

and

exte

rnal

izin

g be

havi

or, a

cade

mic

fu

nctio

ning

(tea

cher

repo

rt)

Feas

ibili

ty in

sch

ool s

ettin

g;

Impr

ovem

ents

in a

t lea

st o

ne

cate

gory

for e

ach

child

Lee,

Sem

ple,

R

osa,

& M

iller

(2

008)

9-12

ye

ars,

gr

ades

4-

6

25

MB

CT-

C; 9

0 m

in, 1

2 w

eeks

, w

eekl

y

Pre

-pos

t N

oncl

inic

al; l

ow

inco

me,

inne

r-city

, pr

imar

ily H

ispa

nic,

A

frica

n-A

mer

ican

; ac

adem

ic p

robl

ems

Ele

men

tary

sc

hool

A

nxie

ty, d

epre

ssio

n,

parti

cipa

nt e

valu

atio

n (s

elf-

repo

rt); i

nter

naliz

ing

and

exte

rnal

izin

g be

havi

or, p

aren

t ev

alua

tion

(par

ent r

epor

t)

78%

com

plet

ion

rate

; red

uctio

ns

in in

tern

aliz

ing

and

exte

rnal

izin

g be

havi

ors;

hig

hly

posi

tive

eval

uatio

n fe

edba

ck

36

children were randomly assigned to treatment or control groups. Most importantly, the study

offers preliminary support that young children are able to participate in mindfulness practices

in a group or childcare setting (Burke, 2009; Saltzman, 2008).

Mindfulness Training with Elementary Age Children Napoli and colleagues (2005) performed a study of 228 non-clinical first through

third grade students who participated in twelve 45-minute sessions of mindfulness training

with the Attention Academy Program (AAP). AAP is designed to help students improve their

quality of life through practicing mindfulness; its goals are for students to enhance their

attention skills, respond without judgment, and approach situations with a “beginner's eye”.

The study took place in nine separate classrooms in two elementary schools, and treatment

sessions were done in classrooms away from students in the control group. The mindfulness

exercises in AAP included paying attention to the breath, body-scan visualization, a body

movement-based task, and a discussion with the teacher and class to conclude each practice

session. At pre and post-intervention, each child completed four standardized scales,

measuring oppositional behavior, attention skills, test anxiety, and social skills. The authors

found that the students practicing in a group-based mindfulness training had significantly

better outcomes than those in the control group, having increased levels of objectively

measured selective attention (the ability to choose where and how to focus their attention)

and decreased levels of self-rated test anxiety and teacher reported levels of ADHD symptom

behaviors. Effect sizes varied from small to medium (d = 0.39 to 0.60). The study's strengths

include its large sample size, RCT design, and use of objective measures of attention. It is

limited by potential bias in teacher ratings; the AAP format also differs from the traditional

MBSR model in regards to overall structure and the lack of home activity practice, making

comparisons with other MBSR programs for children tentative (Burke, 2009). Napoli et al.

(2005) noted that with increases in stress, depression, and anxiety in the lives of youth, it is

essential that children learn techniques to reduce feelings of stress. Elementary schools

generally do not have health related curriculum, and according to the experiences of AAP's

program in elementary schools, mindfulness training can easily and successfully be

implemented in a physical education program. All students would, therefore, be able to

participate and receive tools for reducing stress and improving attention skills in the

37

classroom. Based on their encouraging findings, the authors emphasized the need for further

studies of the same nature to evaluate whether mindfulness programs prove to be beneficial

for older youth.

Greco and Hayes (2008) edited a recent publication of a practitioner's guide,

Acceptance and Mindfulness Treatments for Children and Adolescents. The book describes

and delineates MBSR and MBCT techniques with children and adolescents, among other

clinical applications involving mindfulness skills. In one chapter, Saltzman and Goldin

(2008) describe findings of an 8-week MBSR program with 31 non-clinical children (grades

4-6) and their parents, which was done through the University of Stanford. All of the

participants self-referred voluntarily, and were mostly middle-class European-Americans. All

but one family completed the course, producing an 83% completion rate. This suggests that

MBSR is feasible as an intervention administered to both parents and children together.

Positive changes from pre- to post-MBSR were found in children participants in the domains

of attention control, emotional reactivity, and metacognitive functioning, compared to a

control group of 8 families (8 children). For example, children improved significantly from

pre- to post-MBSR on cognitive control of attention as demonstrated on the Attention

Network Task. Similarly, they showed a greater capacity to direct attention in the presence of

distractions. The authors point out that cognitive control of attention is very closely

associated with strong academic performance. While children showed no significant

improvements in symptoms of anxiety and depression, they did improve on levels of self-

compassion, demonstrating less judgmental thoughts and feelings with themselves. While the

quantitative results are promising, the authors also portray several of the children's personal

reflections and sentiments about the mindfulness course. The qualitative findings are very

positive and inspirational, and tell a lot about the children's enriching experiences in ways

that the hard data will never be able to. A few limitations of the study include: small sample

size, randomized selection was not reported for the control group, and details of validity and

reliability of outcome measures for the child age groups were not discussed. Results

comparing control group versus MBSR participants are in the process; thus, the final analysis

may offer more clarity in the methodology and overall findings.

Two studies have explored the feasibility, acceptability, and helpfulness of MBCT-C

as an intervention for anxious children. While there is ample evidence of successfully

38

integrating mindfulness training in adult psychotherapies, Semple and colleagues (2005)

conducted the first study to explore its feasibility in treating childhood anxiety. The authors

offered a 6-week mindfulness program, with one 45 minute session each week, to 5

nonclinical children (3 boys; 7 to 8 years of age). The weekly mindfulness sessions were

based on MBSR and MBCT, and modified for children to enhance attention skills by

focusing on body sensations and perceptions. Mindfulness exercises integrated simple

breathing techniques with walking, gustatory, visual, auditory, olfactory, and tactile exercises

, and each week focused on a single sense modality. Participants were encouraged each week

to practice the exercises at home, in order to generalize the application of mindfulness to

other aspects of daily living. At the end of the program, some improvements were made for

each child in at least one area of academic functioning, internalizing problems, or

externalizing problems. From clinical observations, 4 of 5 children expressed enthusiasm and

enjoyment in practicing mindfulness and asked for the group to continue. They responded

weekly to the question of “how much did I like class today”, with an overall mean of 4.13 on

a five point scale. Despite the small sample size, and outcome ratings based on a biased

observer (school psychologist), the study provides preliminary evidence that mindfulness-

based interventions in a school setting are feasible and likely helpful with anxious children.

Lee and colleagues (2008) performed another evaluation of MBCT-C with a larger

sample (N = 25) of slightly older children, ages 9-12, grades 4 through 6. The study's aim

was to assess the feasibility, acceptability, and potential efficacy of MBCT-C for treating

internalizing and externalizing symptoms in non-referred, non-clinical children. Participants

were mostly low-income, minority children, primarily of Hispanic and African-American

ethnic background, and with academic problems. The authors found that participants had

significant reductions in the Child Behavior Checklist (CBCL) (Achenbach, 1991) total

score, and significant reductions in CBCL internalizing symptoms in the Intent-to-treat

participants (N = 24). There was a significant reduction in the CBCL Externalizing Problems

score in the Completers group as well. Effect sizes ranged from small to medium in all four

outcome measures of internalizing symptoms, externalizing symptoms, depression and

anxiety, although no significant differences were found in the latter two. The overall

participation rate was 78% for the Intent-to-Treat Sample and 94% for Completers. Research

shows that there is a high rate of dropout in mental health services once children begin

39

treatment. Some studies have shown that 40 to 60% terminate prematurely, and early

termination is typically greater among children who are ethnic minority group members

(Kazdin, 1996; Wierzbicki & Pekarik, 1993) . In light of this challenge in mental health

services for children, the high retention and completion rate demonstrated in this study offers

further support for treatment feasibility. Children completed a participant questionnaire to

evaluate personal experiences of the course, and parents also completed a questionnaire to

report their perceptions of any behavioral changes in the child and their experience of the

program. Data from child and parent evaluation questionnaires showed that ninety-four

percent of children either “Liked” or “Loved” the mindfulness sessions, and 88% of parents

gave a “high” or “very high” rating. Furthermore, 88% of children and 82% of parents

confirmed that mindfulness was beneficial for school involvement. Ancecdotal evidence

indicates that the program was helpful for students in coping with test and performance

anxiety at school. In open-ended questions, one child stated, “Lately, I have not been nervous

or scared of my city-wide test. Long ago, I used to be but not anymore” (p. 24). From clinical

observations, nearly all of the children embraced the concepts of mindfulness,

enthusiastically engaged in exercises, and explored its applications in their daily lives. The

evaluation feedback and clinical observations demonstrate acceptability for MBCT-C with

children in upper elementary grade levels. The primary methodological limitation was the

use of clinical measurement scales to assess children with subclinical levels of symptoms,

which may have reduced the significance and strength of the results. Also, the small sample

size and lack of control group comparison further limits the results. While the quantitative

results are weak for supporting the effectiveness of MBCT-C on internalizing and

externalizing symptoms, the qualitative results show that the intervention has much potential

for such treatment effectiveness, and warrants further investigation (Lee et al., 2008).

Mindfulness Training with Middle School Age Youth Very few studies currently exist that use mindfulness training exclusively with middle

school age youth. Table 3 summarizes two clinical studies were found that use mindfulness

training as either a sole intervention, or a core aspect of a treatment approach. Singh et al.

(2007) evaluated a mindfulness training program with three early adolescents (13-14 years of

40

Tab

le 3

. Stu

dies

of M

indf

ulne

ss-B

ased

Inte

rven

tions

with

Mid

dle

Scho

ol A

ge Y

outh

Stu

dy

Age

/ G

rade

N

Tr

eatm

ent

Pro

gram

R

esea

rch

Des

ign

Par

ticip

ant C

hara

cter

istic

s S

ettin

g D

epen

dent

Var

iabl

es

Out

com

es

Sin

gh, e

t al.

(200

7)

13-1

4 ye

ars,

7th

gra

de 3

Min

dful

ness

M

edita

tion;

4

wee

ks -

3x

wee

kly;

25

wee

ks -

15 m

in

Mul

tiple

bas

elin

e ac

ross

sub

ject

s de

sign

Con

duct

dis

orde

r dia

gnos

is;

thre

at o

f sch

ool e

xpul

sion

; C

auca

sian

Mid

dle

scho

ol

Con

duct

dis

orde

r be

havi

ors:

agg

ress

ion

and

nonc

ompl

ianc

e (R

etro

spec

tive

data

from

sc

hool

reco

rds;

teac

her

and

self-

repo

rt pr

ospe

ctiv

e da

ta)

Sub

stan

tial p

erce

ntag

e de

crea

ses

in a

ggre

ssio

n an

d no

ncom

plia

nce

durin

g 25

wee

k pr

actic

e pe

riod

Wal

l (20

05)

6th to

8th

gr

ade

11

MB

SR

+ T

ai

Chi

; 5 w

eeks

, 1

hr w

eekl

y

Non

e N

oncl

inic

al v

olun

teer

s M

iddl

e sc

hool

N

one

Info

rmal

obs

erva

tions

; po

sitiv

e st

uden

t fe

edba

ck, p

rogr

am

acce

ptab

ility

and

fe

asib

ility

41

age), who were diagnosed with conduct disorder, and at risk of being expelled from middle

school. Each adolescent had a long history of several conduct disorder behaviors (aggression,

bullying, fire setting, cruelty to animals, noncompliance, etc.), as well as significant

impairment in social and academic functioning. A therapist initially met with each of the

students individually for 15 minutes, three times a week for four weeks to provide

mindfulness instruction. During a second phase, the therapist met with each adolescent

15 minutes per week, for 25 weeks, to review and discuss their daily mindfulness practices,

and in connection with their behavior at school. The treatment program was called

Meditation on the Soles of the Feet, which teaches the student to shift attention “from an

emotionally arousing or anxiety-provoking situation to an emotionally neutral part of his

body that evokes calmness” (p. 57). Its purpose is to help the individual calm down and

engage with awareness in the present moment, allowing him/her an opportunity to avoid an

aggressive response. The authors used school records to gather retrospective data on the

adolescents’ behaviors, as well as self-report and teacher reports to track changes in two

behaviors related to conduct disorder. For all three adolescents, bullying and aggression did

not decrease significantly during the mindfulness training phase, but it decreased

substantially during the subsequent 25-week practice phase. Among other variables, one boy

experienced a 52% reduction in fire setting, while another had an 18% reduction in cruelty to

animals. Follow-up data was taken one year after the 25 week practice phase with optimistic

results: all three students were able to graduate from middle school, without further possible

expulsions due to their unruly behaviors. The problem behaviors at school were not

extinguished, however they were reduced enough that the students were not expelled.

Adolescents described other benefits of using mindfulness, such as relaxing, reacting less

impulsively, better sleep, and ability to focus on tasks more easily. Furthermore, they

reported an ability to use the practice even when the therapist was no longer offering

instructions.

Singh and colleagues (2007) state that there is a strong need for evaluating self-

management techniques that adolescents can use to deal with their destructive behaviors.

While cognitive behavioral approaches have demonstrated the best approaches thus far

towards these ends, they are not very effective as long-term strategies, especially without the

continual support of a therapeutic group. In this program, the therapist offered the

42

adolescents a strategy to assume control of their own recovery and responsibility for their

behaviors, with techniques to self-regulate their aggression enough to stay in school. This

exploratory study breaks new ground in research of using mindfulness training with early

adolescents with conduct disorder. The findings are encouraging for both mental health

professionals and school administrators who are interested in longer term solutions at

reasonable costs for dealing with aggressive and troubled youth (Singh et al., 2007).

However, the study is limited by no standardized outcome measures, no control group, and a

very small sample. The training was different in content and structure from traditional

MBSR/MBCT, making it difficult to compare to other findings (Burke, 2009; Singh et al.,

2007).

In another study at a school setting, Wall (2005) describes a clinical project of

combining MBSR with Tai Chi practice with eleven middle school students (6th-8th grade;

five boys) during a five week program. Wall investigated the potential of this one-hour

weekly modified mindfulness training program to sustain the interest of middle school

students and offer some beneficial life skills. All of the students participated voluntarily in

the course and were offered the option to leave at any time during an individual session or all

five weeks. The author reports that during the course, students shared positively about their

experiences and benefits from the program: experiences of calmness, relaxation, and well-

being; less reactivity; improved sleep and overall self-care, greater self-awareness, and

feelings of connection with nature. Without outcome measures, however, the study cannot

assess the efficacy of the program. Since MBSR is offered as part of a larger training

program, direct comparison with other MBSR programs is also limited (Burke, 2009).

Nevertheless, as Wall concludes, the students had continued motivation and interest in the

course, and made positive statements about their involvement, suggesting that this combined

mindfulness and Tai Chi training is a feasible and acceptable program for this age group, can

be implemented in educational programs, and may offer transformational tools for middle

school students (Wall, 2005). Considering the lack of evidence of mindfulness solely with

this age group, the findings are important first steps in the initial testing of mindfulness-based

programs in school settings.

43

Mindfulness Training with High School Age Youth Table 4 summarizes five studies of mindfulness-based interventions with high-school

age youth. To date, the strongest study evaluating MBSR with adolescents was performed by

Biegel, Brown, Shapiro, and Schubert (2009), using an RCT design with adolescents (14-18

years) at an outpatient psychiatric facility. The sample of adolescents (intent to treat N = 102)

had various mental health diagnoses, and ongoing psychiatric care. The MBSR treatment was

used as an adjunct to TAU, and compared to a waitlisted group of TAU only. A manualized

intervention included two-hour sessions for eight weeks, and was adapted from traditional

MBSR for this adolescent population. For example, at-home practices were reduced in

length, there was no day long retreat, and discussions about stress were geared towards issues

of self-image, life transitions, self-harming behaviors, and difficulties with communications

and relationships.

Results of the study showed that both completers and intent to treat participants of the

MBSR + TAU group had significant improvements in self-reported measures of anxiety,

depression, self-esteem, and quality of sleep, when compared with those in the TAU group.

The completers group also had significant reductions in self-reported perceived stress,

interpersonal difficulties, and obsessive symptoms, compared to the control group. The

outcome measure scales used for self-report were standardized and most had strong levels of

reliability and validity. MBSR participants had increased GAF scores as well as improved

diagnostic changes. Almost half (45%) of the MBSR group showed improved diagnostic

change, whereas only one of the waitlisted participants did. These findings were strengthened

by having clinicians who were naïve about the research study and treatment groups, to

perform the diagnostic evaluations including GAF scores. The amount of formal at-home

practice was significantly or marginally associated with improved changes in clinical or self-

report measures; particularly, average length of practice session and number of days of

mindful sitting practice. A completion rate of 78% demonstrated treatment acceptability. In

summary, the study offers promising evidence that MBSR has significant positive effects on

self-reported and clinical measures that are sustained at least eight weeks after treatment is

completed. Further studies may demonstrate replicability and generalizability of these

findings with other adolescent populations, of different ethnic backgrounds, diagnostic

criteria, or other life situations (Biegel et al., 2009).

44

Tab

le 4

. Stu

dies

of M

indf

ulne

ss-B

ased

Inte

rven

tions

with

Hig

h Sc

hool

Age

You

th

Stu

dy

Age

/ G

rade

N

Tr

eatm

ent

Pro

gram

R

esea

rch

Des

ign

Par

ticip

ant

Cha

ract

eris

tics

Set

ting

Dep

ende

nt V

aria

bles

O

utco

mes

Bie

gel e

t al.

(200

9)

14-1

8 ye

ars

102

MB

SR

; 8

sess

ions

, wee

kly;

2

hour

per

se

ssio

n

RC

T (T

AU

); pr

e-po

st; 3

m

onth

follo

w-

up w

ithin

gr

oup

Ado

lesc

ents

un

der

psyc

hiat

ric c

are

Out

patie

nt

psyc

hiat

ric

clin

ic

Psy

chia

tric

diag

nosi

s, G

AF

(blin

d cl

inic

ian

repo

rted)

; stre

ss,

psyc

hiat

ric s

ympt

oms,

sel

f-es

teem

, alc

ohol

/ ill

icit

drug

use

(s

elf-r

epor

t).

Impr

oved

GA

F an

d di

agno

stic

ch

ange

s. S

igni

fican

t im

prov

emen

ts in

stre

ss,

anxi

ety,

dep

ress

ion,

sel

f-es

teem

, qua

lity

of s

leep

, in

terp

erso

nal d

iffic

ultie

s, a

nd

obse

ssiv

e sy

mpt

oms.

Zylo

wsk

a et

al.

