Document 6446619

Child and Adolescent Mental Health Volume **, No. *, 2012, pp. **–**
doi:10.1111/j.1475-3588.2011.00643.x
Review: The contribution of mindfulness-based
therapies for children and families and proposed
conceptual integration
Paul H. Harnett1 & Sharon Dawe2
1
School of Psychology, University of Queensland, St Lucia, Brisbane, Queensland 4072, Australia.
E-mail: [email protected]
2
School of Psychology, Griffith University, Brisbane, Queensland, Australia
Background: Mindfulness is the development of a nonjudgmental accepting awareness of moment-bymoment experience. Intentionally attending to oneÕs ongoing stream of sensations, thoughts, and emotions as
they arise has a number of benefits, including the ability to react with greater flexibility to events and sustain
attention. Thus the teaching of mindfulness-based skills to children and their carers is a potential means of
improving family relationships and helping children achieve more positive developmental outcomes through
increased ability to sustain attention and manage emotions. We provide a review of recent studies evaluating
mindfulness-based interventions targeting children, adolescents, and families in educational and clinical
settings. Method: Searches were conducted of several databases (including Medline, PsychINFO and Cochrane
Reviews) to identify studies that have evaluated mindfulness-based interventions targeting children, adolescents
or families published since 2009. Results: Twenty-four studies were identified. We conclude that mindfulnessbased interventions are an important addition to the repertoire of existing therapeutic techniques. However,
large-scale, methodologically rigorous studies are lacking. The interventions used in treatment evaluations vary
in both content and dose, the outcomes targeted have varied, and no studies have employed methodology to
investigate mechanisms of change. Conclusions: There is increasing evidence that mindfulness-based therapeutic techniques can have a positive impact on a range of outcome variables. A greater understanding of the
mechanisms of change is an important future direction of research. We argue that locating mindfulness-based
therapies targeting children and families within the broader child and family field has greater promise in
improving child and family functioning than viewing mindful parenting as an independent endeavor.
Key Practitioner Message:
• Mindfulness-based interventions hold promise for improving outcomes for children and adolescents
• The number of mindfulness-based interventions being developed and evaluated is increasing rapidly
• There is a need for greater methodological rigor in studies evaluating mindfulness-based therapies
targeting children and adolescents
• Understanding the mechanisms of change is important in the future development of mindfulness-based
family interventions
• Models of mindful parenting have been proposed to guide both research and the clinical application of
mindfulness-based family interventions
Keywords: Mindfulness; child development; parenting; intervention; mechanisms of change
Mindfulness has been described as a process of developing a nonjudgmental accepting awareness of
moment-by-moment experience (Bishop et al., 2004;
Kabat-Zinn, 2005). This involves intentionally attending to oneÕs ongoing stream of sensations, thoughts,
and emotions as they arise, without evaluating these
phenomena as good or bad, true or false, healthy or sick
(Baer, 2003). The practice of mindfulness is integral to
Eastern spiritual, philosophical traditions, most notably Buddhism from which much of the understanding
and practice of mindfulness within Western psychotherapies has derived (Kang & Whittingham, 2010).
When integrated into Western psychotherapies, mind-
ful awareness and an accepting attitude toward
moment-to-moment experience is taught as a way of
helping people tolerate psychological and physiological
distress. Insofar as mindfulness can also raise an
individualÕs awareness of positive experiences that
otherwise may not be attended to, mindfulness training
has been used as a means of enhancing emotional well
being and life satisfaction (Harnett et al., 2010).
The turn of the century has seen a growing interest in
mindfulness as evidenced by a comprehensive search of
the research literature with the term ÔmindfulnessÕ. In
1990, a search of 30 databases across multiple disciplines resulted in 27 hits, when all publication types
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
2
Paul H. Harnett & S. Dawe
(journal articles, book reviews, and dissertations) were
included. For the year 2010 the same search resulted in
1060 hits. Of particular interest for the current article
was the increase in the number of peer-reviewed articles on mindfulness focusing on children, adolescents
or families. Seven were found in 1990 compared to 55 in
2009 and 116 hits one year later (see Figure 1). With
this rapid escalation of interest in mindfulness, it is
timely to consider how the concept of mindfulness can
contribute to efforts to improve child and family functioning.
In this article, we first provide a review of intervention
studies published since 2009. We then consider whether the teaching of mindfulness skills has the potential
to contribute to the treatment of child and family
functioning more broadly than has been attempted to
date. We do so by considering the potential role of
mindfulness in the light of an integrated theoretical
framework for working therapeutically with families.
Method
The review builds upon a preliminary review of 15 studies
on mindfulness-based approaches with children and adolescents written by Burke (2009). Searches were conducted
in the following electronic data bases: PsychINFO, PSYarticles, Medline, Web of Science, and the Cochrane Library.
Search terms included ÔÔmindfulnessÕÕ, ÔÔmeditationÕÕ
ÔÔMBCTÕÕ, ÔÔMBSRÕÕ, ÔÔchildrenÕÕ, ÔÔadolescentsÕÕ, ÔÔyoung peopleÕÕ, ÔÔfamiliesÕÕ, and ÔÔschoolsÕÕ. Dissertation studies and
conference papers were excluded and only articles written
in English were considered. In examining the quality of the
research evidence we focused on the following: (i) research
design, including descriptive studies such as single-case
designs, nonrandomized designs, studies that had a wait
list control group and finally, as the design with the most
rigorous support, randomized controlled designs; (ii) the
extent to which the measures reflected the theoretical
foundation of the intervention; and (iii) the dose of treatment and the extent to which the treatment was manualized or had a published description that addressed
treatment fidelity (Mercer & Pignotti, 2007).
Results of the literature review
We identified 24 studies published since BurkeÕs review
(2009) targeting children and adolescents that had been
1200
all disciplines-peer reviewed
1000
all disciplines-all publication types
Number of hits
child & family all disciplines-peer reviewed
800
child & family all disciplines-all publication
types
600
400
200
0
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Year
Figure 1. Number of hits from database searches of the term
ÔmindfulnessÕ from 1990 to 2010
Child Adolesc Ment Health 2012; *(*): **–**
conducted both in educational settings and with clinical
groups either in the home or in clinical settings. The
school-based studies tended to have a preventative focus and were generally delivered by teachers specifically
trained in mindfulness procedures. The interventions
evaluated in the school setting included programs for
the children themselves and programs aimed at
improving child outcomes by teaching mindfulness
skills to teachers, carers or parents (e.g., Coatsworth,
Duncan, Greenberg, & Nix, 2010; Duncan, Coatsworth,
& Greenberg, 2009b). Two studies focused on reducing
psychological distress of the teachers rather than children (Franco, Manas, Cangas, Moreno, & Gallego, 2010;
Gold et al., 2010). A second group of studies used
mindfulness-based strategies within clinical settings
where children and young people were referred with an
existing psychological disorder or identified as high risk
for a stress-related physical disorder. While we have
grouped the review into school-based and clinical settings, many of the techniques used to improve child
outcomes were common to both types of studies.
Mindfulness-based interventions delivered in
educational settings
Mindfulness-based interventions have been delivered in
educational settings with both pupils and teachers (see
Table 1). When considering those with a focus on
improving emotional well being in children, Joyce,
Etty-Leal, Zazryn, Hamilton, and Hassed (2010) report
pre- and post-group differences in children aged 10–
13 years on measures of behavior problems and
depression. The 10-week program delivered by teachers
lead to a significant reduction in self-reported behavioral problems and depression scores at post-treatment. However, the gains were mainly limited to
students showing clinically significant scores at preintervention. Targeting older adolescents, Broderick
and Metz (2009) reported a study that involved a
curriculum-based program delivered over six lessons.
Using a non-randomized design with a small comparison group of younger school children, the authors
reported a decrease in negative affect and an increase in
feeling calm, relaxed, and self-accepting. Notably,
however, there were no changes in any of the other
measures including rumination, somatization and a
well-established measure of emotional regulation – a
key construct targeted in mindfulness interventions.
Mixed findings were also reported by Schonert-Reichl
and Lawlor (2010) in a study that included both a wait
list control and measures of treatment fidelity in a large
sample of fourth to seventh grade children. The mindfulness-based program, delivered by teachers, involved
10 lessons and three times daily practice of mindfulness meditation. Overall, there was a significant
increase in scores on self-report measures of optimism
(part of a larger scale focusing on resilience) and a trend
toward an increase in positive emotions. There was no
change in self-reported negative affect. An unusual
finding was that students in the preadolescent group
showed an improvement in self-concept, while students
in the early adolescent group showed deterioration relative to controls. Teacher reports showed an improvement in social and emotional competence for children in
the intervention group, and a decrease in aggression
and oppositional behavior, although the lack of
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
N
Participant
Type
120
246
97
Broderick &
Metz, 2009
Schonert-Reichl &
Lawlor, 2010
Mendelson
et al., 2010
Fourth and
fifth grade
students
4th–7th grade
students
All students of
a senior
high
school class
Studies targeting school students
Joyce et al., 2010
175
Year 5 and
6 primary
school students
Study
9–10 years
11.4 years
17.4 years
10–13 years
Age(years)
School
Classroom
Classroom
Classroom
Study
Setting
2 group RCT pre
test post-test
Quasi-experimental
control group pre
test post-test
2 group pre test
post-test
Pre test post-test
Research
design
Table 1. Summary of mindfulness-based intervention studies in educational settings
None
Junior school
students
(n = 17)
Wait list
No treatment
6 · 30 min sessions (3 hr)
of the Learning to
BREATHE based on MBSR
10 · 40–50 min weekly
sessions (7.5 hr)
:mindfulness, selfregulation, goal setting,
learned optimism;
plus 3 · 3 min daily
mindfulness practice
12 · 45 min sessions (9 hr)
of mindfulness and yoga
Control
group
10 · 45 min sessions
(7.5 hr) based on MBSR
Treatment group
Self-report:
involuntary
responses
to stress;
depression;
peer and
school
relationships;
affect
Self-report:
affect;
emotional
regulation;
rumination;
somatization
Self-report:
optimism;
school and
general
self-concept;
positive
and negative
affect.