(200

8)

Ado

l m

ean:

15

.6

year

s

24

adul

ts

and

8 ad

ol

MA

Ps

with

ps

ycho

educ

atio

n;

8 se

ssio

ns,

wee

kly,

2.5

hou

rs

Pre

-pos

t w

ithin

pa

rtici

pant

AD

HD

dia

gnos

is

or “p

roba

ble

AD

HD

”; et

hnic

ity

unkn

own

Unk

now

n A

DH

D, d

epre

ssio

n, a

nxie

ty

sym

ptom

s, a

nd w

orki

ng m

emor

y (s

elf-r

epor

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(200

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34

Min

dful

ness

m

edita

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5-1

0 m

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w

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s w

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m

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unkn

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l ski

lls, p

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, ac

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ce (t

each

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repo

rt); s

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lls, a

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ty (s

elf-

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rt); e

valu

atio

n qu

estio

nnai

re

Impr

oved

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kills

, pr

oble

m b

ehav

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dem

ic

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ent,

stat

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tzin

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vens

(2

005)

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9 ye

ars

55

MB

SR

+ c

ombo

sl

eep

ther

apy

treat

men

t; M

BS

R

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ses

sion

s

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and

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onth

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-ups

in

tent

to tr

eat

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ep

dist

urba

nces

, al

coho

l / d

rug

use;

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mal

e;

66%

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casi

an

Clin

ic

Sle

ep q

ualit

y an

d m

elat

onin

le

vels

(lab

), su

bsta

nce

abus

e,

men

tal h

ealth

dis

tress

, wor

ry,

slee

p qu

ality

(sel

f-rep

ort)

Impr

oved

sle

ep e

ffici

ency

and

qu

ality

, men

tal h

ealth

dis

tress

an

d w

orry

ing;

follo

w-u

p de

crea

sed

drug

use

for

com

plet

ers

only

45

In another study supported by MARC at UCLA, Zylowska et al. (2008) tested the

feasibility of an 8-week MAPs with a combined group of 24 adults and eight adolescents (15

years of age and older) with ADHD or “probable ADHD”. The authors' rationale for this

pilot study is that ADHD includes many self-regulation impairments related to difficulties in

attention, motivation, and emotional regulation. Mindfulness is a self-regulatory practice that

appears to improve attention control skills, emotional self-regulation, and impulsive

behaviors, thereby possibly reducing vulnerability to psychiatric symptoms of ADHD. The

MAPs program is based on the MBSR model and includes weekly sessions of 2.5 hours with

daily home practice assignments. The program was modified by including a psychoeducation

module about ADHD. In pre-to post-MAPs changes, 18 of 23 (78%) participants reported

improvements in ADHD symptoms, and 7 of 23 (30%) had clinically significant reductions.

In the domain of neurocognitive task performance, participants demonstrated significant

improvements in measures of attentional conflict and set-shifting. The adolescent participants

demonstrated high completion (87%) and attendance (average 7 to 8) rates, very high levels

of course satisfaction (9.35 of 10), and weekly attempts at home-practice (42.6 minutes per

week), suggesting feasibility and acceptability in this modified MAPs program for

participants with ADHD. The findings suggest potential benefits of mindfulness training with

this population of adolescents (Zylowska et al., 2008). Given the high rates of youth

diagnosed with ADHD (Merikangas, He, Brody, et al., 2010) as previously discussed,

mindfulness training may be an effective and worthwhile strategy for schools to strengthen

these students' attention and self-regulatory capacities.

Bogels and colleagues (2008) conducted a study with adolescents (11-18 years) who

presented with a variety of different externalizing disorders: ADHD, ODD, CD, and Autism

Spectrum Disorders (ASD). Fourteen adolescents and their parents partook in parallel 8-week

mindfulness courses, using an overall MBCT structure. Due to the youths' shorter attention

spans, the practice was modified by shortening meditation exercises, including more concrete

tasks and more variety to sustain interest (e.g. yoga, massage, mindful walking outdoors,

mindful eating, and mindful speech). In addition the training placed emphasis on relevant

topics for this population of youth, including impulsivity, selective attention, communication,

and identity. Children demonstrated significant improvements from pre- to post-test on

measures of personal goals, attention, awareness, impulsivity, being attuned, social problems,

46

and happiness. Internalizing and externalizing symptoms also decreased significantly.

Improvements were maintained at 8-week follow-up; this is an encouraging result as youth

with attention and impulsive related disorders typically have difficulty maintaining and

generalizing what they learn in group therapy. The therapist trainers earned the positive

results with “hard work”, as adolescents showed overt non-compliant behaviors such as

smoking during mindful walking outdoors, and listening to MP3 players during mindful

eating. Due to the severity of non-compliant behaviors for these youth and its typical impact

on families, the authors suggest that “from a prevention point of view, it may be worthwhile

to investigate mindfulness training in younger children at risk for externalizing disorders”

(2008, p.206). Mindfulness training at any age before the onset of greater non-compliant

behaviors may be helpful as a primary prevention program for these youth and families, with

possible long-term benefits after receiving treatment.

Beauchemin et al. (2009) evaluated the acceptability and usefulness of mindfulness

meditation for students with learning disabilities (LD). This pilot study evaluated 34

voluntary participants (13 to 18 years) in four classes (8 to 12 students each) in a specialized

school setting. The intervention differed significantly from MBSR: after receiving a 2 hour

training, the classroom teachers delivered the majority of the intervention, consisting of 5 to

10 minute meditation sessions at the start of every class period during the week for 5 weeks.

The findings included significant reductions from pre- to post-test in measures of both state

and trait anxiety, and improvements in student-reported social skills. Teacher ratings of

student social skills, problem behaviors, and academic achievement all showed significant

improvements from pre- to post-test as well. Students reported through evaluation

questionnaires that the program was enjoyable, helped them to focus in class, and that they

would continue to practice on their own. While the findings are very positive, the study has

strong limitations such as no control or comparison group. Also, the mindfulness meditation

training is so different from MBSR or MBCT formats, that comparisons cannot be made.

Nevertheless, the study lends further support that time and cost-effective mindfulness

interventions may help schools to maximize their academic and behavioral services to

students.

Bootzin and Stevens (2005) report using MBSR as part of a multi-component group

treatment to treat sleep problems in 55 adolescents (ages 13-19) who had recently finished a

47

substance abuse treatment program. The treatment combined mindfulness training with

cognitive therapy, sleep hygiene education, bright light exposure, and stimulus control

education in a group-based intervention (2 to 6 participants). Participants were mostly male

(62%), approximately two-thirds were Caucasian, had sleep disturbances, used alcohol and

marijuana, and most used other drugs as well. At post treatment, completers (attending 4 of 6

sessions) showed significant improvements in sleep quality: sleep efficiency (p < 0.001),

total sleep time (p < 0.05), and self-ratings of quality of sleep (p < 0.001). All participants

(p < 0.05) also showed significant reductions in levels of mental health distress and

worrying. While drug use increased during the program, at follow-up periods, completers

reported decreases in drug use, while noncompleters reported increases, suggesting a possible

delayed effect of the program on adolescent drug use. A challenge for this treatment was that

less than half, only 23 of 55 participants completed the program, compared to 32

noncompleters; however, this may be representative of this challenged population of

adolescents. Of those who completed the program, 17 of 18 expressed that the program had

lasting value and gave average importance ratings (5.38 out of 7) in anonymous satisfaction

forms. Limitations of the study include the small sample size, and no control group. As

MBSR was included as part of a larger treatment package, it is not possible to assess the

contributing effects of mindfulness training. Nevertheless, the study offers preliminary

evidence of other possible benefits for adolescents, namely better sleep quality.

ORGANIZATIONS SUPPORTING MINDFULNESS TRAINING FOR YOUTH IN SCHOOLS AND OTHER SETTINGS

Mindfulness training for students is also gaining wider support in public education, as

several organizations are dedicated to implementing mindfulness programs in K-12 schools.

The Association of Mindfulness in Education (AME), primarily based in Northern

California, is a “collaborative association of organizations and individuals working together

to provide support for mindfulness training as a component of K-12 education” (Association

for Mindfulness in Education, 2009). The association offers workshops and conferences in

California, and suggests that mindfulness is a foundation for education, offering optimal

learning and teaching conditions in the classroom. On the East coast, the primary umbrella

organization is the Mindfulness in Education Network (MiEN), founded in 2001 by a group

48

of educators and mindfulness practitioners. MiEN's mission is to build communication and

networks among educators, parents, students, and others to foster the growth of mindfulness

in education, both for teachers and students. They see mindfulness as “an antidote to the

growing stress, conflict, and confusion in educational settings as well as an invaluable gift to

give students” (Mindfulness in Education Network, n.d.). MiEN sponsors the annual

Mindfulness in Education Conference bringing together the country's leading teachers and

researchers of mindfulness with youth, and others interested in learning how to implement

mindfulness training in schools.

There are also a growing number of organizations that are dedicated primarily to

teaching mindfulness in schools and other institutions. In the Bay Area of Northern

California, Mindful Schools offers in-class mindfulness instruction to students, a multi-level

training for teachers, parents, and other professionals working with children. As of 2011, the

non-profit organization has offered mindfulness instruction to over 10,000 children and 450

teachers in 38 schools, two-thirds of which serve low-income children. Additionally, Mindful

Schools have provided mindfulness instruction to over 1200 public and private school

parents, teachers, therapists, and other professionals in education and social work. Mindful

Schools claims that its programs bring “dramatic improvements in concentration, attention,

and empathy among students, while building a climate of calm in the classroom” (Mindful

Schools, 2010). The organization is currently conducting studies to assess the effectiveness

of their programs in schools. The previously mentioned organization, Inner Kids teaches

mindfulness to young children through games, activities and instruction, in order to foster

“the New ABCs – Attention, Balance & Compassion” (Greenland, n.d.). The Inner Kids

program has provided mindfulness instruction to both classrooms in LA schools consistently

since 2000. Its program is adapted towards children's developmental stages, using a

combination of play, followed by introspection, and then discussion to help children: (1)

become more attuned to their introspective experiences, (2) learn its significance to their

daily lives, and (3) understand the value of helping in their families and communities

(Greenland, n.d.). A non-profit serving the Virginia and D.C. Area, Inward Bound

Mindfulness Education (iBme) teaches a blend of mindfulness with social-emotional learning

to youth and adults who serve youth. Programs at iBme include weekend and week-long

retreats; on-site training in schools, mental health agencies, and juvenile halls; as well as a

49

five week-long summer seminar. iBme's mission is to “provide fun and age appropriate

opportunities for young people to learn and practice mindfulness skills that enhance mental

focus, strengthen inner-resilience, and develop social, emotional, and ecological intelligence”

(Inward Bound Mindfulness Education, n.d.). Similar to other programs mentioned, iBme

uses age appropriate activities to instill the essence mindfulness in a way that makes the

practice interesting, relevant, and attractive to youth.

These initiatives are just a few examples of what appears to be a growing interest and

movement of efforts to teach mindfulness skills to youth in schools and other youth-based

settings. The Garrison Institute Report (2005) explored nationwide applications of

mindfulness with children and adolescents in schools and community centers. Their

investigation found that while there was not much empirical evidence regarding the

effectiveness of mindfulness programs, dozens of institutions were implementing such

programs. General outcomes were that youth gained more self-awareness, more capacity for

self-reflection, as well as increased emotional intelligence and social skills (Garrison Institute

Report, 2005; Thompson & Gauntlett-Gilbert, 2008).

SUMMARY The high rates of mental and emotional health problems for children and adolescents

are occurring at earlier ages than previously expected. Prevention programs which are

designed to strengthen the attention and emotional coping skills of youth at earlier ages may

not only buffer our youth from harmful risk factors, but also empower them to focus more on

their academic and life goals (Bogels et al., 2008; Saltzman, 2008). Initiatives to offer

mindfulness skills to youth of different ages and backgrounds are springing up around the

county. Not only clinical programs, but schools and community centers are exploring

mindfulness programs to help youth foster attention skills, greater self-awareness, improved

impulse control, and decreased emotional reactivity to difficult situations (Saltzman, 2008;

Thompson & Gauntlett-Gilbert, 2008). Preliminary research studies have shown that youth of

various ages and mental health status who receive mindfulness training have demonstrated

improvement in other domains such as increased selective attention control, self-compassion,

quality of sleep, personal goals, social skills, academic achievement, and happiness; and

decreased internalizing and externalizing behaviors, aggression, noncompliance, impulsivity,

50

quality of sleep, interpersonal difficulties, obsessive symptoms, mental health distress,

general stress, long-term drug use, state and trait anxiety, test anxiety, interpersonal

difficulties and social problems. Considering these potential benefits and the high risk factors

that youth are exposed to today, parents, teachers, counselors, and other youth advocates may

be posing the question, why not offer these trainings to our youth?

While there is a growing popularity and use of mindfulness-based programs with

youth, the empirical evidence documenting their effectiveness is still small, just beginning,

and not reliably tested with youth across various backgrounds and ages. In order to truly

answer the previously stated question to parents and schools, more studies are needed to

demonstrate that mindfulness-based programs are reliably effective, in what domains they are

most effective, with what populations, and in what formats. The current literature indicates

that while applications of mindfulness training are being evaluated with youth having diverse

backgrounds of mental health symptoms and levels, age, and ethnic background, there are

still wide chasms in the research base. To the author’s current knowledge, no studies have

explored teaching a mindfulness course to a class of middle school students in their natural

school environment. However, there have been some encouraging findings of mindfulness

training done individually or with small groups of middle school students as a stand-alone

treatment or as part of a combined program (Singh et al., 2007; Wall, 2005). Furthermore,

Napoli and colleagues (2005) found great results in teaching classes of elementary students

in their school classrooms. These findings suggest that applications with classes of middle

school students may be feasibly implemented and effective. Another gap in the research is

that researchers have yet to explore the possibility of offering mindfulness training to youth

who are facing homelessness. Such youth may be exposed to a greater number of risk factors

than youth on average, making programs that teach emotional coping skills even more

potentially valuable to their situations. Social workers or other professionals who work with

youth and are committed to serving vulnerable populations may well inquire about the

effectiveness of mindfulness-based interventions to serve the interests and needs of these

youth. The following chapter will build upon the evaluation of evidence presented here in the

literature review through posing research questions and subsequent hypotheses that are

relevant and meaningful for the developing field of mindfulness-based interventions with

youth.

51

CHAPTER 3

RESEARCH QUESTIONS AND HYPOTHESES

In the review of literature, evidence supporting the use of mindfulness-based

interventions with children and adolescents was evaluated among different age groups. Based

upon past research conducted in this field, as well as chasms in the current evidence base, the

author poses two research questions which serve as a foundation for the current study. Each

research question is followed by two or three hypotheses which are also guided by supporting

evidence from past studies.

SUPPORTING EVIDENCE FOR RESEARCH QUESTIONS AND HYPOTHESES

A first research question is whether middle school students receiving an 8-week

mindfulness course will demonstrate changes across the three measures of acceptance and

mindfulness, psychological inflexibility, and self-compassion, from baseline to post-

intervention. According to the literature, mindfulness training with elementary school

students and their parents has demonstrated improvements in metacognitive functioning

(i.e. self-compassion) (Saltzman & Goldin, 2008). Mindfulness teaches recognition and

acceptance of one's thoughts and feelings, and not identifying with or becoming lost in them,

which is counter to the premises of psychological inflexibility, characterized by experiential

avoidance and cognitive fusion (Greco, Lambert, & Baer, 2008). Mindfulness training has

also been conducted with elementary and high school age students in schools with

encouraging results in various domains of cognitive and emotional well-being (Beauchemin

et al., 2009; Napoli et al., 2005; Semple et al., 2005; Singh et al., 2007). Therefore, it is

hypothesized that students in the first treatment group participating in the mindfulness course

will make significant improvements from pre- to post-test in these three domains. It is also

hypothesized that the changes will be significantly greater than pre- to post-test changes in a

non-equivalent comparison group, comprised of a separate class of students in the same

middle school.

52

While there is no empirical evidence of mindfulness training with homeless youth,

the literature reveals that mindfulness training has been successfully implemented in various

settings with youth across a variety of socio-economic and ethnic backgrounds, mental health

challenges, academic problems, and substance abuse problems (Beauchemin et al., 2009;

Bogels et al., 2008; Bootzin & Stevens, 2005; Burke, 2009; Singh et al., 2007; Zylowaska

et al., 2008;). Previous studies have also demonstrated positive results with inner-city

children with academic problems (Lee et al., 2008). Given the successful implementation of

mindfulness training with diverse populations of youth, it is hypothesized that students

receiving an 8-week mindfulness course at the school for homeless youth will demonstrate

significant improvements in the three domains from pre- to post-intervention. It is also

hypothesized that the changes over time will be significantly greater than a comparison group

of students in a separate classroom.

A second research question is whether a mindfulness course will be acceptable for

both groups of middle school students and feasibly implemented in their classroom setting, as

demonstrated by students' completion of the mindfulness course, and student responses in

participant evaluation questionnaires. The literature suggests that when delivered in school

settings, mindfulness programs sustained the interest, motivation, and enjoyment of both

elementary and high school students (Beauchemin et al., 2009; Lee et al., 2008), though a

strictly mindfulness based program has yet to be delivered to a class of middle school

students. Qualitative responses from elementary level students reveal positive comments

about their experiences of mindfulness programs (Lee et al., 2008; Saltzman & Goldin,

2008). Mindfulness training has also been taught as part of a larger intervention package to

middle school students which resulted in favorable anecdotal reports and clinical

observations about student interest and motivation (Wall, 2005). Therefore, it is hypothesized

that a mindfulness course delivered in a classroom setting will be acceptable for students

attending a traditional middle school, as demonstrated by student completion of the course

and quantitative and qualitative feedback from evaluation questionnaires. It is also

hypothesized that a mindfulness course implemented in a school for homeless youth will be

acceptable to middle school students based on their completion of the course as well as

quantitative and qualitative feedback from student evaluation questionnaires.

53

RESEARCH QUESTIONS AND HYPOTHESES PRESENTED Research Question 1: Will students in middle school receiving an 8-week

mindfulness course demonstrate changes in acceptance and mindfulness, psychological

inflexibility, and self-compassion?

H1: Students in treatment group one, who are attending a traditional charter middle school will show significant improvements from pre- to post-test on measures of acceptance and mindfulness, psychological inflexibility, and self-compassion.

H2: Treatment group one will show significantly greater improvement on measures of acceptance and mindfulness, psychological inflexibility, and self-compassion by the end of the mindfulness course as compared to a comparison group of students who did not receive the course.

H3: Students in treatment group two attending a middle school serving homeless youth will show significant improvements from pre- to post-test on measures of acceptance and mindfulness, psychological inflexibility, and self-compassion.

H4: Treatment group two will show significantly greater improvement on measures of acceptance and mindfulness, psychological inflexibility, and self-compassion by the end of the mindfulness course as compared to a comparison group of students who did not receive the course .

Research Question 2: Will an 8-week mindfulness course be acceptable for middle

school students and feasibly implemented in their classroom setting, as demonstrated by

completion of the mindfulness course, and qualitative and quantitative feedback from

participant evaluation questionnaires?

H5: A mindfulness course implemented in a traditional middle school classroom is expected to demonstrate treatment feasibility and acceptability as shown by completion rates of the course, as well as quantitative and qualitative feedback from students in participant evaluation questionnaires.

H6: A mindfulness course implemented in a middle school classroom that serves homeless youth is expected to demonstrate treatment feasibility and acceptability as shown by completion rates of the course, as well as quantitative and qualitative feedback from students in participant evaluation questionnaires.

54

CHAPTER 4

METHODOLOGY

The primary goal of this study is to test the research questions regarding the

feasibility, acceptability, and effectiveness of a mindfulness course for two groups of middle

school students when implemented in their school classroom. Several instruments were used

to explore the research questions and test the hypotheses that were presented in the previous

chapter. The methodology used to test the hypotheses is described in detail in this chapter.

The chapter is organized into five sections: (a) design of the investigation, (b) participants,

(c) measures, (d) statistical analysis, and (e) limitations of the methodology.

DESIGN OF THE INVESTIGATION The research design is a pre- and post-test with a non-equivalent comparison group.

Students from two classes at the traditional middle school (site #1) received the mindfulness

course, while a third classroom at this site served as the non-equivalent comparison group.

The comparison group class received a mindfulness session after data collection at site #1

was completed. Students from a class at a separate middle school for homeless youth (site

#2) also received the mindfulness course though this was time-lagged, and took place after

the mindfulness course was completed at site #1. The assessments and 8 week mindfulness

course was carried out from March through June, 2010 at site #1, and from September

through December 2010 at site #2. None of the students in the treatment or comparison

groups had previously received a mindfulness course during the school year.

All participating students in both treatment and comparison groups completed a

baseline assessment and then a post-test assessment after the 8-week mindfulness course was

finished. Pre- and post-test assessments of treatment group participants were analyzed to

determine if significant levels of change took place after the mindfulness course. The non-

equivalent comparison group was included to help mitigate the effects of maturation or other

external conditions that may affect the outcome measures in the treatment groups. Changes

55

from pre- to post-test from the participant groups were then contrasted with changes in the

comparison group to determine if there were significant differences.

PARTICIPANTS Two schools in San Diego were selected as sites for the study. The selection was

based primarily upon the schools' ongoing relationship with The Meditation Initiative (TMI),

which had been providing weekly mindfulness meditation courses in various classrooms to

the schools for several years prior to the current study. Another consideration for the study

was the grade level of students, as the principal investigator preferred to work with middle

school students, as the literature review revealed a lack of empirical research with this

population. The specific classrooms within each school site were selected for study inclusion

based upon the school administrators' recommendations, and the teachers who preferred or

agreed to have the study conducted during their classes. No screening process was conducted

and no other criteria were assessed for either including or excluding potential subjects.

Administrators and faculty members of these schools collaborated with TMI in the past and

gave their consent for the study to take place at their school/classroom site. Letters of

permission to perform data collection in the classrooms of these school sites are provided in

Appendix A. A letter from TMI to collaborate in the research study is also presented in

Appendix B. As the Meditation Initiative had previously offered mindfulness and meditation

courses to these schools, some of the faculty and administration were familiar with the aims

of the mindfulness program. Prior to commencing the study at the first site, TMI offered an

introductory mindfulness session during a school faculty meeting to help the school teachers

and administrators who were unfamiliar with the program to better understand the purpose

and potential benefits of the mindfulness program.

A charter middle school served as site #1, where students (n = 38) from two classes

agreed to partake in the study and completed baselines assessments. Students (n = 20) in a

third classroom agreed to partake in the study and served as a non-equivalent comparison

group. A second charter school which serves youth (ages 7-18) was selected as site #2. This

school serves youth who are currently or have been recently living in a homeless shelter.

Students (n = 18) from one 7- 8th grade classroom (ages 12-14) agreed to be in the study.

The teacher of this class requested and received mindfulness meditation instruction from

56

TMI for her classes of students during the past two years. A total of 76 students in both

treatment and comparison groups participated in the study.

The recruitment and informed consent process was conducted in two steps. First, the

principal investigator addressed each of the participating classrooms individually about the

proposed study. The students were asked to participate in a research study which measured

the effects of the mindfulness instruction they received weekly in their class. It was explained

that the students were already receiving a weekly mindfulness course in their classroom and

the purpose of the study was only to measure the effects of the course. The PI explained the

steps and processes of the research study, orally reviewed all of the information on the assent

form, and answered questions. The PI presented the information to the students in simple and

elementary language, similar to the language in the assent form. The PI provided the students

with a packet including the student assent and parent consent forms (Appendix C), as well as

a cover letter addressed to the parents (Appendix D). The cover letter explained the general

purpose and details of the study in a more personal manner, in order to help the parents feel

more comfortable with the research study process and increase the parents’ willingness to

read through the rest of the assent and consent forms, which are quite long and detailed. The

language of the consent form and the cover letter were about 6th grade reading level in order

to help parents who may not have much formal education to be able to understand the

documents. All of the consent and assent forms were written in English. Several students

expressed that their parents did not speak or read English, so the PI encouraged the students

to translate and explain the consent form to the parents as best as they could. In addition to

orally reviewing the assent form in class, the PI encouraged the students to take home the

assent form to review with their parents before agreeing to participate. The language used in

the assent form was about 4th to 5th grade reading level, which was deemed a sufficient

vocabulary level for the 7-8th grade students to complete in each of the classrooms. The

consent forms provided two options for the parent to “give permission” or “not give

permission” for the child to participate in the study. All of the informed assent and consent

documents as well as the cover letter were approved by the Institutional Review Board of

San Diego State University.

In order to increase the likelihood that the students would return the forms back to

their class after reviewing with their parents, the PI offered a reward of one large candy bar

57

for returning the consent and assent forms. It was clearly stated that the reward was only for

returning the forms, and was not dependent on the student's participation in the study.

Students were informed that the study and data collection would be completely

confidential, that no information which they provided on the assessment forms would be

made known to others. The PI conducted the data collection procedure. Following the

students' completion of the assessment forms, the forms were all coded and student names

were blacked out in order to protect confidentiality. The master code list was kept in a

securely locked location by the PI, and then destroyed after data collection and analysis was

completed.

Conditions and procedures for data collection at the two schools with the consenting

participants were reviewed and approved by the Institutional Review Board of San Diego

State University, and were in compliance with all federal requirements regarding human

subjects protections. A letter of approval for the study is presented in Appendix E.

MINDFULNESS COURSE INSTRUCTOR EXPERIENCE AND TRAINING

The 8-week mindfulness course provided in this study contained many different

components and was based upon the instructor’s experiences of practicing and teaching

mindfulness as well as the professional work of many other individuals. A detailed overview

of the mindfulness course is provided in Appendix F. It explains the foundations of the

course curriculum, the instructor's past experience and training, the structure of the course

and individual sessions, and the different mindfulness exercises that were offered during the

course.

MEASURES The student participants completed a demographics questionnaire at baseline, three

standardized scales at baseline and post-intervention, and a participant evaluation

questionnaire at post-intervention. All three scales have been used by leading researchers and

experts in the field of child and adolescent development, focusing on mindfulness-based

interventions for youth. Information on the assessment instruments used as outcome

measures is provided below.

58

Acceptance and Mindfulness Acceptance and Mindfulness was measured by the Child Acceptance and

Mindfulness Measure (CAMM). The CAMM assesses two categories of child cognitive and

behavioral functioning: acting with mindful awareness (e.g., “It’s hard for me to pay

attention to only one thing at a time.” [reverse scored]), and accepting internal experiences

without judging them (e.g., “I think that some of my feelings are bad and that I shouldn't

have them” [reverse scored]). The CAMM is a 10-item measure, based on a 5-point Likert

scale. It addresses the core tenets of mindfulness-based interventions such as awareness,

attention, and acceptance, while remaining developmentally appropriate for youth. It has

shown good internal consistency (α = 0.80), and is a single factor model. The CAMM

correlates significantly and negatively with scales measuring closely related processes of

psychological inflexibility (AFQ-Y) and thought suppression (WBSI), as well as with other

measures of internalizing symptoms, externalizing behavior problems, and child-reported

somatic complaints, and correlates positively with overall quality of life. And to a lesser

extent, though still significantly, the CAMM correlates in expected directions with social

skills (teacher-reported), problem behaviors, and academic competence. On a positive note,

the scale was tested with youth grades 5 through 10, with no significant differences between

age groups. However, the sample was primarily composed of Caucasian youth from middle

to lower socio-economic neighborhoods, making it less generalizable to students of diverse

ethnic and socio-economic backgrounds (Greco, Baer, & Smith, in press).

Psychological Inflexibility Psychological Inflexibility was measured by the Avoidance and Fusion Questionnaire

for Youth (AFQ-Y) (Greco et al., 2008). The AFQ-Y is a seventeen-item self-report measure

which assesses:

child and adolescent psychological inflexibility characterized by high levels of experiential avoidance (e.g. “I push away thoughts and feelings that I don't like”), cognitive fusion (e.g. “The bad things I think about myself must be true”), and behavioral ineffectiveness in the presence of unpleasant emotions (e.g. “I do worse in school when I have thoughts that make me feel sad”) (Greco et al., 2008, p. 96).

Subjects rated the items based on a five-point Likert scale. The authors of the scale

performed a multimethod psychometric approach which provided support for the validity and

59

reliability of the scale. The researchers administered the scale to three samples, for a total of

1369 children and adolescents, ages of nine to seventeen years. They reported convergent

validity and good internal consistency (Cronbach's α = 0.90 to 0.93). The scale's convergent

validity was supported by a positive correlation with a measure of thought suppression, the

White Bear Suppression Inventory (WBSI) (Wegner & Zanakos, 1994), as well as a negative

correlation with measures of mindfulness and acceptance (CAMM) (Greco & Baer, 2006).

The AFQ-Y was also shown to have a positive correlation with child problem behaviors and

internalizing symptoms, and a negative correlation with quality of life for youth (Coyne,

Cheron, & Ehrenreich, 2008). The authors of the AFQ-Y state that the scale was needed to

assess clinical intervention processes and outcomes in the fast growing field of mindfulness

and acceptance-oriented approaches (Greco et al., 2008).

Self-Compassion Self-Compassion was measured by the Self-Compassion Scale for Children

(Saltzman, unpublished). This scale was developed for use in the mindfulness-based stress

reduction program for school-age children and their parents (Saltzman & Goldin, 2008). This

scale is a child-modified version of the Self-Compassion Scale (SCS) (Neff, 2003) for

adolescents and adults. While the adult scale has been used with high school students, the

vocabulary is too advanced for use with middle school students. Neff describes self-

compassion as being “kind and understanding toward oneself... rather than being harshly

self-critical; perceiving one's experiences as part of the larger human experience rather than

seeing them as isolating” (p. 23). It also entails holding “thoughts and feelings in mindful

awareness, rather than over-identifying with them” (p. 223). In Neff's development and

validation of the scale, results indicated that self-compassion is positively correlated with

positive mental health outcomes such as higher life satisfaction and less depression and

anxiety. The internal consistency of the SCS was found to be .92 (Neff, 2003). Saltzman's

child-modified version of 26 items attempts to retain the original meaning of the adult

version as much as possible. During discussions with both Saltzman and Neff regarding

appropriateness of the scales for use middle school students, both of them encouraged the PI

to use the children's version. In her research on the effects of mindfulness-based stress

60

reduction with school-age children and parents, Saltzman used the self-compassion scale for

the children and the SCS for the parents (Saltzman & Goldin, 2008).

Demographics Questionnaire The Demographics Questionnaire is in Appendix G. The demographics survey was

developed by the investigator with the help of his faculty sponsor, Dr. Mathiesen. It is an 11-

item questionnaire designed to gather basic information about all of the subjects (e.g., age,

grade level, ethnicity, school behavior). It also pays special attention to lifestyle and family

issues that may be relevant to students who have faced homelessness (e.g., “Where do you

live right now?” and “How long have you been living there?”). The teacher of students at site

#2 also provided feedback on the scale, suggesting that some of the wording and content be

modified due to sensitive issues for students who experience homelessness. For example, the

option of living “on the streets” was removed from the question of “Where do you live right

now?”. The teacher explained that none of the students actually lived on the streets and the

question may feel degrading or be confusing for the students. Other options, such as “In a

car” and “In a motel” were included in the response boxes, as the teacher explained that some

of the students did face those circumstances.

Participant Evaluation and Questionnaire The Participant Evaluation and Questionnaire is in Appendix H. The participant

questionnaire was adapted from an original version created by Lee (2006) to evaluate the

students' overall experiences in an MBCT-C program, as part of a controlled clinical trial.

The survey consists of ten questions rated on a 5-point Likert scale such as “How would you

rate the Mindfulness Course for students?” or “Mindfulness has helped me at school”. Lee's

version also includes ten open-ended questions, with sentence completion options: “The best

part of the program is...” or “My least favorite exercise is...”. The questionnaire used in the

present study included only five of the open-ended questions, in order to shorten the total

amount of assessment questions for the participants. The original version also included a

third section of the questionnaire to evaluate the acceptability of certain mindfulness

exercises, however this section was not included either for the previously stated reason. The

questionnaire used in the present study included a longer open-ended question, given in the

61

form of a letter writing exercise. This exercise has been used in other studies of mindfulness

with children (Lee, 2006; Saltzman & Goldin, 2008). Participants were asked to write a letter

to a friend, whether real or imaginary, and to describe “what mindfulness is, how it feels to

rest quietly and calmly in mindfulness, and how you are able to use mindfulness in your daily

life”. Thematic analysis was performed on responses to the sentence completion questions

and the letter writing exercise as measures of qualitative data for program evaluation.

STATISTICAL ANALYSES All analyses were conducted using SPSS version 19.0. In the demographics tables,

significant differences among items between the treatment and comparison groups were

calculated using the Chi-Square Goodness of Fit Test for ordinal and nominal values and a t-

test was used for ratio values. Results with the three standardized scales were calculated

using the one-way within subjects analysis of variance (ANOVA) to test for significant

differences between pre- and post-test outcome measures for both treatment groups. Since

the sample sizes were rather small, within-subjects repeated measures ANOVA was also

conducted comparing the pre and post-test results with both treatment groups together. Next,

changes from pre to post-test scores from each of the treatment groups was compared with

changes from pre- to post-test scores of the comparison group, using the one-between-one-

within subjects analysis of variance (ANOVA). Graphs depicting the pre-to post test changes

of the treatment and comparison groups for each outcome measure were performed with

plots of the repeated measures ANOVA. For the participant evaluation and questionnaire, a

simple frequency depiction and table graphs were performed in order to show how students

responded to the close-ended Likert-scale questions. Results were displayed by showing the

total number or percentage of students' responses to each question. Finally, thematic analysis

was performed on the sentence completion and open-ended questions, with the help of a

research assistant who had not been previously involved with the study. The PI and the

research assistant each separately reviewed the student responses, eliciting frequently cited

thematic elements. Independently identified themes were compared and discussed between

the PI and research assistant, and then consensus was determined for each theme.

Subsequently, student responses were categorized for expressing either one or more of the

identified themes.

62

LIMITATIONS OF THE METHODOLOGY Two significant limitations exist in the study that are related to the methodology: two

measurement tools have not been validated, and lack of experience and training of the

mindfulness instructor. The child version of the Self-Compassion Scale (Neff, 2003) has not

undergone reliability or validity testing. Saltzman (unpublished) modified the adult version

of the scale, by rewording many of the items in age appropriate language for children.

Saltzman and Goldin's (2008) study is the only source thus far to report the use and results of

the scale. It is unknown whether the child modified version is a valid measure of self-

compassion for children in general, as well as for children of different age groups or ethnic

backgrounds. A participant evaluation questionnaire was used to gather student feedback

about the mindfulness course and to what extent they apply mindfulness in their lives. The

questionnaire was created by Lee (2006) for a study of mindfulness-based cognitive therapy

for children (MBCT-C), and has not undergone validity or reliability testing.

A last limitation mentioned here is regarding the instructor's experience of teaching

mindfulness to youth. The details of training and experience are more adequately described

in the Mindfulness Course Overview in Chapter 4. For this section, it suffices to say that

while the instructor has had extensive training in mindfulness practice and a moderate

amount of experience teaching mindfulness to adults and youth, he has had little experience

teaching mindfulness to middle school students in a school classroom. Thus the relative

inexperience of the instructor in this format and setting limits the overall effectiveness of the

mindfulness course.

In addition, the instructor participated in a web-based training for teaching

mindfulness to children and adolescents before and during the treatment offered to TG2 only.

Further details of this training are also described in the Mindfulness Course Overview.

Despite the new training, the instructor still taught the same basic format of instruction to

both treatment groups, with similar mindfulness exercises; although the ultimate delivery and

skillfulness of the instruction changed with the enhanced training. Due to the experience of

providing several months of instruction to TG1, as well as the web-based training between

treatment groups, TG2 was provided with a slightly different and likely enhanced

mindfulness course than TG1. This is likely to have raised the quality of instruction delivered

to TG2 as well as their treatment outcomes.

63

CHAPTER 5

RESULTS

This study intended to investigate the effects of a mindfulness course when

implemented in classrooms of both traditional middle school students as well as homeless

middle school students. The two research questions inquire whether (1) a mindfulness course

will be feasibly implemented in a middle school classroom and acceptable to the sample of

students, and (2) students in the course will make changes in the domains of mindfulness and

acceptance, psychological inflexibility, and self-compassion. Chapter 5 displays the results of

the data analysis which offer evidence for the two research questions. The first section

describes participant characteristics of each treatment and comparison group and also

significant differences between the groups across the demographic variables. The second

section presents the outcome measures of the self-report scales, describing both treatment

group changes from pre- to post-test, as well as well as in comparison to the non-equivalent

comparison group. The next two sections present findings on the quantitative and qualitative

results of the participant evaluation questionnaire, which is necessary for later determining

treatment acceptability. A final section presents the course completion rates for the treatment

and comparison groups, which will be used as evidence for determining treatment feasibility.

PARTICIPANT CHARACTERISTICS Tables 5 and 6 describe the demographic characteristics of subjects in both treatment

and comparison groups. Table 5 includes ordinal and nominal demographic variables, and

Table 6 includes interval variables. The results suggest that a typical student in TG1 would

be either male or female, in 7th grade, 12.5 years old, identify as Latino, live in his parent’s

home with either his mother or mother and father together, reside there for longer than 2

years, have good class behavior, and have less than a “B” average in grades. A typical

student in TG2 would also be either male or female, in 8th grade, almost 13 years old,

identify as either African-American, Latino, or mixed race, live with his mother at a shelter

or a motel, have moved within the past 6 months, have good class behavior, have a “B”

64

Tab

le 5

. Par

ticip

ant C

hara

cter

istic

s

G

roup

ed b

y S

choo

ls a

nd C

ompa

rison

Trea

tmen

t G

roup

1

Trea

tmen

t Gro

up 2

C

ompa

rison

Gro

up

Tota

l S

igni

fican

ce

N

%

N

%

N

%

N

%

G

ende

r M

ale

16

42.1

8

50.0

11

55

.0

35

47.3

N

one

Fem

ale

22

57.9

8

50.0

9

45.0

39

52

.7

G

rade

Lev

el

6th

Gra

de

0 0

0 0

20

100

20

27.0

*

7th

Gra

de

38

100

5 31

.3

0 0

43

58.1

8th

Gra

de

0 .0

11

68

.8

0 0

11

14.9

Eth

nici

ty

Whi

te /

Cau

casi

an

1 2.

6 1

6.3

0 0

2 2.

7 *

Afri

can-

Am

eric

an

1 2.