teacher report:
social and
emotional
competence
Self-report:
child
behavior
problems;
depression;
DV
< in child behavior
problems
for high and low
scorers; <
in depression for high
scorers only; > in
prosocial
functioning for low
scorers only.
< in negative affect; > in
feeling calm/relaxed/
self-accepting; No change
in emotional regulation,
rumination or
somatization.
> in self-reported
optimism
and positive affect for all
students; no change in
negative affect; > in
self-reported general
self concept for pre
adolescents only. > in
teacher report of
attention, emotional
regulation, social and
emotional competence; <
in teacher report of
aggression and
oppositional behavior.
Good retention and
acceptability of program
to students and
teachers; < in rumination,
intrusive thoughts and
emotional arousal; no
change in positive or
negative affect,
depression,
or relationships with
peers and teachers;
trend toward
greater trust in friends.
Results
doi:10.1111/j.1475-3588.2011.00643.x
Mindfulness-based therapies for families
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3
18
25
166
Liehr & Diaz, 2010
Semple et al., 2010
Gregoski et al., 2011
Afro-American
adolescents
at risk of
cardio-vascular
disease
Children
struggling
academically
Minority
children
Participant
Type
Duncan et al.,
2009b
5
Families of nine
children in
6th grade
11.5 years
Care-givers
own
children
aged 9–16
15 years
9–13
9.5 years
Age(years)
School
Home
School and
home
School
School
Study
Setting
Uncontrolled pilot
study
Multiple-baseline
across participants
3 group RCT pre
test post-test
RCT
2 group RCT pre
test post-test
Research
design
Heath
education;
life skills
training
12 · weekly (10 min
weekdays, 20 mins
weekends;
14 hr total; BAM)
taken from MBSR
None
None
Waitlist
12 · 90 min weekly sessions
(18 hr) MBCT for children
7 session mindfulness
training
provided to carers
to work
with individuals in
their care
7 · 2-hr sessions
(14 hr; MSFP)
Health
education
Control
group
10 · 15 min sessions daily
for 2 weeks (2.5 hr) of
attention to breath,
mindful movement
and generosity.
Treatment group
Parent report:
qualitative
feedback
Number of noncompliant
responses
made by
children
Physiological:
ambulatory
diastolic
blood
pressure;
overnight
sodium
excretion;
self-report:
perceived
stress
Attention;
anxiety;
behavior
Self-report:
depression;
anxiety
DV
Training carers in
mindfulness in group
home setting lead to
< in non-compliant
responses in carers
own children.
Qualitative feedback
showing usefulness
and acceptability
of MSFP to parents.
< in depression in
intervention
group only; < in
anxiety in
both intervention and
control group.
< in attention
problems; <
in anxiety, but
no group
differences; < in
behavior
problems, but
no group
differences.
BAM group showed
greatest improvement
in systolic blood
pressure; BAM group
showed greater
reduction in diastolic
blood pressure and
heart rate compared to
LST; No change in
perceived stress.
Results
Paul H. Harnett & S. Dawe
Studies targeting parents, carers or teachers
Singh et al., 2010
3
African American
caregivers
N
Study
Table 1. Continued
4
Child Adolesc Ment Health 2012; *(*): **–**
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68
31 & 39
Gold et al., 2010
Franco et al.,
2010
Jennings et al.,
2011 - reported
2 studies
th
Teachers
working in
a high-poverty
urban setting
(study 1) and
student teachers
working in a
semi-rural/
suburban
college
town setting
(study 2)
Secondary school
teachers
Qualified
teachers
teaching
assistants
Families of 5 –7
grade students
transitioning
from elementary
school
th
Participant
Type
Pre test post-test
Study 1: pre test
post-test Study 2;
waitlist control
School
Mean age
teachers
was 40
(study 1);
mean
age of
student
teachers
was 21
(Study 2)
Pre test post-test
School
School
20–50 years
3-group RCT (stratified
by school district)
pre test post-test
Research
design
24–58 years
School
Study
Setting
Child 11.7
years;
mother 39.4
years
Age(years)
Two day weekend
workshop,
phone coaching and
one day workshop - The
Cultivating Awareness
and Resilience in
Education
(CARE) professional
development program
None
8 · 2.5 hr weekly
sessions
(25 hr) of a
mindfulness
course taught by MBSR
teacher
10 · 1.5 hr sessions (15 hr)
of mindfulness program
Listening
to relaxing
music
Study 1: none
Study 2:
waitlist
1)7 · 2-hr 2)
wait list
control
Control
group
7 · 2-hr sessions
(14 hr) of
(MSFP) - parents
and youth
both involved
in sessions
Treatment group
Teacher
self-report:
well being;
depression;
time
urgency;
physical
symptoms;
motivation
orientation;
teacher
efficacy;
mindfulness.