6 6

37.5

0

0 7

9.5

† La

tino

/ Lat

ina

34

89.5

5

31.3

19

95

.0

58

78.4

Mix

ed R

ace

or O

ther

2

5.3

4 25

.0

1 5.

0 7

9.5

M

ain

Car

egiv

er

Fath

er

2 5.

3 0

.0

0 .0

2

2.7

Non

e M

othe

r 15

39

.5

11

68.8

4

20.0

30

40

.5

Fa

ther

and

Mot

her

17

44.7

4

25.0

13

65

.0

34

45.9

Mix

ed F

amily

/ O

ther

4

10.5

1

6.3

3 15

.0

8 10

.8

W

here

Liv

ing

Par

ent's

Hom

e 36

94

.7

4 25

.0

19

95.0

59

79

.7

* R

elat

ive'

s H

ome

1 2.

6 1

6.3

1 5.

0 3

4.1

S

helte

r / M

otel

/ O

ther

1

2.6

11

68.8

0

.0

12

16.2

How

Lon

g Li

ving

Th

ere

Less

than

6 m

onth

s 2

5.3

12

75.0

6

30.0

20

27

.0

* 6

mon

ths

to 2

yea

rs

10

26.3

4

25.0

4

20.0

18

24

.3

† M

ore

than

2 y

ears

26

68

.4

0 0

10

50.0

36

48

.6

B

ehav

ior

Out

stan

ding

9

23.7

2

12.5

4

20.0

15

20

.3

Non

e G

ood

18

47.4

9

56.3

8

40.0

35

47

.30

A

vera

ge

7 18

.4

5 31

.3

6 30

.0

18

24.3

Diff

icul

t 4

10.5

0

0 2

10.0

6

8.1

*

p <

0.00

1 †

p <

0.00

5

65

Tab

le 6

. Age

and

Gra

des R

ecei

ved

Gro

ups

by S

choo

ls a

nd C

ompa

rison

Trea

tmen

t Gro

up 1

Tr

eatm

ent G

roup

2

Com

paris

on G

roup

To

tal

Sig

nific

ance

Mea

n S

D

Mea

n S

D

Mea

n S

D

Mea

n S

D

Age

at p

re-in

terv

entio

n 12

.47

.56

12.8

1 .7

5 11

.30

.57

12.2

3 .8

4 *

Gra

des

Usu

ally

Rec

eive

in

Sch

ool

2.22

1.

12

1.97

1.

06

1.80

.5

0 2.

05

.98

Non

e

* p

< 0.

001

66

average in grades. A typical student in the comparison group would be either male or female,

be in 6th grade, 11.5 years old, identify as Latino, live with his father and mother together in

their home for at least two years, have good behavior, and receive above a “B” average in

grades.

In addition to further describing the sample of participants, it is helpful to understand

how the treatment and comparison groups differed significantly from each other across the

demographic variables, in order to draw conclusions from the outcome measures between the

three groups. As TG1 was composed of 7th graders, TG2 had both 7th and 8th graders and

the comparison group had 6th graders, significant differences clearly existed between all

three groups. In the variable of age however, treatment groups 1 and 2 both differed

significantly from the comparison group, but not from each other. The mean age of

participants in the comparison group (11.3 years) was more than one year younger than both

TG1 (12.5 years) and TG2 (12.8 years).

In the domain of ethnicity, students at the school for homeless youth had a more

heterogeneous sample of ethnic backgrounds, as students identified as African-American

(37.5%), Latino (31.3%), mixed race (18.8%), and Caucasian (6.3%). While students in TG1

and the comparison group identified predominantly as Latino, at 89.5% and 78.4%,

respectively., TG2 differed significantly from both TG1 (p < 0.001) and the comparison

group (p < 0.005).

In response to current living situation, half of the students in TG2 reported living in a

homeless shelter, a quarter of them reported living at their parent's home, and almost a fifth

(18.8%) reported living in a motel. In contrast, the vast majority of students in TG1 (94.7%)

and in the comparison group (95%) reported that they live at their parent's home. TG2

differed significantly (p < .001) from the other groups in this domain. For length of time that

students had been living at their current location, over 90% of the students in TG2 reported

having lived at their current location for one year or less. In contrast, over three-quarters

(76.8%) of students in TG1 and almost two-thirds (64.8%) of students in the comparison

group reported having lived at their current location for more than one year. Significant

differences existed between TG1 and TG2 (p < 0.001), between TG1 and CG (p < 0.001), as

well as between TG1 and CG (p < 0.005).

67

The average grade that students reported receiving among all three groups was a “B”

(2.05) (A = 1, B = 2,), with no significant differences among the groups. Among all three

groups, about half of the students (47.3%) indicated that teachers rated their behavior as

“good”, while nearly one quarter (24.3%) reported “average” behavior, nearly one fifth

(20.3%) reported “outstanding” behavior, and only 6.3% of students reported “difficult”

behavior. No significant differences were found. The groups did not significantly differ in

other variables such as gender and main caregiver in the home.

OUTCOMES IN ACCEPTANCE AND MINDFULNESS, PSYCHOLOGICAL INFLEXIBILITY, AND SELF-

COMPASSION As displayed in Table 7, subjects improved significantly on the CAMM from pre- to

post-intervention in TG1 (p = 0.002), and also in a combination of TG1 and TG2 (p < 0.001),

though not in TG2 alone. Participants in the comparison group experienced a negative

direction of change, with decreased scores over time. Participants in TG1 improved

significantly more over time than the comparison group (p = 0.002), and TG2 also improved

more over time than the comparison group, while closely approaching significance

(p = 0.055). A combination of TG1 and TG2 showed significant improvements over time in

relation to the comparison group (p < 0.001). Figure 1 illustrates the changes over time of all

three groups.

Table 7. Results for Three Scales

Groups by Schools and Comparison

Treatment Group 1

Treatment Group 2

Comparison Group Significance

Mean SD Mean SD Mean SD CAMM

Pre-test Post-test

AFQY Pre-test Post-test

SCS-C Pre-test Post-test

24.59 28.02

26.73 23.39

61.40 61.88

1.54 1.62

2.80 2.87

2.81 3.04

26.27 28.07

25.36 25.14

63.00 62.23

2.07 2.17

3.81 3.91

3.90 4.21

24.68 19.67

28.22 31.11

55.35 52.55

1.89 1.98

3.36 3.45

3.14 3.39

* --

† --

-- --

* TG1 improved significantly more over time than the CG (p =.002). TG2 made greater improvements over time compared to CG, that approached significance (p = .055)

† TG1 improved more over time than CG, though the results were not statistically significant (p = 0.071)

68

Figure 1. Results of children’s acceptance and mindfulness measure.

There were no significant differences from pre- to post-test in either of the treatment

groups in the AFQ-Y measures. TG1 did make improvements over time versus the

comparison group though no statistical significance was found (p = 0.071). As illustrated in

Figure 2, participants in both treatment groups experienced a positive direction of change

with improved scores at post-intervention, while participants in the comparison group

displayed a negative direction of change, with decreased scores.

For the SCS-C, there were no significant differences from pre- to post-test in the

treatment groups, nor in relation to the comparison group. As shown in Figure 3, the

comparison group showed a marked negative direction of change over time, while TG1

experienced a slight positive change, and TG2 experienced a slight negative change.

In summary, both treatment groups had greater pre- to post-test changes in all three

scales compared to the comparison group, which demonstrated a negative direction of change

in all three measures. In the domain of acceptance and mindfulness, TG1 made significant

improvements over time compared to CG, while TG2 made improved changes that

approached statistical significance. No statistical significance was found in measures of

psychological inflexibility and self-compassion for either of the treatment groups from pre-

to post-test or in relation to CG.

69

Figure 2. Results of avoidance and fusion questionnaire for youth.

Figure 3. Results for self-compassion scale for youth.

70

PARTICIPANT EVALUATION QUESTIONNAIRE: QUANTITATIVE RESULTS

Student responses to ten Likert-scale questions in the participant evaluation

questionnaire are displayed in Table 8. There were mixed findings in student evaluations,

especially between the two treatment groups. TG2 reported the most positive feedback about

the program and applications of mindfulness practice in daily life. For example, 86% of the

students either liked or loved the mindfulness class, and the same percentage agreed or

strongly agreed that they would recommend the program to their friends. When asked

whether they would continue to use mindfulness skills after the class was over, 79%

indicated they would. Seventy-nine percent of students also said that mindfulness has helped

them at school, and that mindfulness has helped them to manage their anger. Lastly, 71%

agreed that mindfulness has changed the way they interact with others, and no students

disagreed with this statement.

Table 8. Results for Participant Evaluation Questionnaire Grouped by Schools and Comparison

Treatment Group 1

Treatment Group 2

Combined Groups

Significance between

TG1 & TG2

Ẋ SD Ẋ SD Ẋ SD

How would you rate the mindfulness class? 2.88 1.09 4.21 0.89 3.36 1.20 *

I would recommend this program to my friends

3.52 1.08 4.21 0.70 3.77 1.01 *

Mindfulness has changed the way I interact with other people

3.12 1.13 3.86 0.66 3.38 1.04 *

Mindfulness has helped me at school 3.20 1.12 4.00 0.68 3.49 1.04 *

Mindfulness has helped me control my anger

3.04 1.24 3.86 1.17 3.33 1.26 †

This program has been helpful to me 3.16 0.85 3.79 0.80 3.38 0.87 *

Mindfulness has helped me be more patient in my life

3.32 1.14 3.86 0.66 3.51 1.02 None

I will continue to use mindfulness techniques in my life, even after the program is over.

2.76 1.20 3.79 0.90 3.13 1.20 *

Mindfulness has helped me at home 3.40 1.15 3.71 0.91 3.51 1.07 None

Mindfulness has helped me feel less worried in my life

2.92 0.95 3.38 1.26 3.10 1.09 None

Mean Score for all 10 Questions 3.13 0.85 3.87 0.56 3.39 0.83 * Significant differences: * p < 0.05; † p = 0.051

71

Mean student scores for each question ranged between 3.38 and 4.21. Figure 4

displays the percentages of student responses from TG2 to several of the evaluation

questions. TG1 generally reported more satisfaction and usefulness of the mindfulness

program than not, though the ratings were not as high as TG2. For example, over half of

participants in TG1 (56%) said they would recommend the program to their friends, versus

only 12% who said they would not. Almost two-thirds (64%) stated that mindfulness has

helped them at home, while 20% stated that it did not. Over half (52%) indicated that

mindfulness has helped them to be more patient, while less than a quarter (24%) indicated

that it had not. Similarly, over half (52%) said that mindfulness has helped them at school

while less than a quarter stated that it did not (24%). Less positive outcomes included the

student rating of the mindfulness class, in which an equal amount of students (28%) reported

having liked and not liked the class. More students indicated that they would not use

mindfulness techniques after the class finished (32%) than those stating that they would

(28%), with 40% of students unsure. Most students (52%) said that they were unsure whether

the mindfulness class was helpful for them, versus 36% who agreed that it was helpful. Mean

scores for each question ranged between 2.76 and 3.52. Figure 5 (p. 74) illustrates the student

responses from TG1 for several of the evaluation questions. Results from a combination of

both treatment groups were positive overall. For each question, the average scores of student

responses were between agree and neutral, ranging from 3.10 (“Mindfulness has helped me

feel less worried”) to 3.88 (“I would recommend this program to my friends”). Results in the

combined group category are more heavily weighted to TG1 which had 25 student responses

versus group 2 which had only fourteen responses. Graphs displayed in Figure 6 (p. 75)

illustrate the percentages of student responses to selected questions from both treatment

groups.

Considering the noticeable differences between the group means for each of the

questions, additional analysis was conducted using the two-tailed t-test to explore whether

significant differences occurred between TG1 and TG2. These results are displayed in

Table 8 with the rest of the findings for the evaluation questionnaire. Initially, the total mean

of all 10 individual mean scores was compared between the two groups, and significant

differences (p = 0.006) were found between TG1 and TG2. Subsequently, individual mean

72

Figure 4. Graphs depicting TG2 student responses to selected questions from the participant evaluation questionnaire.

scores from each question were compared. TG2 had significantly higher evaluation scores

than TG1 in six of the ten items (p < 0.05), and an additional item was closely approaching

significance (p = 0.051). Considering that the total mean score of the items as well as six

individual items between the two groups were significantly different, it is safe to say that

TG2 had significantly higher feedback ratings of the mindfulness course and its applicability

to the students' lives. Likely reasons for these findings will be discussed in the discussion

sections.

QUALITATIVE RESULTS FOR PARTICIPANT SATISFACTION AND APPLICATIONS OF MINDFULNESS

Table 9 (p. 75) shows the results of student responses to the open-ended question of

how it feels to practice mindfulness and how one is able to use mindfulness in one's daily

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Figure 5. Graphs depicting TG1 responses to selected questions from the participant evaluation questionnaire.

life. For each question, themes from student responses were identified through thematic

analysis by the investigator and a research assistant. Several themes were usually identified

in each student's response. Twenty of 23 (87%) students in TG1 and 11 of 15 (73%) students

in TG2 expressed that mindfulness helped them to feel “calm”, “relaxed”, “peaceful”, or

“less stressed”. Twelve (52%) students in TG1 and 10 (67%) students in TG2 wrote that they

practice outside of class, at home, or at school. Nine students in both TG1 (39%) and TG2

(60%) wrote that mindfulness practice has helped them to deal with feelings of anger. Five

students (22%) in TG1 and 8 (53%) students in TG2 expressed that mindfulness was “cool”,

“awesome”, “fun”, or “feels good”. As for less positive responses, 5 (22%) students in TG1

and 3 (20%) students in TG2 said that they felt “bored” or “sleepy” during the mindfulness

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Figure 6. Graphs of participant responses from both TG1 and TG2 to selected questions from the participant evaluation questionnaire.

class. Five (22%) students in TG1 and 1 (7%) student in TG2 wrote that they do not practice

at home or outside of class.

For the sentence completion portion of the participant evaluation questionnaire,

Tables 10 and 11 display results for TG2 and Tables 12 and 13 (p. 77) for TG1. Similar to

analysis of the open-ended prompt, themes from student responses were identified through

thematic analysis. The first table for each treatment group (Tables 10 and 12) shows

identified themes from the first four questions, which ask the student what is the “worst part

of the program”, “the best part of the program”, and what is his/her “favorite exercise” and

“worst exercise”. Identified themes from the responses are in the left hand column, and the

number of student responses for each theme and question are on the right columns. In both

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Table 9. Themes and Results from Student Open-Ended Responses

Identified Themes Tx Group 1 (n = 23)

Tx Group 2 (n = 15)

N % N %

Calming, relaxing, peaceful, or reduced stress 20 87 11 73

Practice at home or in daily life 12 52.2 10 66.7

Practice mindful eating at home 4 17.4 4 26.7

Liked mindful eating in class 0 0 8 53

Helps with sadness, feeling down, or tired 3 13 1 6.7

Better attention, concentration, clear mind, alert 5 21.7 1 6.7

Helps with anger issues 9 39.1 9 60

Is fun, feels happy, good, awesome, really cool 5 21.7 8 53.3

Helps with fear, feeling scared 2 8.7 0 0

Helps with school / grades / tests 2 8.7 2 13.3

Helps in interactions with others 3 13 5 33.3

Recommends to friend / family member 4 17.4 3 20

Intends to practice at home, or daily life more 0 0 3 20

Sleepy, tired at first, then not 2 8.7 1 7

Helps with sleeping 1 4.3 3 20

Sleepy, boring 5 21.7 3 20

Does not practice at home 5 21.7 1 6.7

Table 10. TG2 Responses to Sentence Completion Participant Evaluations

Treatment Group 2 (n=14) Worst Exercise Best Exercise

Least Favorite Part of Program

Most Favorite Part of Program

Bell 4 1

Sitting still 1 3

Eating 4 6

Sleepy 1

Breathing 4 5

Stretching 2 5 1

Relax 1

Balancing, exercise 1 3

Everything 1 2

Nothing 6 1 4

Other 6 3 2 1

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Table 11. TG2 Responses to Experiencing Past Eight Weeks

Treatment Group 2

Themes (When I look back on the past 8 weeks, I feel ...) N %

Happy / Glad / Proud 4 29%

Helped / Improved / better / better attitude more concentrated 5 36%

Relaxed / Calm / Patient 3 21%

Okay / boring 1 7%

Other 1 7%

Table 12. TG1 Responses to Sentence Completion Evaluations

Treatment Group 1 (n=25) Worst Exercise

Best Exercise

Least Favorite Part of Program

Most Favorite Part of Program

Mindful Eating 4 1 6

Silence 5 1 1 1

Breathing / Meditating 1 4 5 5

Calm / Relaxed 6

Mindfulness Bell 2 2 1

Mindful Mimicking exercise 1 4

Class was helpful / More concentrated 2

Mindful movements / Stretching 3

None 5 2 6 3

Other students distracting, talking 6

Sitting up 1 2

Hot in classroom 3

Don't go to p.e. (attend class instead) 1 1

Boring / Sleepy 1 1

Don't know / Other 5 4 5 3

Table 13. TG1 Responses to Experiencing Past Eight Weeks

Identified Themes: “When I look back on the past 8 weeks, I feel...” N %

Happy, Good, Proud, Better 10 43

Peaceful, calm, relaxed, less stress 4 17

More concentrated, mindful 2 9

Appreciation 1 4

Less angry / control anger better 2 9

Neutral, don't know, the same 5 22

Misunderstood Question 2 9

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treatment groups, mindful eating practice appears to be the most favored activity among

students, with ten favorable scores (combined “best” and “most favorite”) from TG1 and ten

favorable scores from TG2. For breathing practice, TG2 had nine positive responses and no

negative responses whereas TG1 had nine positive responses and six negative responses to

the activity. In TG1, six of 23 students expressed that the best part of the program was

feeling more calm or relaxed. Six students expressed that the worst part of the program was

other students talking and distracting them. Five students expressed that the length of silence

during mindfulness exercises was the worst part of the program. In TG2, four of 14 students

enjoyed the bell as the best activity. Two students expressed that everything was the most

favorite, while 6 students reported that nothing was the worst and four students reporting that

nothing was the least favorite. Five students stated that the stretching and mindful movement

exercises were the least favorite for them.

Tables 11 and 13 display results of the last question, “When I look back on the past

eight weeks, I feel...”, with identified themes in the left column and the corresponding

number of student responses on the right. In TG1, 19 of 25 students (76%) expressed positive

feelings about their involvement in the course over the past 8 weeks, while five students

(20%) felt neutral, and two students misunderstood the question. In TG2, 12 of the 14

students (86%) expressed positive feelings about the mindfulness course: five students (36%)

expressed that the course helped them in some way, such as their attitude or concentration;

four students (29%) stated that they felt happy, glad, or proud; and three students (21%)

stated that they felt more calm, relaxed, or patient. Only one student expressed that he/she

experienced boredom.