Observations:
classroom
climate
(study 2 only)
Psychological
distress
Parent report:
mindful
parenting;
Child
management
strategies;
Maternal
anger and
affect
toward child
Youth
report:
discipline
consistency
Psychological
distress,
mindfulness
DV
Results
Study 1 < in time
urgency; >
in mindfulness. No
change
in wellbeing,
depression,
physical symptoms,
motivation
orientation
or teacher efficacy.
Study 2 > in
motivation
orientation (support
student autonomy); >
in teacher efficacy. No
difference in
wellbeing,
depression, physical
symptoms, mindfulness
or classroom climate.
< in depression, stress,
but not anixety; > in
Ôaccept without
judgmentÕ
scale, but not other
scales of the KIMS.
< in psychological
distress
> in parental report
of mindful parenting
in MSFP group; > use
of effective child
management practices
in both SFP and
MSFP groups. > in
youth report of
parental
discipline consistency
in MSFP group.
MBSR, Mindfulness Based Stress Reduction; MBCT, Mindfulness Based Cognitive Therapy; BAM, Breathing Awareness Meditation; MSFP Mindfulness-Enhanced Strengthening
Families Program; KIMS, Kentucky Inventory of Mindfulness Skills. < indicates decrease in outcome; > indicates increase in outcome.
65
N
Coatsworth
et al., 2010
Study
Table 1. Continued
doi:10.1111/j.1475-3588.2011.00643.x
Mindfulness-based therapies for families
5
6
Paul H. Harnett & S. Dawe
independent ratings raises concerns about the reliability
of these findings. Mendelson et al. (2010) employed a
mindfulness-based intervention to improve self-regulatory capacities in fourth and fifth grade children from
disadvantaged backgrounds. The current intervention
included yoga-based physical activity, breathing techniques and guided mindfulness practice designed to
help children manage arousal and stress levels. Randomization occurred at the school level with two schools
receiving the intervention four days per week for
12 weeks while the other two schools served as wait list
controls. The treatment was acceptable to both students
and teachers and some significant reductions were
found in the subscales and total score on a measure of
involuntary response to stress. No effects were found on
negative or positive affect, depression or peer relationships, although a trend was noted for greater trust in
friends.
There has been one small randomized trial in which a
mindfulness-based intervention was compared to an
active intervention focusing on improving depression
and anxiety (Liehr & Diaz, 2010). In this study involving
18 children, minority and disadvantaged children recruited from a summer camp were randomly assigned
to either a mindfulness-based intervention or to heath
education. Children attended ten 15 min classes of
mindful breathing and mindful movement over two
weeks. There was a significant reduction in depression
symptoms for those in the mindfulness group and a
reduction in anxiety for both groups, in the immediate
post-treatment follow up. Using a waitlist control,
Semple et al. (2010) assessed the impact of a 12-week
group program based on mindfulness-based cognitive
therapy in children who were struggling academically.
The authors proposed that anxiety influences attention,
which in turn impacts academic performance. Significant improvements were found on measures of attention compared to the wait list. There were reductions in
anxiety and behavior problems, although no group differences at posttest or follow-up. While the authorÕs
suggestion that mindfulness served to enhance selfmanagement of attention and emotion regulation was
supported, whether this, in turn, influenced academic
performance was not tested. One randomized study
investigated the impact of mindful breathing meditation
on 166 Afro-American adolescents at risk of cardiovascular disease (Gregoski, Barnes, Tingen, Harshfield,
& Treiber, 2011). Three-month interventions were offered in two high schools during regular health education classes. The interventions were delivered by
teachers who were each randomly assigned to deliver
one of the interventions. The teachers were provided
with training in an intervention and treatment fidelity
measures assessed adherence to treatment. Breathing
awareness meditation produced greater reductions in
systolic blood pressure compared to Life Skills Training
(LST) or the usual Health Education program. Participants taught breathing meditation also showed greater
reductions for 24 hr diastolic blood pressure and heart
rate compared to LST.
Six studies reported interventions that targeted the
parents, carers or teachers of children. Singh et al.
(2010) investigated the transfer of mindfulness skills
following mindfulness training of carers in a group
home for individuals with severe physical and intellec-
Child Adolesc Ment Health 2012; *(*): **–**
tual disabilities. Records were kept of non-compliant
responses by the carersÕ own children. Results showed
that the mindfulness training they received in the work
context transferred to the home context, demonstrated
by a reduction in noncompliant responses by the carers
children. A small pilot study involving five families
reported by Duncan et al. (2009b) described a modification of the Strengthening Families Program (SFP), an
evidence-based, universal, family focused intervention
designed to reduce risk factors and enhance protective
factors as a means of preventing adolescent substance
use and problem behaviors. The modifications included
teaching the principles of mindfulness and specific
mindfulness practices such as mindful breathing.
Results were limited to positive qualitative feedback.
However, in a larger scale study, Coatsworth et al.
(2010) found the addition of the mindfulness component in MSFP resulted in improvements on a newly
developed measure of mindful parenting, while the
youths reported their parents to be more consistent in
their use of discipline. Two studies targeting teachers
found that a course in mindfulness lead to reduced
psychological distress for those who participated
(Franco et al., 2010; Gold et al., 2010). Jennings et al.
(2011) found mixed support for the Cultivating Awareness and Resilience in Education (CARE) professional
development program designed to reduce teachersÕ
distress and promote improvements in teachersÕ well
being, motivational orientation/efficacy, and mindfulness. A significant increase in mindfulness was found
in only one of the two studies reported. One study found
a decrease in teacherÕs sense of time urgency, suggesting that teachers experienced less stress associated
with time demands after participating in the program.
The increase in mindfulness was found when CARE was
offered to a group of experienced teachers working in an
urban district with high levels of poverty, a high proportion of at-risk students and a context of limited
institutional support. CARE was designed for teachers
working in the context of high emotional stress that can
lead to emotional reactivity in the classroom. The program did not appear to be relevant to a group of student
teachers and mentors working in a less stressful semirural setting with few at risk students and effective
institutional support.
On balance there is reasonable cause for optimism
when considering whether to include mindfulnessbased approaches within an existing school curriculum
and targeting both students and teachers. Positive
mood does appear to be increased while more traditional measures of mood symptoms in particular
depression, show reductions. What is clearly needed,
however, is a clearer understanding of what treatment
should consist of and the dose of treatment that is
necessary to effect change given the considerable variability noted across the studies reviewed above. Variability in outcome measures and methodological
limitations of studies, which are discussed in more
detail below, limit conclusions that can be drawn.
Mindfulness-based interventions delivered in
clinical settings
Single case studies have been conducted by Singh and
colleagues using meditation-based strategies to reduce
aggressive behavior in young people with autism or
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
doi:10.1111/j.1475-3588.2011.00643.x
Asperger syndrome (Singh, Lancioni, Manikam, et al.
2011; Singh, Lancioni, Singh, et al. 2011). In these
studies mothers, after being trained in a meditative
procedure, taught their children to redirect attention
from an aggression-triggering event to a neutral body
part – the soles of their feet. In both studies parents and
siblings reported a decrease in the frequency of
aggressive incidents suggesting that the adolescents
with developmental disorders can learn, and effectively
use, a mindfulness-based procedure to self-manage
their physical aggression.
Several studies reported on the effectiveness of
mindfulness-based treatments incorporated into either
an existing treatment process or delivered as a standalone treatment in clinical populations. Britton et al.
(2010) conducted a prospective uncontrolled clinical
trial of 55 adolescents who had been recent inpatients
receiving substance abuse treatment. Six 90 min group
sessions based on MBSR aimed to improve sleep with
the rationale that poor sleep contributes to mood
problems, which in turn may increase the risk of
relapse to substance use. Outcomes were emotional
distress, relapse and substance use measured across
60 weeks. Completion (defined as attendance at 4 of 6
sessions) was poor (42%) and substance use increased
across the group. There were, however, significant
improvements on measures of emotional distress with a
trend favoring those who were classified as completers
and a reduction in daytime sleepiness for those who
completed the program. A study of youth who were
either HIV infected or Ôat riskÕ who were attending a
pediatric primary care clinic investigated the impact of
an MBSR program on health-related quality of life and
psychological distress. Youth self-reports found a statistically significant decrease in hostility and general
and emotional discomfort. However, significant
improvement was found on only three of 18-subscales.
A small-scale uncontrolled trail of a mindfulness-based
program for adolescents diagnosed with ADHD found
little change on a variety of measures (van de WeijerBergsma, Formsma, Bruin, & Bögels, 2011). While
there was some improvement in the adolescentsÕ
behavior and attention, and some reduction of parenting stress in fathers and overreactivity in mothers,
these changes were not reported by all informants and
were generally not sustained at follow-up. However, the
study was very small, with data from only eight participants available for analysis. Thus, the statistical power
to detect change was very low.