PARTICIPANT COMPLETION OF THE COURSE AND ASSESSMENT MEASURES

Thirty-eight students in TG1 initially agreed to partake in the study and completed

baseline assessments. Three students completed only partially completed the pre-test

assessments due to being absent on one of the two days the assessments were given. Of the

38 students who began, nine students did not complete both of the post-test assessments for

the standardized scales, while 29 did. Fifteen students did not complete the participant

evaluation questionnaire, while 25 did. Two students requested to participate in the study

after the course had already begun. They were admitted halfway during the mindfulness

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course or earlier, and completed participant evaluation questionnaires but not the

demographic questionnaire or other scales. In summary of completion rates for TG1, 29 of

the original 38 participating students (76.3%) completed at least one of the standardized

scales at post-test assessment, and 25 of 40 students (62.5%) (including the two that joined

later) completed the participant evaluation questionnaire. In the comparison group, all 20

students who initially participated in the study filled out the assessment forms at both pre-

and post-test. One student at pre-test and two students at post-test did not fill all the scales

due to student absences.

Of the 18 students in TG2 that agreed to take part in the study, 15 of them (83.3%)

completed all or most of the post-test assessments (two students only partially completed

post-test assessments due to absences on one of the two days that tests were administered).

Two students completed only half of the baseline assessments. One student was absent

during the participant evaluation assessment and one of the standardized scales, and the three

other students changed schools during the mindfulness course. In summary, 83% of students

in TG2 completed the course from beginning to end which was moderately higher than TG1

which had a 76% completion rate. In contrast, the comparison group finished with 100% of

students filling out both pre- and post-test assessments. Likely explanations for the

differences between the three groups will be discussed in the following chapter.

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CHAPTER 6

SUMMARY, DISCUSSION, AND CONCLUSION

In the preceding chapter, the results of participant characteristics, outcome measures,

and data analysis were provided. Chapter 6 builds upon the previous section and includes an

introduction, summary of the study, discussion, implications for practice, recommendations

for further research, and some concluding words for the thesis. These sections will discuss

the significance of the results in light of the research questions and hypotheses, draw

conclusions about the effectiveness of mindfulness courses with this sample of middle school

students, offer possible reasons for success and limitations of the study. Based on the

findings and lessons learned, the chapter will make suggestions to those who are considering

or currently implementing mindfulness-based programs with youth, and will offer leads for

future studies to evaluate other potential benefits of mindfulness programs with youth as well

as variables affecting treatment effectiveness. Finally, a summative statement is provided to

encapsulate the scope and significance of this research study to the field of mindfulness

programs with children and adolescents.

SUMMARY OF THE STUDY A review of past literature reveals that mindfulness-based programs with children and

adolescents have demonstrated treatment acceptability and feasibility with some preliminary

positive results with certain populations of youth. However, there is still a paucity of

empirical evidence in this field, and no studies have empirically tested the acceptability and

effectiveness of a strictly mindfulness-based course with a class of middle school students or

with students experiencing homelessness. The purpose of this study was to evaluate the

feasibility, acceptability and beneficence of a mindfulness course with middle school

students from both a traditional charter school and a school serving homeless youth. The aim

of mindfulness practice is to help individuals attend to the present moment in a

nonjudgmental way; this allows greater awareness of habitual reactions and a fuller range of

choices available in the present moment. Such awareness should help youth to respond with

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less emotional reactivity, greater impulse control, and more compassion for their experiences

(Thompson & Gauntlett-Gilbert, 2008). The study's research questions are as follows:

1. Will students in middle school receiving an 8-week mindfulness course demonstrate changes in acceptance and mindfulness, psychological inflexibility, and self-compassion?

2. Will an 8-week mindfulness course be acceptable for middle school students and feasibly implemented in their classroom setting, as demonstrated by completion of the mindfulness course, and qualitative and quantitative feedback from participant evaluation questionnaires?

Each research question was explored with two different treatment groups: treatment

group one (TG1) was composed of 38 students from two classrooms at a traditional middle

school, and treatment group two (TG2) included a class of 18 students at a school serving

homeless youth. The study's research design was quasi-experimental, using a non-equivalent

comparison group to compare results of pre- to post-test changes in the treatment groups. The

comparison group was composed of 20 students from a separate class as students in the

treatment groups. The mindfulness course was delivered over the course of 8 weeks to each

class, with 45 minute sessions per week. The course offered instruction in mindfulness

exercises such as mindful breathing, body scan, mindful eating, mindful listening, test-taking

exercises to deal with anxiety, discussions about the practice, and home activity suggestions,

among other activities. Participant demographics were assessed at the beginning of the

course and included variables pertaining to homeless youth. The demographics data was used

to describe the participant sample as well as make comparisons between the different

treatment and comparison groups. Students in all three groups were assessed at baseline and

post-intervention with scales measuring acceptance and mindfulness, psychological

inflexibility, and self-compassion. A participant evaluation questionnaire with both closed

and open ended responses was given at post-course for program evaluation and to assess

students' satisfaction of the course and applications of mindfulness in the their daily lives.

To answer the first research question, an ANOVA was performed on the quantitative

data from the three standardized scales. Quantitative and qualitative student feedback from

the evaluation questionnaire was the foundation for answering the second research question,

and t-test was used to compare quantitative results of participant evaluations between the two

treatment groups. Thematic analysis was performed for the sentence-completion and open-

ended responses to evaluate student responses. While the self-report scales were able to

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assess relatively objective measures of treatment effectiveness, the qualitative measures were

able to explore multiple intrapsychic and interpersonal dynamics of how the mindfulness

training was applied in the students' daily lives at school and at home.

DISCUSSION OF THE FINDINGS This section first addresses the implications of demographic characteristics between

the three groups to determine reliability of the comparison group. Subsequently, a discussion

of the results will shed light on each of the 6 hypotheses that were originally posed for the

study.

Reliability of the Non-Equivalent Comparison Group Before proceeding to a discussion of the findings in light of the hypotheses, a

discussion of the demographic differences between the groups is necessary to evaluate

whether the waitlisted group serves as a reliable non-equivalent comparison group. Of the

nine demographic variables assessed, the majority of items were not significantly different

between TG1 and CG. In addition, both groups attended the same middle school, and were

under similar influences of the larger school environment. Thus, the non-equivalent

comparison group may serve as a reliable control for TG1. However, the demographic items

that were different should be noted as these factors may influence each group’s outcomes.

TG1 included 7th grade students while CG was composed of 6th grade students, and there

was over one year’s difference between the mean ages of each group. While there were no

significant differences in ethnic background between the groups, the noticeable differences in

this domain as previously shown in Table 5 should also be regarded as possible influences on

outcomes. Lastly the significant differences for length of time at their current living situation

may be another important factor influencing the results between TG1 and CG.

TG2 had significant differences from CG in regards to age, grade level, ethnicity,

current living situation, and length of time living there. Besides the demographic variables

assessed, TG2 was also at a different school site than the comparison group and TG1.

Furthermore, the intervention took place about four months after the data collection ended

with TG1 and the comparison group. Originally, hypothesis four was formulated with the

expectation that more demographic variables would not be significantly different and that

results between the groups could be reliably compared. Because of the differences in

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demographics, and data collection sites and periods, the non-equivalent comparison group

may not serve as reliably for TG2 as it does for TG1. It is possible that these demographic

dissimilarities may account for some of the different results between TG1 and CG measured

in the three assessment scales. Therefore, comparing pre- and post-test results between TG2

and the comparison group should be regarded tentatively.

On the other hand, significant differences between TG2 and TG1 only existed in a

few demographic categories, namely ethnicity, currently living situation, and length of time

at current residence. Ethnicity was the only variable not directly related to homelessness, and

both groups were primarily composed of ethnic minorities. Considering the few demographic

differences, the relationship between the two treatment groups may serve as an interesting

and novel comparison. How students facing homelessness receive and apply skills from

mindfulness training versus students attending a traditional charter middle school who

receive the same basic training, is a new topic for exploration in this field. The different

outcomes between the treatment groups may be fairly assessed; however, the few

demographic dissimilarities between the groups should also be recognized as potentially

influencing their different outcomes in both the three scales and the participant evaluation

measure.

Hypotheses One and Two H1: Students in TG1, who are attending a traditional charter middle school will show

significant improvements from pre- to post-test on measures of acceptance and mindfulness, psychological inflexibility, and self-compassion.

H2: Students in TG1 will show significantly greater improvement on measures of acceptance and mindfulness, psychological inflexibility, and self-compassion by the end of the mindfulness course as compared to a comparison group of students who did not receive the course.

The results indicate that the first hypothesis was upheld in only one of three domains,

as the participants' levels of acceptance and mindfulness increased significantly from

baseline to post-intervention. TG1 did show a positive direction of change in each of the

measures from pre- to post-test. The second hypothesis was also partly upheld, as TG1

demonstrated significant improvements over time in relation to the comparison group for

acceptance and mindfulness. Though there were no significant changes for psychological

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inflexibility and self-compassion, TG1 did show a positive direction of change over time

while the comparison group had a negative direction of change.

Greco and colleagues (in press) developed and validated a developmentally

appropriate measure of mindfulness skills in youth, constructed through expert and child

feedback. The author has yet to find other studies in the literature that used this newly

developed scale, however, such findings will likely appear its after publication. The positive

results on the CAMM indicate that the mindfulness course fulfilled its primary function in

helping students to develop mindfulness skills. As the CAMM has demonstrated negative

correlations with measures of psychological inflexibility, thought suppression, internalizing

symptoms, and externalizing symptoms, as well as positive correlations with academic

competence (Greco et al., in press), the findings here may be an introduction to other

potential benefits of a mindfulness course with students.

For the domain of psychological inflexibility, the improvements over time in relation

to the comparison group is a positive finding for the study. However, it is not surprising that

the modest gains from pre- to post-test alone on the AFQ-Y were not significantly different

considering the small sample size. Another possible reason is that mindfulness-based

interventions teach a set of skills that are not limited by qualities defined in psychological

inflexibility. Improving psychological flexibility means reducing cognitive fusion, thinking

and feeling that one's thoughts are automatically true, as well as experiential avoidance, an

unwillingness to openly experience private events as they are (Greco et al., 2008).

Psychological acceptance, non-identification with thoughts, and not accepting that thoughts

accurately reflect reality are core aspects of mindfulness practice (Kabat-Zinn, 1994).

However, MBSR and youth oriented mindfulness programs do not solely focus on

developing these qualities of mind. Mindfulness training focuses additionally on recognizing

and attending to different sensory experiences as they take place in the present moment, as

well as cultivating kindness and care for oneself and others. Psychological inflexibility is a

central aspect in ACT, which includes mindfulness practice as part of a broader treatment

approach; the AFQ-Y has primarily been used to evaluate children and adolescent outcomes

with ACT and DBT. Therefore, the moderate improvements for TG1 reflect the limited

amount of time and attention on reducing cognitive fusion and experiential avoidance. The

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author did not find any studies of strictly mindfulness-based programs with youth which

reported results of the AFQ-Y.

Saltzman and Goldin (2008) found that elementary students improved in self-

compassion, demonstrating less judgmental thoughts and feelings towards themselves after

they and their parents participated in parallel 8-week mindfulness courses. Mindfulness

embodies a nonjudgmental stance towards one's thoughts and feelings, and many

mindfulness programs cited in the literature emphasize the importance of kindness and

compassion when teaching mindfulness to youth. Therefore, an increase in self-compassion

seems likely to occur. Some of the possible reasons why significant differences were not

found over time and in relation the comparison group include the small sample size, the

relative time and focus dedicated to developing self-compassion as part of the mindfulness

course, and the lack of validity and reliability testing of the child modified scale, which was

explained in the introductory chapter.

Considering that the comparison group did show decreased levels of self-compassion

over time, and that TG1 made small improvements, it is possible that the sample size (n = 25)

was not large enough to show significant differences over time or between the groups. A

possible reason for the minimal improvements from pre- to post-test in TG1 is the influences

of the school environment. Given the comparison group's decreased levels of self-

compassion over time, it is possible that environmental factors at the school contributed to an

overall reduction of compassionate attitudes and behaviors in both groups. It is possible that

the treatment groups were able to successfully maintain their levels of self-compassion over

time while the school's student population experienced decreases over time. This possible

explanation cannot be verified however.

Another possible reason for the findings is that the course did not provide as much

time and focus on the particular constructs of self-compassion as defined by Neff (2003):

self-kindness versus self-judgment, common humanity versus isolation during difficult or

painful experiences, and mindfulness versus over-identification of painful thoughts and

feelings. The intervention offered to students focused more on developing mindful awareness

of thoughts and feelings in a gentle and compassionate manner, and also taught ways to

cultivate kindness towards oneself and others. However, the course did not focus on

transforming feelings of isolation into feelings of connectedness with others during difficult

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experiences. This may partly explain the lack of significant differences between the treatment

and comparison groups.

Hypotheses Three and Four H3: Students in TG2 attending a middle school serving homeless youth will show

significant improvements from pre- to post-test on measures of acceptance and mindfulness, psychological inflexibility, and self-compassion.

H4: Students in TG2 will show significantly greater improvements on measures of acceptance and mindfulness, psychological inflexibility, and self-compassion by the end of the mindfulness course as compared to a comparison group of students who did not receive the course.

Participants in TG2 fared better at post-intervention than at baseline on the CAMM,

minimally so with the AFQ-Y, and had slight decreases on the SCS-C. Since the results were

not significant in any of the measures, hypothesis three was not upheld by the results. In

relation to the comparison group, TG2 participants did report more improved changes from

baseline to post-intervention compared to CG for all three outcome measures. TG2

participants made improvements over time compared to CG in acceptance and mindfulness

that approached statistical significance. Considering the small sample size in TG2 (n = 15)

for this measure, this is an encouraging finding. Similar to TG1, the results of the CAMM

scores in relation CG indicate that the mindfulness course fulfilled its primary function of

helping students in TG2 to develop the skills of acceptance and mindfulness, which partially

confirms hypothesis four. However, considering the discussion on participant demographics

and the differences in group characteristics between TG2 and CG, the conclusions of

hypothesis 4 should be regarded tentatively.

While several reasons may explain the lack of significant differences between pre-

and post-test results and in relation to the comparison group, one primary reason is the small

sample size of the treatment group and an even smaller size (n = 13) during the SCS-C

assessment due to two student absences. Other reasons, such as those previously discussed

for TG1 results in measures of psychological inflexibility and self-compassion are also

relevant for TG2.

A final explanation why the results for several measures were not found to be

statistically significant and thus only partially supported the hypotheses relates to the

experience of the mindfulness instructor, as explained in previous sections (Chapters 1

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and 4). Teaching mindfulness skills in a school classroom is a challenging task and requires a

dynamic combination of experiences and training. Without a decently strong background in

many areas deemed necessary for proper instruction, the effectiveness of a course may be

limited. That is not to say that students in this study did not receive the core elements of

mindfulness training, but the extent of their learning was most likely limited by the

instructor's own limited experience of teaching mindfulness in this format and setting.

Considering the positive findings that were found, it is encouraging for school social

workers, classroom teachers, or other professionals who are interested in offering

mindfulness courses to youth that benefits can occur even when one's skills as an instructor

have not yet fully ripened, or one has not yet had extensive experience teaching in a school

setting.

Hypothesis Five H5: A mindfulness course implemented in a traditional middle school classroom is

expected to demonstrate treatment feasibility and acceptability as shown by completion rates of the course, as well as quantitative and qualitative feedback from students in participant evaluation questionnaires.

Students at the traditional middle school reported moderately positive feedback of the

program in the quantitative section of the participant evaluation questionnaire, and generally

positive feedback in the open-ended questions and sentence completion portions. In the latter

two sections, students expressed that the mindfulness course and practicing mindfulness in

general was beneficial for improving their mood or state of mind and for helping in daily life

situations at school, with friends, and at home. TG1 experienced moderately successful

completion rates of the course, with over three quarters of the class completing the course

from beginning to end. The highly positive feedback in the qualitative sections and

moderately positive feedback in the quantitative sections demonstrates treatment

acceptability, while the moderately high course completion rates demonstrate treatment

feasibility for this sample of middle school students.

In addition to the quantitative scores and the numbers from thematic analysis, the raw

student reactions to the course can be valuable sources of evidence which can help to

determine treatment acceptability. Student responses to the open-ended questions in their

own words can express something that the hard data never will be able to. They express

dynamic themes of how the students were able to generalize the skills to many areas of their

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lives, and better handle external situations through an increased awareness and capacity to

regulate their internal world. While there were many positive and inspirational quotes from

the students, only a few are included here. The comments appear without correction to

preserve the quality of the student’s voice. One student shared about using mindful breathing

techniques to cope with different challenging emotions that arise for her at school or at home:

When you practise at home you get better. Like when you get in a fight with your brothers you could take a deep breath and you will feel better. Also when you do it in school like for example when you are taking a test you breath in and you will feel smarter.

Some themes arose in several student responses that were not initially expected from the

course, such as the improvement of anger management skills. One student responded at post-

course:

Now that I consentraded & I pay more attention I get it & It helps me to control my anger issues. I practice sometimes at skool when I get angry w/ my friends or teachers I try to feel calm & relax.

Other students felt that the mindful breathing techniques helped them not only to feel great,

but also as a refuge when they felt scared:

This breathng techniqs makes me feel aswome, relax, not stress – u shoud try it. I use breathig techniqs by sleeping in the night or when scared. So this is why I would recommend this to u. So try it at home school or where ever you want to do it.

The range of both external situations and internal feelings to which the students were able to

apply the mindfulness skills indicates that the program can be generalized to the students'

lives in concrete ways that impact their internal and external worlds. These examples further

demonstrate the program's acceptability and usefulness to this sample of middle school

students.

Hypothesis Six H6: A mindfulness course implemented in a middle school classroom that serves

homeless youth is expected to demonstrate treatment feasibility and acceptability as shown by completion rates of the course, as well as quantitative and qualitative feedback from students in participant evaluation questionnaires.

Participants in the school for homeless youth had much higher ratings of course

evaluation on the quantitative section, and moderately greater positive feedback on the

qualitative sections than participants in TG1. In the last section of the sentence completion

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portion, positive statements about the course were unanimous among students, with reported

feelings of satisfaction and improvements in mood and concentration during the course.

Compared to TG1 this treatment group also had higher rates of course completion as more

than 4 of 5 students (83%) completed the course. Except for the three students who moved

during the course of the program, all of the students completed the course from beginning to

end. The highly positive student evaluations and the high student completion rate

demonstrate treatment feasibility and acceptability for this group of middle school students.

Similar to TG1, students at the school for homeless youth shared about their living

examples and embodiment of mindfulness practice in ways that the hard data, including the

numbers representing the qualitative responses simply cannot capture. Some of the responses

help to answer a question which several authors of mindfulness-based studies have tried to

explore: whether mindfulness-based programs can relate and be applied to the lives of

students who come from disadvantaged or high-risk backgrounds – in other words, treatment

acceptability (Bootzin & Stevens, 2005; Lee et al., 2008). One student wrote:

Meditation is really helpful, because it will help you relieve stress. When we have done meditation in the class, after I felt happier and like a whole different person because I was more calm. If I could do meditation 24/7 I would, or if I could teach it I would. I would suggest meditation to you because I know that kids our age have a lot of drama, at school, home, or even on the streets.