Two randomized controlled trials compared mindfulness-based treatment with an active alternative
treatment. In a small study of depressed adolescents,
Hayes, Boyd, and Sewell (2011) found that an adaptation of Acceptance and Commitment Therapy for adolescents produced greater decreases in a measure of
depression compared to treatment as usual (cognitive
behavioral therapy). There were also decreases in
behavior problems, although this difference was not
significantly greater for the ACT condition. Finally,
Catani and colleagues investigated the effectiveness of
meditation-relaxation compared to narrative exposure
therapy in traumatized children living in refugee camps
in Sri Lanka (Catani et al., 2009). The latter treatment
protocol was designed specifically for people who have
been exposed to enduring trauma associated with war
Mindfulness-based therapies for families
7
and torture. Treatment was delivered by local therapists
trained in the two models. Treatment duration was of
equal length (six 60–90 min sessions over two weeks).
Follow up occurred 4–5 weeks and again 6 months later
by interviewers blind to the treatment condition. While
there were no differences between the two treatments,
the reductions in post-traumatic symptoms were
striking, with recovery rates of 81% for the narrative
exposure group and 71% for the meditation relaxation
group post-treatment. The improvements were maintained at 6 months. Oord, Bögels, and Peijnenburg
(2011) reported on a randomized controlled trial with a
short (8 weeks) follow-up period. The study evaluated
an 8-week mindfulness course for children displaying
symptoms of ADHD that included a parallel course for
parents. Statistically significant changes between preand post-intervention included a decrease in both child
and parent ADHD symptoms and an increase in
parental mindfulness as measured by the Mindfulness
Attention and Awareness Scale. No changes were
observed in parenting stress or parenting style. At follow-up, the reduced levels of ADHD symptoms
remained for both children and parents. A reduction
was found in over-reactive parenting and parental
stress between the pre-intervention and follow-up
assessment. However, mindfulness scores did not vary
between pre-intervention and follow-up.
Our own work in this area has involved the evaluation of an intensive home visiting program focusing on
multiproblem families characterized by emotional dysregulation, maternal psychopathology, and substance
abuse. The program, Parents Under Pressure (PuP), is
based on the premise that sensitive and responsive
parenting requires emotional regulation skills that are
generally dysfunctional in parents with a history of
trauma or psychopathology, including substance misuse and mood disorders. Thus the program draws from
the recent literature on emotional regulation with an
explicit adaption of mindfulness strategies integrated
with parenting skills. The PuP program has been evaluated in three separate case studys (Dawe, Harnett,
Rendalls, & Staiger, 2003; Frye & Dawe, 2008; Harnett
& Dawe, 2008) and one randomized controlled trial
(Dawe & Harnett, 2007). These studies found a reduction in child abuse potential as well as reductions in
maternal mood difficulties and parenting stress. Notably, the studies did not directly measure mindful parenting or parental emotional regulation capacity. As in
other studies, measures of mood were used as proxy
measures of this.
Overall, the studies carried out in clinical settings,
like those in educational settings, justify optimism for
the potential of mindfulness based therapies to improve
child, adolescent and family functioning. In addition to
the efficacy of programs that deliver interventions
directly to children and adolescents, programs that
target parents and carers appear to be effective in
improving parental functioning, and in turn, promote
positive child outcomes.
Methodological limitations
While the majority of the studies reviewed were pilot
studies that had a range of methodological problems, a
small number of studies have been randomized control
trials. Thus, some caution needs to be exercised when
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
33
10
Sibinga et al.,
2011
van de WeijerBergsma et al.,
2011
55
3
3
Singh, Lancioni,
Singh et al.,
2011a
Lancioni,
Manikam,
Singh et al.,
2011a
Britton et al.,
2010
N
Study
Adolescents
with ADHD
Adolescents
with sleep
problems
following
substance
abuse
treatment
HIV-infected
and at-risk
youth
Adolescents
with
Asperger
Syndrome
Adolescents
with Autism
Participant
Type
Academic
treatment
center
Pediatric
primary
care hospital
clinic
13–21
11–15
Outpatient
Home
Home
Location of
intervention
16.4
(SD = 1.2)
14–17
13–18
Age
Pre-post with
8 week
followup
Pre-post
Pre-post
Multiple-baseline
across
participants
Multiple-baseline
across
participants
Research
design
Table 2. Summary of mindfulness-based intervention studies in clinical settings
None
None
None
None
6 · 90 min weekly
group sessions (9 hr)
modified (MBSR)
and CBT
8 · ? weekly sessions
based on MBRS.
8 · 90 min weekly group
mindfulness sessions for
adolescents. Eight
parallel sessions with
parents.
None
Comparison
treatment
5 days of training in
Meditation on
the Soles of the Feet
17–24 weeks of
ÔMeditation on
the Soles of the FeetÕ
Treatment
group
Adolescent report: behavior;
executive functioning;
mindfulness; fatigue;
happiness; attention.
Mother and father report:
behavior; mindfulness;
parenting style; parenting
Stress. Teacher report: behavior
Self-report: health related
quality of life;
psychological distress
Self-report: emotional
distress; relapse
resistance; substance use
Number of aggressive
incidents
Number of aggressive
incidents
DV
< in one of nine domains
of psychological distress
(hostility); > in two of
nine domains of quality
of life (general and
emotional discomfort).
< in externalizing
behavior problems
reported by fathers
only; < in executive
functioning problems
reported by fathers
only; > in some
aspects of attention,
but overall no change;
no change in
adolescent internalizing,
attention problems.
fatigue or happiness;
no change in
adolescent or parent
mindfulness; < in
parenting stress for
fathers but not
mothers at post but
nor follow-up; < in
mothers overreactivity
at post but not follow-up
> in substance use; < in
emotional distress;< in
daytime sleepiness for
completers only.
< in aggressive incidents
maintained over 3 years.
< in aggressive incidents
maintained over 4 years.
Results
8
Paul H. Harnett & S. Dawe
Child Adolesc Ment Health 2012; *(*): **–**
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
12 Families on
methadone
maintenance
In home,
4 years In home,
parents
referred by
community
methadone
clinic
12 sessions · 1.5 hr/per
session
DV
6 sessions
Narrative
Exposure
Therapy
None
None
< in depression greater
for ACT than TAU;
greater proportion of
ACT condition showed
clinically significant
change in depression;
no change in behavioral
problems.
< PTSD symptoms at
1 month for both
groups.
Results
Pre-post change: < parent
reported child ADHD
symptoms; < parent
ADHD symptoms; >
Mindful awareness of
parents; no change in
parenting stress or
parenting style.
Pre-Follow-up change:
< child ADHD symptoms;
< parent ADHD
symptoms; < parenting
stress; < in over-reactive
parenting style; no
change in parental
mindful awareness.
Parent report: parenting
9 of 12 completed
stress, child
program, reduction in
abuse potential, child behavior
variables measured
problems, drug use, alcohol use, found for 6/7 of the
Risk taking behavior
families except risk
behaviors where only
three showed a decrease
Parent report: parenting stress,
All 10 families were
mood, child abuse potential,
followed up. Significant
child behavior problems, social
< on all measures
support
pre-post, 2 of 10 families
showed no change on
any domain.
Parent report: parenting stress;
parenting style; mindful
awareness; parent ADHD
symptoms. Parent & teacher
report: child ADHD symptoms;
child behavior problems.
PTSD symptoms
TAU-manualized Depression, Emotional and
CBT provided by behavioral functioning
the psychiatric
service
Comparison
treatment
8 · 90 min weekly group
none
sessions for parents based
on MBCBT and
MBSR.Parallel sessions
with children.
6 sessions Meditationrelaxation
ACT -individual sessions
using published
treatment manuals
Treatment
group
Single case study, Mean number of
pre postsessions 11.5
measures
(range 9–13)
Single case
study, pre
post-measures
Outpatient
Waitlist
mental
control; 8
health clinic week
follow-up
8–12
RCT
RCT
Research
design
Community transitory
camp
Outpatient
psychiatric
clinic
Location of
intervention
8–14
12–18
Age
Harnett &
10 Families
<8
Dawe, 2008
referred by
child protection
services
Dawe et al.,
2003
Catani et al., 31 Children
2009
affected by
tsunami in
northeastern
Sri Lanka
Oord et al., 22 Children with
2011
ADHD and
their parents
38 Adolescents
experiencing
moderate
to severe
depressive
symptoms
Hayes et al.,
2011
Participant
Type
N
Study
Table 2. Continued
doi:10.1111/j.1475-3588.2011.00643.x
Mindfulness-based therapies for families
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
9
Child Adolesc Ment Health 2012; *(*): **–**
MBSR, Mindfulness Based Stress Reduction; ACT, Acceptance and Commitment Therapy; TAU, treatment as usual.
< indicates significant decrease in outcome; > indicates significant increase in outcome.