Another student shared:

Mindinfullness medition is something good cause like for me it help me to take the tension and the bolts I have inside my head cause then I wont be mean and strike people with my lighting bolts. I am happy and nice because of meditation It relaxes me. I use medition in my life by like wen I get mad I just sit down and breath.

The illustrative language communicates very authentically the students' internal and external

challenges, as well as their confidence in being able to apply mindfulness to beneficially

transform their emotional difficulties. An initial concern for the mindfulness instructor was

whether the practice would feel too foreign and even “uncool” to students and that they

would be reluctant to accept the practice as culturally relevant and acceptable for their lives.

However, the previous two quotes show that students viewed the practice positively, as a tool

that can be applied to their lives.

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Similar to the student responses in TG1, several of the homeless youth found that

mindfulness exercises were applicable to a variety of daily life experiences, from the bitter to

the sweet. One student wrote:

I have used meditation during football after school. I count and breath instead of screaming and saying hurtful things to the kids I play with. But I also breath in and out to calm my anger so I don't take it out on my friends and other people I hang out with. And I also tried the mindful eating to enjoy a desert way better.

This student shared an example of how increased awareness from mindfulness practice

helped her to avoid partaking in harmful and potentially destructive actions, as well as to help

her enjoy another completely different aspect of her life such as eating desert. While

generalization to different home and social environments is important, several students also

wrote about the impact of the practice on school related issues, as one student wrote:

It feels cool, because when you are in school, you always distress for everything, and now I feel really motivated. The things are going better with meditation. I used to meditate when I feel my mind is in trouble. My grades are better, because now my mind is clear.

As the program was implemented in the school classroom, the relevance to school-related

goals should be a primary goal. This passage illustrates the student's capacity to tie together

dynamically related themes, such as the relevance of emotional well-being with intellectual

and academic progress. This is noteworthy evidence for school systems and related

professionals to understand in consideration of mindfulness programs for their students. The

written voices of students offer further evidence of the treatment's acceptability and

usefulness for this sample of middle school students who face homelessness in their lives.

Differences between TG1 and TG2 in Participant Evaluation Results

Significant differences existed between TG1 and TG2 on the majority of items in the

quantitative section of the participant evaluation questionnaire. Compared to TG1,

participants in TG2 expressed higher evaluations in several areas: overall rating of the

course; helpfulness of mindfulness practice with interpersonal situations, at school and at

home; would recommend the course to a friend; and likeliness of maintaining the practice

after the course is over. There are several possible reasons why this may have occurred. First,

it is important to consider demographic differences as an explanation. As previously

discussed, TG1 differed from TG2 on only three demographic variables, and two of them

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directly pertained to homelessness (current living situation and how long living there). While

ethnic identity was also significantly different, both groups were also primarily composed of

ethnic minorities. The other six demographic variables were not significantly different

between the groups. Therefore, other explanations are more likely to explain the different

outcomes.

Class size was a big difference between the two groups, and oversized classrooms

were an initial problem for instruction with TG1. The school faculty was very optimistic

about the mindfulness course to help their students, and faculty initially included one and a

half classes of students in the course. During the first two sessions, over 40 students were

present in one class and about 35 in a second class, about half of which were participating in

the study. The instructor's capacity to attend to all of the students and sufficiently teach the

practice was limited, and classroom behavior management was also difficult. After the first

two weeks, the instructor made a request to limit the class size to about 30 students. In

contrast, the class size in TG2 was about 20, so students were able to enjoy more individual

attention from the instructor throughout the course, both during discussion time and for

teaching selected practices. Unique student needs and questions about learning the practice

and incorporating mindfulness techniques into their lives were given more individualized

attention and support, which can be very important for students' engagement in learning the

practice. Lee (2006) states that the MBCT program is adapted for children by reducing the

instructor-to-student ratio. The traditional ratio of one instructor per 12 adult participants is

changed to two instructors per 6 to 8 children participants. She states that this offers more

individualized attention for each student. In the same way, it is possible that the smaller class

size in TG2 provided more opportunities for the instructor to help the students to make

progress in learning mindfulness which resulted in higher post-course evaluations.

Another possible reason for the difference between the two groups is the amount of

classroom teacher support given to each class in the treatment groups. In TG2, there were

usually two faculty or staff members present in the class during the mindfulness sessions, a

classroom teacher or substitute, and an assistant teacher. Both faculty members expressed a

lot of support and encouragement for the students to engage in and reap the benefits of the

mindfulness course. Communication between the faculty and the mindfulness instructor was

great which led to collaborative responses to inappropriate or disruptive student behavior,

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especially when the instructor was occupied while engaging with other students. Overall,

students in TG2 experienced a range of classroom management support, resulting in less peer

distractions and more attention focused on the mindfulness class. In contrast, TG1 had only

one classroom teacher present in a class of over 30 students. A few different teachers rotated

supervising the class, each offering different styles and degrees of classroom management, so

there was not the consistency of one teacher's support. During a few class sessions, the

classroom teacher was absent, and a substitute was not available. The mindfulness instructor

was asked to be the sole adult figure in the room if the mindfulness class was to continue that

day, which it did. The significantly higher student to teacher ratio, the lack of one

consistently attending teacher, and the occasional lack of a classroom teacher at all resulted

in less supervisory and behavior management support for the students in TG1. The

mindfulness instructor experienced more behavior management challenges including

disruptive and noncompliant student behaviors which made it more difficult to focus the

class' attention on learning mindfulness skills. The instructor's observations correlate with

student feedback in the evaluation questionnaire, in which a fair amount of students

expressed that other students talking and distracting them was the worst part of the program.

In contrast, no students in TG2 indicated that student distractions were a problem. It is likely

that students in TG2 experienced an advantage of more classroom supervisory support and

that this contributed to higher evaluation ratings for the course and being able to effectively

learn and apply the mindfulness skills.

A last likely explanation for the significantly different outcomes between TG1 and

TG2 relates to the instructor's level of training and experience. As previously noted, the

instructor has had extensive training in mindfulness practice, and much experience teaching

mindfulness to youth and adults, though little experience as a mindfulness instructor in

educational settings. Serving as an instructor for TG1 was the first multiple-week

mindfulness course that the instructor had provided to students in a school classroom. The

experience of teaching two classes of students in TG1 served as a valuable experience which

may have improved the quality of instruction when the instructor began working with TG2

several months later. In addition, the instructor participated in a 10-week web-based training

for teaching mindfulness to children and adolescents several weeks before and during the

mindfulness course with TG2. Despite the new training, the instructor still taught the same

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basic format of instruction to both treatment groups, with similar mindfulness exercises;

although the ultimate delivery and skillfulness of the instruction may have changed with the

enhanced training. Due to the experience of providing several months of instruction to TG1,

as well as the web-based training between treatment groups, TG2 was provided with a

slightly different and likely enhanced mindfulness course than TG1. This is likely to have

raised the quality of instruction delivered to TG2 as well as their treatment outcomes.

IMPLICATIONS FOR PRACTICE The study's findings and lessons learned during the study raise several noteworthy

considerations for professionals working with early adolescents, including school faculty and

administrators, school social workers and counselors, as well as parents of students.

School faculty and administrators in middle schools may be interested in programs

that help students in both their academic success as well as their life success, which includes

emotional intelligence. In their study of mindfulness program with elementary school

students, Napoli and colleagues (2005) assert that with the increasing levels of stress and

anxiety in the lives of youth, it is imperative that youth be empowered with tools and

strategies that can help them manage these difficult feelings. In order for children to succeed

at optimum levels in the classroom, learning how to focus attention and manage difficult

feelings is crucial Mindfulness programs have demonstrated an ability to help youth focus

and maintain their attention; evidence shows that this will reduce stress and increase learning

abilities (Napoli et al., 2005). This study's results indicate that a mindfulness course may

improve levels of acceptance and mindfulness, and psychological inflexibility in middle

school students. In addition, qualitative findings suggest that students may cultivate reduced

stress, better anger management skills, and improved general sense of well-being. Qualitative

findings also suggested that these benefits helped students to perform better in school. The

positive findings of increased mindfulness and emotional well-being in this study as well as

past research demonstrating links between improved attention and improved learning abilities

should persuade school systems to implement mindfulness-based programs for their students.

Professionals working in school systems, such as school social workers, counselors,

nurses, psychologists, as well as classroom teachers can be optimistic about the feasibility of

offering such a course to students. It is encouraging that a mindfulness course offered by an

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instructor who has experience with youth and a steady daily practice, but little experience

teaching mindfulness in a school classroom may still offer various benefits for students.

Furthermore, the mindfulness skills may be generalized to multiple domains of the students'

lives, at school, at home, and with peers. Those who are interested, considering, or already

engaged in offering mindfulness to students may like to know that one does not need to be an

expert instructor to begin sharing mindfulness with youth. However, it is also vitally

important for those interested in teaching mindfulness to consider the recommended criteria

for teaching mindfulness to youth, the range of options that are available for training, and the

likelihood that such training will help to prepare or enhance one's instruction with students.

While the study does not offer concrete evidence, the experience of the

instructor/investigator is that such a training can vitally enhance the depth and quality of the

training offered to the students. This occurs when an instructor can offer practices that are

more relevant to the students' lives, contain age-adapted language, and ultimately come from

the experiences and insights of one's own daily practice. As discussed in the literature

review, a growing number of individuals and organizations are offering excellent training

opportunities for school personnel and other professionals to teach mindfulness in schools.

Not only school-related professionals, but also volunteers in community organizations, as

well as parents of students who work with youth and have established mindfulness practices

may be interested and ready to engage in such trainings and begin applying them with

students.

Other lessons for those offering mindfulness training in schools is that class size and

the amount of classroom teacher support may be important variables affecting the success of

the course. Most important on this topic is that good communication exists between the

mindfulness instructor and the classroom teachers. This may improve collaboration for

classroom management and attending to disruptive students. It is also important for the

faculty to be encouraging, supportive, and optimistic that the course will be helpful for

students as intended.

School social workers, counselors, nurses, and psychologists have a vested interest in

the general well-being of students, which is not limited to their academic lives. The

qualitative responses by students indicated that the skills taught in the course were

generalized to many areas of the students' lives at school, with peers, and at home. A

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consistently applied mindfulness program integrated into a school program may offer

students the opportunity to not only enhance their attention and success with school, but also

cultivate stronger emotional health in their personal lives. This knowledge may rouse further

interest in these professionals to advocate for mindfulness-based programs in their schools.

RECOMMENDATIONS FOR FURTHER RESEARCH A big question that has yet to be empirically explored in the field of mindfulness

programs with youth is the relative impact that instructor training and experience has on the

effectiveness of the mindfulness course. It would be helpful for those interested in teaching

or providing mindfulness courses to youth to understand the relative level of effectiveness

that a training can have upon the instructor and the effectiveness of the course. Several

distinguished organizations and individuals have developed training programs with formal

curricula to train adults in teaching mindfulness to youth (Mindful Schools, 2010; Saltzman,

2008). A limitation and threat to the internal validity of the current study was that the

instructor training occurred between treatments of the two groups; the treatment changed to a

certain unknown degree, with likely benefits for the second treatment group. On the one

hand, it disqualified comparisons between the second group and the comparison group. On

the other hand, however, it provided a novel comparison between the two treatment groups to

better understand the training's effects upon quality of treatment. Future studies may more

rigorously compare the effectiveness of mindfulness courses which have different levels of

instructor training.

Other methodological limitations of this study include the small sample size of

homeless youth, and no comparison group in the same school. A non-equivalent comparison

group should ideally experience many of the same environmental factors as the treatment

group, such as schoolwide influences. Future research may use comparison or control groups

that can reduce threats to internal validity by mitigating the influences of variables such as

maturation over time and treatment placebo effect.

Another topic for future research is optimum class sizes for teaching mindfulness to

youth. Are the effect sizes greater or lesser depending on the instructor to student ratio? For

example, are the differences negligible or significant when teaching a class of 20 students

versus 30 students? Exploring this topic may be helpful for instructors and program providers

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especially if there is some flexibility around the number of students that participate in a

course at one time.

A fourth question which evolved out of this study deals with the benefits of the

mindfulness course in ways that were not systematically measured. In the open-ended student

responses, more than four out of five students in both treatment groups wrote that they felt

feelings of calm, relaxation, or reduced stress while practicing mindfulness. Almost half of

the participants expressed that they had used the practice to manage feelings of anger. A

large portion of the students further expressed feelings of general well-being and improved

attitudes. Future research may explore the potential of mindfulness courses to improve

students' abilities to cope with and reduce feelings of stress, manage feelings of anger, and

experience increased quality of life. For example, the Life Events and Coping Inventory

(Dise-Lewis, 1988) measures experiences of stress as well as coping strategies for early

adolescents. In the domain of anger management, there is a plethora of youth adapted scales

that measure both self-reported and observed levels of anger and aggression in children and

adolescents. Some measure observable behaviors of anger or aggression, while others

measure how youth would feel, think, and respond to anger-provoking situations (Blake &

Hamrin, 2007). Lastly, the Youth Quality of Life-Revised scale (Patrick, Edwards, &

Topolski, 2002) assesses general well-being in various domains, such as peer relationships,

family, school, and personal fulfillment. These are a few examples of reliable scales that may

empirically measure some of the benefits of a mindfulness course which were initially

identified through thematic analysis in the current study.

Another methodological limitation of the current study is that all the measures were

self-report scales, which are subject to participant bias. Teacher and parent reports may

complement the self-report assessments for a more objective assessment of outcomes.

Furthermore, it would add a stronger measure of behavioral outcomes, which were lacking in

this study as well. As previously noted, participants reported applying mindfulness

techniques in their interactions with others, especially around issues of anger. This is

indicative of potential behavioral improvements, which could be empirically evaluated in

future studies. Scales with reported observations such as the Child Behavior Checklist for

parents and teachers (Achenbach, 1991) contain subscales which measure delinquent

behavior, aggressive behavior, and social problems.

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Future research may also continue to explore offering mindfulness training to

different populations of youth with disadvantaged backgrounds. Considering the preliminary

positive findings with youth attending a homeless school, as well as a past study

demonstrating successful outcomes with inner-city, ethnic minority youth from low-income

neighborhoods (Lee, 2006), the door is open wider for researchers to explore offering

mindfulness training in different settings and institutions that serve disadvantaged youth.

These youth may especially benefit from skills that empower them to more effectively self-

regulate their difficult feelings and manage stress. Residential settings in child welfare

services, youth homeless shelters, and juvenile correctional facilities may be just a few of the

areas that mindfulness teachers and researchers can explore together.

CONCLUDING WORDS The literature on child and adolescent mental health suggests that high percentages of

youth experience a range of emotional and mental health challenges which often begin at

early ages. Evidence-based prevention-based programs are needed in schools and other

youth-based settings to either help prevent the onset of such problems, or mitigate their

effects. Mindfulness-based programs with youth are becoming increasingly popular and

utilized in various settings to help students cultivate better attention and improve emotional

well-being and behaviors. To the author's knowledge, this study is the first to have

empirically evaluated a mindfulness course for a class of middle school students. It is also the

first study to have evaluated a mindfulness course with a sample of students facing

homelessness. The findings indicate that the mindfulness course with traditional middle

school students demonstrated treatment feasibility and acceptability, as well as improvements

over time compared to a non-equivalent comparison group in measures of acceptance and

mindfulness, and psychological inflexibility. Treatment feasibility and acceptability was also

achieved with the class of participating homeless students. In addition, highly positive

student evaluations indicated that mindfulness skills were applied in various domains of their

daily lives, and led to improved sense of well-being, reduced stress, management of difficult

emotions, and improved interpersonal dynamics. Future studies may be enticed by such

qualitative findings to more objectively explore the effects of a mindfulness course upon

levels of stress, anger and aggression, and overall quality of life in youth. This will provide

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further conclusions to the effectiveness of mindfulness-based programs to increase protective

factors and reduce risk factors that lead to further mental health or behavioral problems.

School systems and mental health professionals working with youth should continue to

explore the capacity of mindfulness-based programs to enhance student's levels of

mindfulness and attention, and emotional coping skills so that they have more energy and

strength to devote to important goals in school and life.

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APPENDIX A

LETTERS OF PERMISSION FROM TWO

SCHOOL ADMINISTRATOR/FACULTY

MEMBERS TO CONDUCT THE STUDY AT THEIR

SCHOOL SITES

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APPENDIX B

LETTER OF COLLABORATION FROM THE

MEDITATION INITIATIVE

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APPENDIX C

INFORMED STUDENT ASSENT AND PARENT

CONSENT FORMS

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Assent Form for students

Dear student,

Hello, my name is David Viafora, and I am a volunteer with the Meditation Initiative. I work with Jeff Zlotnik who is the director of the Meditation Initiative. We at the Meditation Initiative teach students about mindfulness and meditation in school classrooms, colleges, and at other places in San Diego. I am also a college student at San Diego State University, where we do research. I am interested in doing a research study here at your school with the Meditation Initiative. We want to learn about whether mindfulness meditation helps students to be more relaxed, to calm themselves, and to be kind to others. Mindfulness and meditation is about being aware of what is happening inside and outside of us, and how to take care of ourselves. Your class will already have a mindfulness course , because it is part of your class schedule, once a week for about 45 to 60 minutes. The study will try to measure how 12 weeks of mindfulness class can benefit or not benefit students' behaviors and thinking. The mindfulness class uses guided exercises to teach students how to breathe and relax their bodies and feelings in order to calm themselves, release stress, and gain concentration. There is a period of discussion after the mindfulness activities. Taking part in the study is your choice. It includes filling out a few forms about behaviors related to mindfulness meditation. If you agree to be in this study, you will be asked to fill out four forms before the mindfulness class begins and four forms after the class ends. For students at King-Chavez School, you will just fill out the forms two times. If you are a student at Monarch School, I will come back about six weeks later for you to fill out the forms one more time after that. It will take about 35 to 45 minutes to fill out the forms each time, but you can have more time if you need. I will explain the forms, and hand them out to all the students in class. Those who wish to participate will fill them out, and those who do not want to participate, can read or do other work. I will also be writing down how many times you attend during the 12 weeks of the mindfulness course. While you may benefit from the mindfulness classes, you will not receive any benefits from participating in the study such as filling out the forms. One thing we try to be very careful about in research studies is to keep the information you provide safe and not known to anyone else. If you agree to be part of the study, no one will know the information that you give on the forms. The forms will be given a special code, and your names will be erased so no one will know the answers you put. If you decide not to participate, it will not affect your grade in your class. No one will be upset with you for not participating. By choosing to take part in the study, you will be helping us out a lot at the Meditation Iniative, and others who teach mindfulness to young people. Because we want to learn how mindfulness skills helps students to learn, to calm themselves, to take care of their feelings and to be happy. Other people, such as teachers, may learn from this research study about teaching mindfulness in a classroom to students. The results from these studies will help to improve the quality of mindfulness courses for students in the future, who may benefit from learning the mindfulness skills. Please talk to your parents about this study before you decide whether to participate. We will also ask your parents if it is all right with them for you to take part in this study. If your parents say that you can be in the study, you can still decide not to participate. You can

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ask me any questions that you have about this study and I will try to answer them for you. Taking part in this study is up to you. If you decide to participate, you can always change your mind and stop any time you want. If you have questions that you think of later, you can call me at (619) 300-0873.

Sincerely,

David Viafora, Graduate Student at San Diego State University

□ I agree to be take part in this study. □ I do not agree to take part in this study.

____________________________________________________________________ (Name of student) (Signature of Student) (Date)

____________________________________________________ (Signature of Researcher) (Date)

San Diego State University

Consent to Act as a Research Subject Measuring Mindfulness in Middle School Students

Your child is being asked to participate in a research study. Before you give your consent for him to volunteer, it is important that you read the following information and ask as many questions as necessary to be sure you understand what your child will be asked to do. Investigator: David Viafora is a graduate student at San Diego State University in the School of Social Work. He is conducting a research study with middle school students in San Diego about mindfulness activities in a school classroom. David is working with the Meditation Initiative (MI) which already offers mindfulness instruction to your child's school. For this study, David will be supervised by a professor and experienced researcher in social work at San Diego State University, Dr. Mathiesen.

Purpose of the Study: This study will measure how mindfulness instruction helps middle school students to deal with difficult emotions such as decreasing stress or test anxiety, to increase their awareness in daily activities, and to be kind to other people and themselves. The MI organization already offers the free mindfulness course to school classrooms at your child's school. The study will assess the effectiveness of the course with students who will already be receiving a mindfulness course in their classroom one time per week for about 45 to 60 minutes. The mindfulness course which takes place in your child's classroom teaches

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breathing and awareness techniques to help the students cultivate calm and relaxation, release stress, and focus their concentration. There will be a period of discussion after the breathing and awareness techniques are practiced. Many research studies have shown that mindfulness techniques with adults and youth are very helpful for reducing stress, gaining concentration in the mind, and increasing feelings of joy and happiness. There will be about 75 to 85 students, from various classrooms at two school sites, who will participate in the study.

Description of the Study: The study includes survey items that will be completed in your child’s classroom before the mindfulness course begins and after it finishes in 12 weeks. It will take about 35 to 45 minutes for students to fill out four surveys about the mindfulness course. If your child is a student at King-Chavez School, then your child will be asked to complete the surveys once before the mindfulness course begins, and once after the course ends. If your child is a student at Monarch School, then he/she will be asked to complete the surveys before and after the mindfulness course, plus one more time six weeks later.

The forms will be explained in class and then handed out to all of the students, to minimize attention to those who do not wish to participate. Those students who wish to participate will fill out the forms, while those who choose not to participate can read or do other work silently.The researcher will also record how many sessions your child attends during the 12 mindfulness classes. Besides the questionnaires and recording attendance, no other information about your child will be gathered.

Some of the items on the survey which your child will be asked to answer include:

• I tell myself I’m still okay when I make a mistake or don’t do well at something

• I push away thoughts and feelings that I don’t like

• At school, I walk from class to class without noticing what I’m doing

1. Please write a brief note to a friend who knows nothing about mindfulness. Describe how it feels to rest quietly and calmly in mindfulness, and how you use mindfulness in your daily life.

The questionnaires used in this study have all been used many times by professionals in the field of child and adolescent development.

Discomforts and Risks of the Study: One discomfort which your child may experience if he or she takes part in the study is that he may not enjoy filling out the questionnaires. Some of the questions ask about his/her thoughts and emotions, and may be challenging for him/her to think about and answer. It is important to know that your child will not receive any negative consequences for participating or not participating in the study. Also, your child will not receive any negative consequences for anything he or she answers in the questionnaires. If your child begins to feel uncomfortable, he or she may stop participation in the study at any time.

One risk of taking part in the study is that the information on the questionnaires may be seen by others. This is a risk in almost every study with questionnaires or surveys. Your child's name will be coded so that the information he fills out on the questionnaires will not

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be known to others. The name will be blacked out immediately after completing the form and replaced with a non-identifiable code.

The study will be completely confidential. The questionnaires do not ask for any other personal or family information.

Benefits of the Study: Students at your child’s school and many others schools in San Diego and in the country have courses which teach skills of mindful awareness. It is very important for researchers to study and understand how mindfulness courses benefits students, or does not benefit them. The results from these studies will help to improve the quality of mindfulness courses for students. It will be very helpful to both educators and other professionals teaching mindfulness to learn more about using mindfulness courses in a school classroom.

Past studies have shown that mindfulness skills helps students' behaviors and concentration, which can be helpful for their academic success. It may be a positive educational experience for your child to learn about how a research study works, and that he is taking part in a research study. The researcher will explain all steps of the study to your child. Your child will already be taking the mindfulness course at his school.

Your child will not receive any direct benefits from taking part in the study, which includes answering the questionnaires and recording attendance.

Confidentiality: As shared above, the survey forms will be coded immediately after your child completes the questionnaires so that your child’s name will not be linked to the information which he provides on the forms. No other personal or family information will be asked for on the survey forms.

No one will be able to link your child’s identity, name, or personal information with any information which is part of the study. In addition, the researcher will keep all the survey forms which the child completes in a locked box in the researcher’s private location. Therefore, no one will have access to the completed survey forms. They will only be shared with the person who is supervising the study, Professor Mathiesen.

No Financial Rewards for Participation: Your child will not be paid to participate in this study.

Participation is Voluntary: Participation in this study is voluntary. Both you and your child’s choice of whether or not to participate in the study will not affect your child's grades and he will not be penalized in any way at his school. Also, your choice will not influence you or your child’s future relations with San Diego State University.

If you or your child decide not to participate, your child can stop participation at any time without penalty or loss of benefits which you would normally have.

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Questions about the Study: If you have any questions about the research now, please ask. If you have questions later about the research, you may contact the main researcher, David Viafora at (619) 300-0873.

If you have any questions about your child’s rights as a participant in this study, you may contact the Division of Research Administration at San Diego State University (telephone: 619-594-6622; email: irb@mail.sdsu.edu).

Consent to Participate: The San Diego State University Institutional Review Board has approved this consent form, as signified by the Board's stamp. The consent form must be reviewed annually and expires on the date indicated on the stamp.

Checking one of the two labeled boxes below indicates that you either agree or disagree for your child to take part in the study.

Your signature below indicates that you have read the information in this document and have had a chance to ask any questions you have about the study; you have been told that you can change your mind and withdraw your consent for your child to participate at any time. You have been given a copy of this consent form. (This will be sent back home with your child). You have been told that by signing this consent form you are not giving up any of your legal rights.

□ I give permission for my child to take part in this study. □ I do not give permission for my child to take part in this study.

____________________________________ Name of Parent (please print) ____________________________________ _________________ Signature of Parent/Guardian of Participant Date ____________________________________ Name of Child (print) Again, if you have any questions related to your child's participation in this study, please contact David Viafora at (619) 300-0873.

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APPENDIX D

COVER LETTER TO PARENTS

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Cover Letter to Parents

Dear Parents, Hello, my name is David Viafora and I am a graduate student at San Diego State

University School of Social Work. I am a volunteer with an organization that offers free classes of mindfulness skills at your child's school. Our organization is called the Meditation Initiative, and we have been working at your child's school for the past two years.

Teaching mindfulness skills to young students, such as middle school students, helps them learn how to be calm and relaxed, to reduce their levels of stress, and to concentrate more effectively. Mindfulness skills can help people to be more aware of what they are doing, thinking, and feeling, as well as what is happening around them. Many students and teachers at different classrooms in San Diego have shared how helpful the mindfulness classes are.

As a graduate student at SDSU, and in collaboration with the Meditation Initiative, we will be doing a study which will measure how helpful the mindfulness skills class is for the students. This study will help us to learn in what ways the mindfulness skills class helps students in their behavior and in their thinking, and in what ways it is not helpful. This study will also be helpful for educators to understand how to best manage the students' behavior and concentration in their classrooms.

In order to do a study like this, it is necessary to have the permission of both a parent and the student to participate. Giving permission means allowing your child to fill out some assessment forms about his or her behavior and thinking related to the mindfulness exercises. Your child will already be taking the mindfulness class as part of the regular classroom education. Participating in the study only means filling out the assessment questionnaires and background information.

There are two forms attached to this cover letter. The blue form is for the parent and gives more detailed information about the study. Please sign if you will allow your child to participate. The green form is for your child. If you child would like to participate, a signature is also needed here. We have already read and discussed these two forms in your child's class. We also encourage you to review the forms with your child.

We ask that you please choose whether or not you agree to allow your child to take part in the study. Then, please sign the form and have your child return it to school. If you have any questions about this study, please feel free to contact me, and I will be happy to discuss with you.

Thank you for your time and attention to your child's education.

Sincerely, David Viafora Graduate student School of Social Work - San Diego State University (619) 300-0873 dpviafora@gmail.com

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APPENDIX E

APPROVAL LETTER TO CONDUCT THE STUDY

FROM THE INSTITUTIONAL REVIEW BOARD

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February 15, 2010

Dear David Viafora:

Project #449048 "Assessing a Mindfulness Course for Middle School Students" was reviewed and approved

in accordance with SDSU's Assurance and federal requirements pertaining to human subjects protections within

the Code of Federal Regulations (45 CFR 46; 21 CFR 50). This review is valid through 1/19/2011, and applies

to the conditions and procedures described in your protocol. Please notify the IRB office if your status as an

SDSU-affiliate changes while conducting this research study (you are no longer an SDSU faculty member, staff

member or student).

The approved consent form(s) labeled, IRB STAMPED has been uploaded to your protocol file within the vIRB

system, within the Supporting Documents section. This document bears the IRB's stamp of approval. Please

print a copy of this stamped form to use when documenting informed consent from research participants.

Changes may not be made to the consent document(s) without prior review and approval of the IRB. You are

required to keep signed copies of the consent document(s) for three years after your project has been completed

or terminated, unless this requirement has been waived as per 45 CFR 46.117.

If your study requires consent document translation, please note that the SDSU Institutional Review Board

(IRB) does not verify the accuracy of the translated document. IRB approval of this document for use in subject

recruitment is based on your assurance that the translated document reflects the content of the IRB approved

English version of the document.

Please note the following:

(a) For studies requiring consent translation: The SDSU Institutional Review Board (IRB) does not verify the

accuracy of the translated document. IRB approval of this document for use in subject recruitment is based on

your assurance that the translated document reflects the content of the IRB approved English version of the

document.

(b) If you have indicated that you will be utilizing existing data; ensure that you have the proper

permission to utilize this data.

(c) If recruitment will take place through an outside agency or organization, confirm with that

institution that you have permission to conduct the study prior to initiation of any study activities.

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(d) Approval is contingent upon the completion of the SDSU human subjects tutorial (found at:

http://www-rohan.sdsu.edu/~gra/login.php) by all members of the research team. This certification

must be renewed every 2 years.

For questions related to this correspondence, please contact the IRB office ((619) 594-6622 or e-mail

irb@mail.sdsu.edu). To access IRB review application materials, SDSU's Assurance, the 45 CFR 46,

the Belmont Report, and/or any other relevant policies and guidelines related to the involvement of

human subjects in research, please visit the IRB

web site at http://gra.sdsu.edu/research.php.

Graduate Students: This message may be used to verify approval by the SDSU Institutional Review

Board (IRB) for enrollment in Thesis 799A. If you are not presently enrolled in 799A, attach a copy of

this letter to your Appointment of Thesis/Project Committee form prior to submitting the completed

form to Graduate and Research Affairs Student Services Division. If you enrolled in 799A using the

IRB e-mail notification, forward a copy of this final approval letter to the Graduate Division for

completion of your record.

Sincerely

Jeanne Nichols

Chair, Institutional Review Board

Wendy Bracken

Coordinator, Human Research Protection Program

Amy McDaniel

Regulatory Compliance Analyst

Choya Washington

Regulatory Compliance Analyst

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APPENDIX F

OVERVIEW OF MINDFULNESS COURSE:

STRUCTURE, CURRICULUM CONTENT, AND

INSTRUCTOR EXPERIENCE AND TRAINING

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MINDFULNESS COURSE OVERVIEW

The 8-week mindfulness course offered to middle school students in this study

contains many different components and was ultimately implemented based upon the

professional work and guidance of many other supporting individuals. This chapter

acknowledges past work which provided a foundation for the curriculum, describes the

instructor's past experience and training, and explains the course structure and the different

mindfulness practices that were offered during the course. The main chapter sections include:

(a) foundation and flexibility of the mindfulness course, (b) instructor experience and

training, (c) course structure, setting, and a safe environment, and (d) mindfulness practice

and activities.

FOUNDATION AND FLEXIBILITY OF THE MINDFULNESS COURSE

The mindfulness course was primarily based upon the the work of Dr. Saltzman, in

her 8-10 week MBSR course for children and adolescents, which has been adapted from

traditional adult programs of MBSR (Saltzman, 2008; Saltzman & Goldin, 2008). Saltzman

(2008) acknowledges that any mindfulness course should be tailored uniquely to the

participating students, the setting, as well as the instructor's experience. In her manual for

teaching mindfulness to youth, she explains that “ultimately every group creates its own

masterpiece – moving lines and adding shading and color to reveal depth and perspective. It

is essential that each session and the course overall be responsive to the individuals and the

experiences in the room” (p. 21). With this in mind, the mindfulness exercises were

occasionally modified for the classes, while trying to keep an overarching intent, content, and

structure. Some of the practices were used more with some classes than with others,

depending on their preferences and needs as observed by the instructor. Similarly, not all of

the practices offered in the manual were included in the present study, due to time

constraints, and appropriateness to the age and background of the sample of students.

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EXPERIENCE AND TRAINING OF THE MINDFULNESS INSTRUCTOR

The mindfulness instructor in this study has had extensive training in personal

mindfulness practice, has worked with youth in a variety of capacities, including in school

classrooms, and has taught mindfulness skills to youth for over six years. However, the

instructor had less experience teaching mindfulness to youth in secular settings and had not

yet taught a mindfulness course to students in a school classroom for more than a few

sessions, and much less than for eight weeks. Most of the prior experience of teaching

mindfulness to youth occurred in spiritual-based communities, at summer camps and

programs, and occasionally in secular settings such as homeless shelters for youth and

occasionally in school classrooms. Thus the relative inexperience of the instructor in the

format and setting in the present study limited the overall effectiveness of transmitting

mindfulness skills to the students.

Teaching mindfulness in a school classroom has various challenges that only

experience and guidance can fully master. It requires a dynamic combination of depth of

personal mindfulness practice, experience working with youth from different backgrounds,

training and experience in teaching mindfulness to youth, and experience working in schools.

Without a decently strong background in all of these areas, the results of a mindfulness

course may be limited. Becoming an expert instructor of mindfulness with youth does not

simply happen after a weekend workshop or even a four month course. These trainings may

help to provide some preliminary skills, however, experience in the four aspects previously

described is key for competently and proficiently teaching mindfulness. There are different

levels of depth that a mindfulness instructor may have depending on the number of years

teaching in general, with certain populations, and in specific environments. A well seasoned

instructor of mindfulness such as Dr. Saltzman will likely provide better results for a class of

students than someone who has only been practicing and teaching mindfulness for a few

years. Classroom behavior management, communicating and collaborating effectively with

school administrators and faculty, skillfully requesting balanced levels of the classroom

teacher's support, teaching to a larger than preferred number of students at one time, and

balancing the individual needs and temperaments of many youth at one time are some of the

main challenges which do not even encompass the mindfulness curriculum itself.

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Understanding what works best and what doesn't over the course of an 8-week program with

students takes a growing amount of experience. That is not to say that students in this study

did not receive the core elements of mindfulness training, but the extent of their learning was

most likely limited by the instructor's own limited experience of teaching mindfulness in this

format and setting.

The experiences of teaching mindfulness to youth in other settings besides a school

classroom are not without merit, even in non-secular settings that promote teaching and

learning mindfulness practice. Kabat-Zinn recognizes that mindfulness practice is rooted in

Eastern religious traditions; Western Buddhist communities and teacher-led retreats “provide

a range of rich resources for personal practice and dialogue that can contribute toward the

training and development of a cohort of highly competent teachers, from a wide variety of

professional backgrounds, committed to the effective delivery of authentic mindfulness-

based interventions in various settings” (Kabat-Zinn, 2003, p. 146). Kabat-Zinn suggests that

training in non-secular settings may be useful for mindfulness instructors, however, this also

needs to be balanced with experience or training in secular formats.

WEB-BASED TRAINING ON TEACHING MINDFULNESS TO CHILDREN AND ADOLESCENTS

The instructor participated in a 10-week web-based training for teaching mindfulness

to children and adolescents several weeks before and during the mindfulness course with

TG2. The course was developed and taught by Dr. Amy Saltzman, a pioneering teacher and

researcher in the field of mindfulness-based programs with youth. Saltzman emphasizes a

well-balanced approach to sharing mindfulness with youth, stating, “It is essential that our

offerings come from the depths of our own practice, that we use age-adapted language, and

that the offerings are engaging” (Saltzman, personal communication, March, 2010). Topics

of the training included: skillful adaptations of mindfulness instruction for youth; language

and practices that are accessible and interesting for youth; observing a 10-session course for

elementary school students; discussing curriculum modifications for older children;

collaboration with school administrators, teachers, and parents of students; and reviewing

current research in the field (Saltzman, 2008). The instructor's experience was that the

training enhanced his capacity to teach mindfulness in ways that were relevant and

appropriate for the youth's developmental levels. Despite the new training, the instructor still

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taught the same basic format of instruction to both treatment groups, with similar

mindfulness exercises; although the ultimate delivery and skillfulness of the instruction may

have changed with the enhanced training.

COURSE STRUCTURE AND CLASSROOM SIZE The mindfulness course was provided to classrooms of middle school students with

sizes typically ranging from about 20 to 35 students. The middle school at site #1 initially

wanted more of its students to attend the class in hopes of improved attention and behavior

for more students. During the first two sessions, the school had combined two classes in the

mindfulness course, with over 40 students in the room. However, due to classroom

management challenges and overall difficulties in teaching mindfulness techniques to so

many students, the mindfulness instructor requested that the class size be reduced.

Thereafter, the class size hovered between 30 and 35 students in one class and about 30 in

another class. In MBCT-C programs, two therapists are recommended for 6 to 8 children

(Lee, 2006). However, other organizations such as Mindful Schools and Attention Academy

Program offer programs to entire classes of students. As mindfulness courses are still

relatively new in primary educational settings, there is no adopted standard for suggested size

limits as there are in adult MBSR courses, which are usually limited to 30 participants (Baer,

2003). The mindfulness course was delivered in 8 weeks, with 45 minute weekly sessions.

Classroom teachers were encouraged to be present in the class during sessions. They were

encouraged to find their own balance and level of comfort between helping with overall

classroom management and experiencing the mindfulness exercises themselves. The

classroom environments were only slightly adapted to prepare for sessions. One classroom

had student desks which were facing each other; this created some challenges for students

who felt less comfortable and more self-conscious about practicing the mindfulness exercises

while directly in front of their peers. For this classroom, the mindfulness instructor arranged

the desks and chairs to all face in the same direction.

CREATING A SAFE AND MINDFUL ENVIRONMENT IN THE CLASS

During the first class session, after listening practice, the instructor introduces himself

and reviews the “ground rules” for the mindfulness sessions. The ground rules are provided

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in the Still Quiet Place manual of mindfulness courses for youth (Saltzman, 2008). The first

ground rule is Confidentiality. In order to better engage the students and gauge their level of

understanding, the instructor may ask the students what confidentiality means to them. The

instructor may also offer a simple definition, such as: what is said in the room stays in the

room. The second ground rule is Right to Pass. During discussions, students have the right to

speak when called upon, but every student has the right not to speak for any reason and at

any time. It is especially important during the beginning sessions that the students and their

emotional state of being be accepted just as they are, whether that involves silence or not.

The third rule is Respectful Behavior. It can be helpful for the instructor to ask the students to

recommend guidelines that they feel are important to them in fostering a environment of

respect for one another; the instructor can write these down and include them in the class

ground rules. In addition to the students' ideas, the instructor should state the following

essential elements of respectful behavior: (1) Mindful Listening: paying attention to whoever

is talking with your full presence; (2) Mindful Speaking: Not interrupting when other are

speaking, sharing one's personal experiences with “I” statements, and noticing when you

want to share just to show off or be silly; and (3) Controlling One's Body: staying in one's

own space, while not distracting, poking, or in any way disturbing another person's space.

The last ground rule is Being a Team Player, which means trying to support others in

learning about and experiencing the mindfulness practices together (Saltzman, 2008). After

reviewing the guidelines, the instructor should ask for feedback from the students about any

of these rules, while validating their questions and comments and trying to incorporating

them into the class guidelines. Then the instructor may ask if anyone has a problem or

disagrees with any of the course guidelines mentioned, so that questions or disagreements

can be resolved. Consequences for behavior that do not comply with the ground rules can

vary from class to class, especially depending on the classroom teachers' level of behavior

management. Typically though, the instructor may tell the students that if someone chooses

not to follow any of the class guidelines that have been discussed, then the instructor will

first give a warning to that student. Then the instructor may have to ask for the teacher to talk

to the student individually. Lastly, the instructor may have to ask the student to leave. It is

important for the instructor to explain to the students that he/she would love for all of the

students to stay in the class and enjoy learning together; but if one student is acting in a way

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that prohibits the other students from participating in the mindfulness practice, then the

instructor has the responsibility to uphold the course “ground rules” for the benefit of the

entire classes' well-being and commitment to learning together.

MINDFULNESS PRACTICE AND ACTIVITIES Several different types of mindfulness activities and exercises are incorporated into

each session, although each session is unique and often includes a new exercise. This section

introduces several of the mindfulness exercises used, including listening, inviting the bell and

breathing, mindful eating, guided mindful breathing exercises, pleasant experiences practice,

test-taking practice, mindful movements, discussion, and weekly home activity practice.

Listening Practice Each class session began with listening practice. This is intended to quiet any chatter

in the room, bring down rambunctious energy, and focus the students' collective attention.

The mindfulness instructor invites the children to listen as long as they can to the sound of a

musical instrument (e.g. a tone bar, bell), until the sound stops. The instructor asks if the

students are able to listen to the sound all the way until the end to test whether their level

concentration is strong enough. Sometimes, to better engage the students, the instructor will

invite the students to raise their hands when they first hear the bell, and then to lower their

hands when they no longer hear the sound. This helps to engage the students in a way that

outwardly expresses their participation in the listening exercise.

Inviting a Mindfulness Bell and Breathing with the Mindfulness Bell

Besides listening to the sound of the instrument, the students are also invited to

become aware of the sensations of their breathing when listening to the sound. Throughout

the course, the instructor may periodically invite a “mindfulness bell”, which can help to

restore an atmosphere of calm and awareness in the room when needed as well as teach the

students to occasionally stop and pay attention to what they are experiencing in the present

moment.

After the first few times of listening to a mindfulness bell, the instructor may call

upon individual students who have been demonstrating appropriate and engaged class

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behavior to come to the front of the class and invite a sound of the tone bar or bell. This is

usually a favorite activity for students to try. Inviting the bell is also a profound mindfulness

practice, especially as it is done in front of others in the class. Before inviting a sound, the

student is advised to follow his/her breathing for two or three full breaths, in order to ground

their attention and focus, and calm some of their anxiety or excitement. It is explained that

the focus and calm that they experience will affect the quality of the sound of the bell that

will be offered to the class. After the student invites 3 sounds and returns to his/her seat, the

rest of the class is invited to applaud the student's efforts, which usually brings a smile and

some confidence to the student for trying.

Mindful Eating This practice is designed for students to develop their mindfulness of sensory

perceptions, as well as feelings and thoughts associated with their experience. Students are

first invited to be aware of feelings and thoughts occurring before the eating takes place. The

instructor encourages them to smell, observe and be fully aware of the snack for several

moments before taking a bite. The instructor may ask questions such as “What is happening

in your mouth as you smell the slice of orange?” or “Notice your thoughts about the snack,

whether it be 'Yeah, I love these crackers', or 'Darn, bananas again'. Just mindfully recognize

and accept whatever feelings and thoughts are coming up for you right now.” Then the

students are invited to take one bite, let it rest in their mouth for a few moments, and then

take slow, mindful bites without rushing, noticing what is happening in their mouths, bodies,

and minds. During the first several times of practicing mindful eating, the instructor may

guide the students very methodically to notice different sensations in their mouths, throats,

other parts of their body, or with their feelings. Then the instructor can offer the students

more freedom in exploring mindful eating in a way that feels authentic and comfortable to

them, with fewer instructions as the course progresses. This practice is a concrete way for for

youth to be more easily in touch with the present moment through their senses. Furthermore,

it is easier for the students to experiment with this practice in their daily life, since eating

occurs several times a day. The mindful eating practice was typically incorporated for several

minutes near the beginning of each class. As recommended in other mindfulness programs

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for youth, the instructor provided snacks that are low in sugar, such as fruit or crackers

(Saltzman, 2008).

Guided Sitting Meditation Exercises Each session includes a guided mindful breathing exercise which the students can

follow while sitting in their chairs. While following the sensations of one's breathing is

always a core element, the exercises may also include focusing one's attention upon a range

of other topics. The first several sessions include simple exercises, such as following the

sensations of one's breath or mindfulness of bodily sensations. Later exercises include

mindfulness of feelings practice, guided imagery to enhance awareness of bodily sensations

and feelings, lovingkindness practice, and feeling at home in the present moment. During the

initial sessions, the guided exercises may last from 6-8 minutes. In later sessions, as students

become more comfortable, the exercises may last longer, such as 12-15 minutes long. In each

guided practice, the students are first invited to find a comfortable position, and are

encouraged to sit upright, with their backs straight but also relaxed. Being upright and

relaxed helps to foster more alert attention, while slouching induces torpor, and sitting up too

erect may incur stiffness and unease. The students are invited to close their eyes in order to

better relax. However, if closing their eyes feels uncomfortable, then they are advised to open

their eyes only half-way and focus on a point a few feet in front of them.

During the mindful breathing exercise, the students are invited to notice the

sensations of their breathing whether in their nostrils, in their throat, chest, or abdomen. If

they have trouble feeling the breath, then they can place a hand on their abdomen to feel the

sensations of their breathing there. For several minutes, the instructor will guide them in

continually bringing their attention back to their breathing, in a way that helps them cultivate

attention, calm, and acceptance of whatever they are feeling in the moment.

The second session included a mindfulness of bodily sensations through a body scan.

The practice begins by having the students feel their breathing in their belly, noticing how the

belly rises on the inhale, and falls on the exhale. After grounding their attention on their

breathing for about one minute, the instructor guides the students in bringing awareness to

sensations in different parts of their body: their toes, their feet on the floor, their legs, the

sensations of the clothes on their skin, and so on, all the way up to their head. On the in-

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breathe, the participant brings awareness to a body part, and on the out-breathe, he/she

accepts how the body part just as it is and however it feels. Each region of the body is

brought into awareness slowly and methodically, enhancing awareness of sensations in that

region with the in-breath, and then releasing tension in that region with the out-breath. The

practice both invites mere awareness of a body region, as well as releases any tension and

stress in that region. Participants are encouraged not to force or try too hard in relaxing and

releasing tension, but rather to allow their awareness and mindfulness of breathing to help the

body relax naturally.

For a more detailed description of these guided meditation exercises (i.e. awareness

of breathing, body scan) or other meditation practices such as feelings practice, guided

imagery, and lovingkindness practice, please see work by Saltzman (2008) and Saltzman &

Goldin (2008).

Pleasant Experiences Practice During the second or third class, the students are given a pleasant experiences

worksheet, which is designed to help them pay greater attention to events and their internal

responses in their daily life. The students are offered two worksheets – an in-class worksheet

which contains four bubbles for the students to reflect on and fill in, and a pleasant events

calendar to take home and fill out a few times during the week. In both worksheets, the

students write about a pleasant event that was recently experienced, what he/she noticed in

his/her body at the time of the event, what did feelings were observed, and lastly, what bodily

sensations and feelings does the student currently observe while writing. After completing

the worksheet, the instructor opens up a discussion for the students to share about their

experiences and reflections. To help the discussion progress, the instructor may ask about

experiences through the five senses, questions about what makes a pleasant experience, and

any feelings or thoughts that were associated with the experience. The instructor may also

remind the students that simple experiences can also count, such as petting one's cat, eating

lunch with friends, or noticing a beautiful flower on the way to school. It is important for

students to know that they always have something pleasant or special to share about,

however small, and that they don't feel self-conscious about not having a big event to share

about with their peers (Saltzman, 2008).

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Test Taking Mindfulness Practice Throughout the course, students are encouraged to try using mindfulness practice

when they felt uncomfortable, nervous, excited, or during any situation that they may benefit

from more relaxed awareness. During two class sessions, the students role played using

mindful breathing techniques during a testing scenario, when high levels of anxiety or

frustration may arise. The students were instructed to imagine that they were about to take a

test or quiz, and to feel any thoughts or feelings that could come up in that situation. Then

they were guided to follow the sensations of their breathing, especially the rise and fall of

their abdomen. After following three full in- and out-breaths, the students were encouraged

to simply recognize and allow any feelings that they have to be there, not pushing them away

or fighting the feelings. Then they were encouraged to redirect their attention back to their

breath and their bodily sensations, particularly in their toes and feet on the floor, or their legs,

which are more neutral regions of feeling. Then the students were invited to try forming a

half-smile, whether they felt like it or not. The reason was explained that smiling helps to

calm and relax areas of the brain and in the body, which can be very helpful when difficult

feelings arise. The students were advised to just note the bodily sensations and feelings that

may change when they smile. After mindfully breathing and smiling, the students were

instructed to bring their attention back to the test in the role-play scenario, noting how their

mind and body feels compared to when the exercise first started. After the role-play, the

instructor led a short discussion to hear students' experiences of the practice and answer any

related questions.

Mindful Movements During a 45 minute class, students may become sluggish or feel antsy, especially if

they have been sitting down for a period before the class begins. As this energy is not

conducive to the students' sustained attention, most sessions involved a mindful movement

exercise during the middle of the class. This can help to enliven the energy of the students if

they are feeling tired or display the need to move their bodies more, which depends on each

class. Saltzman (2008) offers several different movement exercises which can embody

mindfulness, such as yoga poses, mindful slow and fast walking, and seaweed practice

(moving one's body like he/she is seaweed flowing in the water). Regardless of the particular

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exercise or movement game that is offered, it is important to offer an exercise that is age-

appropriate for the youth, entertains and stimulates them, allows them to let out some wiggles

and silliness if needed. Throughout the exercise the instructor should offer reminders for the

students to be aware of their bodily sensations, feelings, and thoughts, as well as the presence

of others that are nearby if it is an interactional exercise. Encouraging students to become

aware of their breathing is also a key component of maintaining mindful awareness during

the exercises. The present study included mindful movements that reinforced breath

awareness, such as simple stretches, tai chi exercises, and some fun interactional movements

between students.

Discussion Discussions are included after ending a mindfulness exercise, or at the end of a class

for students to share about their experiences, relate to others, and ask questions. Before

inviting the students to talk, the instructor can remind the students that mindfulness practice

will continue, but now in the form of mindful listening and speaking, as was discussed in the

course ground rules. It may also help to occasionally offer specific reminders such as trying

to speak from personal experiences, not interrupting, and trying to be a team player by

learning from others' experiences. During the discussion time, it is important for the

instructor not to merely praise and welcome positive comments and experiences of the

students about the practice. It is important that those who felt uncomfortable or had

unpleasant experiences during a practice be able to express themselves and not feel judged

about their experiences; the instructor should frequently ask for comments from those who

experienced difficulties with the practice. Honesty and openness to their authentic

experiences is crucial for learning about and making progress in mindfulness practice. At the

base, mindfulness is about cultivating awareness in the present moment, whether that be

pleasant or unpleasant; it is not about being continually calm and relaxed, though these

feeling states may be cultivated in the practice at times as well. For example, if someone

notices feelings of aversion, boredom, anxiety, this is also mindful awareness. Later, the

discussion may evolve to finding skillful ways to be with these feelings and states of mind in

positive ways. Students may also be encouraged to investigate whether these feeling states

arise only during the mindfulness course or at many times during their day. Thus, being

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mindful of and skillfully taking care of these feelings can help the students with a variety of

other important but difficult tasks in their lives (e.g. math class, p.e. exercises, sports

exercises) (Saltzman, 2008).

Discussions may take place with the entire class, or the instructor may choose to

divide the students into dyads or triads, so that each student has more time to discuss his/her

experiences and insights with others. The instructor can periodically change the format of the

discussion from asking for voluntary sharings to asking each student in the class to speak.

This allows students who are more shy to contribute to the class discussion as well. For those

students who are reluctant to share even after several class periods, their right to pass should

be respected, but the instructor should also gently encourage them to test their flexibility and

try sharing their experiences with the class (Saltzman, 2008).

Home Activity Practice Practicing at home is an integral aspect of students' development of mindfulness

skills, so that they can generalize the practice to their everyday lives, and maintain the

mindfulness skills after the course is finished. Adult programs in MBSR also stress the

importance of daily mindfulness practice. Kabat-Zinn (1990) emphasizes to clients in the

Stress Reduction program, “The most important thing to remember is to practice every day.

Even if you can make only five minutes to practice during your day, five minutes of

mindfulness can be very restorative and healing.” Similarly for youth, a consistent practice of

various exercises can help them to apply mindfulness during different daily routines (eating,

walking, listening, lying down before bed, etc.). The aim is for students to learn a

combination of different forms of mindfulness practice so that they can more successfully

manage the ups and downs of their everyday lives (Lee, 2006). Home activities are

introduced at the end of a session, and the instructor will encourage the students to try some

of the practices that were just learned in class, when they are at home or at school. For

example, the instructor may encourage the students to try eating mindfully during the first 5

bites of their breakfast o4 lunch during the week. Another example is after week 2, the

students have an assignment to practice the body scan while lying down on their bed before

falling asleep. During the following week's class, the instructor will open up a discussion for

students to share about their practice during the week. Saltzman (2008) notes that it is

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important for students who did not do the home practice to feel comfortable expressing that,

in order to openly discuss the challenges and obstacles for them without judgment or

criticism. Involving other students in the discussion of what gets in the way, what times of

day work best for the practices, or how some students are able to do the practice at home can

help many of the students to discover new ways to try the practice at home. Student

responses of being too busy or tired to practice can serve as springboards for discussing the

benefits of mindfulness practice, and its relevance to our often fast-paced, very busy, and

high stress culture. Sometimes, it can be helpful for the instructor to challenge the students to

try the practice for 5 minutes at home each day, and to personally investigate the results of

their efforts. In order to further encourage the students, the instructor may share that they are

learning a new skill, just like playing an instrument or playing a new sport, and it takes

practice to improve and see positive results. When offering home activities, it is usually

helpful for the instructor not to use the term “homework” because of its associations and

often negative student responses (Saltzman, 2008).

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APPENDIX G

DEMOGRAPHICS QUESTIONNAIRE

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Demographics Questionnaire Date:

Please take a few minutes to answer these questions.

1. Name: _________________________________________________________________

(First) (Last)

2. □ Male □ Female

3. Date of Birth:

Month: ______ Day: ______ Year: _______

4. Please mark your current grade in the correct box below:

□ 7th grade □ 8th grade

5. Ethnicity – Please mark all that apply:

□ Caucasian/White □ African American □ Latino/Latina

□ Asian American □ Native American □ Other

6. Please indicate the main caregiver(s) in your home (who takes care of you ?):

□ Father only □ Mother only □ Father and mother together

□ Live with grandparents □ Live with foster parents □ Live in group home

□Other (please write in)_____________________________________

7. Where do you live right now ?

□ My parent's home □ My relative's home (including grandparents)

□ A friend’s home □ A group home □ A shelter □ In a car □ In a motel

□ Other (please write in)___________________

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8. How long have you been living there?

□ Less than 3 months □ Between 3 and 6 months □ More than 6 months,

but less than 1 year □ Between 1 and 2 years □ More than 2 years

9. Where did you live before the place you are living right now?

□ My parent's home □ My relative's home (or grandparents) □ A friend’s home □ A group home □ A shelter □ In a car □ In a motel

□ Other (please write in)___________________________________________

10. What grades do your teachers usually give to you in school?

□ Outstanding (As) □ Satisfactory (Bs) □ Average (Cs)

□ Below average (Ds) □ Failing (Fs)

11. How would your teachers usually rate your behavior in class?

□ Outstanding behavior □ Good behavior □ Average behavior

□ Difficult behavior □ Very difficult behavior

Thank you for filling out this questionnaire. ☺

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APPENDIX H

PARTICIPANT EVALUATION QUESTIONNAIRE

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Name________________________________________

Date___________________________

Please circle the answer that best describes your experience.

There are no right or wrong answers.

1. Overall, how would you rate the Mindfulness Program for Students?

1 I hated it 2 I did not like it 3 I’m not sure 4 I liked it 5 I loved it 2. This program has been helpful to me.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree 3. I would recommend this program to my friends.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree 4. I will continue to use mindfulness techniques in my life, even after the program is over.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree 5. Mindfulness has changed the way I interact with other people.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree

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6. Mindfulness has helped me be more patient in my life.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree 7. Mindfulness has helped me at school.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree 8. Mindfulness has helped me at home.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree 9. Mindfulness has helped me control my anger.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree 10. Mindfulness has helped me feel less worried in my life.

1 Strongly Disagree 2 Disagree 3 Neutral/ Not Sure 4 Agree 5 Strongly Agree

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As best you can, please complete the following statements about the program:

The worst part of the program is_________________________________________________

___________________________________________________________________________

___________________________________________________________________________

The best part of the program is _________________________________________________

___________________________________________________________________________

___________________________________________________________________________

My least favorite exercise is ___________________________________________________

___________________________________________________________________________

___________________________________________________________________________

My favorite exercise is ________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

When I look back on the past 12 weeks in the program, I feel _________________________

___________________________________________________________________________

___________________________________________________________________________

Please write a brief note to a friend about what mindfulness is, how it feels to practice

mindfulness, and how you are able to use mindfulness in your daily life:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Thank you very much