12 Women offenders 5.6 years In home or
in low
in low
security or
security
just released
prison
Frye & Dawe
Dawe &
64 Families on
Harnett, 2007
methadone
maintenance
DV
Comparison
treatment
Treatment
group
Research
design
Location of
intervention
Participant
Type
Age
N
Study
Table 2. Continued
Single case
Mean number of
None
Parent report: parenting stress,
8 remained in treatment,
mood, child abuse potential,
Significant < on all
study, pre
sessions for treatment
post- & 3-month completers 20
child behavior
measures at 3 month
(range 11–38)
follow up
follow up
measures
Mean number of sessions TAU, 2 sessions Parent report: parenting stress,
Significant < on all
Randomized
3.5 years In home,
measures for PuP
controlled
for PuP group
clinic based
mood, child abuse potential,
parents
10.5 (SD = 2.9)
on parenting
child behavior Methadone dose, group, significant <
trial
referred
on child abuse
information
by community
potential for brief
methadone
intervention, > on
clinic
child abuse potential
in TAU group
Paul H. Harnett & S. Dawe
Results
10
considering the balance of evidence for including
mindfulness into interventions for children and families. The heterogeneity of the populations in which
studies have been conducted makes it difficult to build
a consistent picture of efficacy, although arguably does
speak to the issue of generalizability. Related to
the issue of diversity in populations studies is the
range of outcome measures adopted, again leading to
little consistency to allow for a more measured appraisal of the benefits of mindfulness. The dimensions
of
functioning
measured
included
behavioral
(internalizing and externalizing problems), emotional
(psychological distress, emotional regulation), cognitive
(rumination, attention, self concept) social (peer functioning, relationship with parents), child abuse potential and health (blood pressure). Only a small number of
studies measured the construct of mindfulness itself,
which is largely explained by the lack of a suitable
instrument to measure mindfulness in young people
over the period the studies were conducted. Only
recently has a promising measure been described in the
literature (Greco, Baer, & Smith, 2011). While the
interventions being evaluated can be classified as
Ômindfulness-basedÕ, there was in fact a large variation
in both the content and dose of the interventions evaluated. In around half of the studies, the intervention
involved an adaptation of the Mindfulness Based Stress
Reduction program (Kabat-Zinn, 2003), although there
was no single agreed adaptation of this program. Other
programs adapted included Mindfulness Based Cognitive Therapy and Acceptance and Commitment Therapy
– programs that have differing theoretical underpinnings and were developed for adults. The adaptations
described for use with children and adolescents were
generally practical concerns (e.g., shorter duration
sessions for children with limited attention spans)
rather than adaptations informed by models of child
development and family functioning. In general, the
sample size of the studies reviewed was small, compromising the power to detect changes in participant
functioning. Most studies assessed only the short-term
impact of interventions using pre-post designs. When
follow-up assessments were included they were generally short (around 8 weeks). Thus it is not possible to
determine how enduring the treatment effects may be
both in the presence and absence of ongoing meditative
practice. A primary concern was the lack of focus on
evaluation mechanisms of change, a point we turn to
next.
Parental mindfulness and proposed
mechanisms of change
Despite the methodological limitations, sufficient
studies showed evidence that mindfulness-based techniques led to positive changes to justify optimism for
the inclusion of mindfulness-based techniques as part
of a practitionerÕs therapeutic repertoire for treating
children and families. However, we see a problem for
the field to be the proliferation of Ômindfulness-basedÕ
interventions targeting children and families that vary
both in content and dose, as well as their theoretical
underpinnings. Kazdin has persuasively argued that
the emphasis of research in the child and family field
should be on developing a greater understanding of the
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
doi:10.1111/j.1475-3588.2011.00643.x
active ingredients of programs if any are to be optimally
effective (Kazdin, 2007; Kazdin & Nock, 2003). While
ÔmindfulnessÕ as a psychological construct is assumed
to be responsible for improved outcomes, this was not
systematically investigated in any of the studies above.
One obstacle for research on mechanisms of change is
the lack of psychometrically sound measures of the
construct of ÔmindfulnessÕ as it relates to parents and
children. We note that two measures are in development that will help to facilitate such research in the
future (Coatsworth, Duncan, Greenberg, & Nix, 2009;
Greco et al., 2011). However, another obstacle has been
the lack of an agreed model of mindful parenting to
guide research on mechanisms of change. An important
development, then, are recent attempts to identify the
mechanisms that change as a consequence of improved
parental mindfulness. Duncan, Coatsworth, and
Greenberg (2009a) describe a model of mindful
parenting that focuses on the benefits of mindfulnessbased interventions to enhance the parent-child relationship. Specifically, the authors suggest that parents
who acquire mindfulness skills will have an enhanced
capacity to listen with full attention (increased sensitivity to the childÕs cues); will adopt a more nonjudgmental acceptance of self and child (a balance between
parent-orientated, child-orientated, and relationship
orientating goals); have greater emotional awareness of
self and child (acknowledgment of the childÕs emotional
state and responding to the childÕs needs with less
negative emotions); be better able to self-regulate in the
parenting relationship (maintaining a focus on long
term parental goals and values and avoidance of shortterm automated reactive responses); and display more
compassion for self and child (the expression of more
positive affect toward the child and avoidance of
self-blame in the parenting role). More recently Bögels,
Lehtonen, and Restifo (2010) have argued that mindfulness-based interventions improve aspects of attention, in particular the ability to disengage from
unexpected and emotionally charged stimuli. Integrating findings from the experimental literature on mindfulness, the authors suggest mindfulness-based
parenting interventions may exert their effects by: (a)
reducing parental stress; (b) reducing parental preoccupation resulting from parental and/or child psychopathology; (c) improving parental executive functioning
(in particular reduced impulsivity); (d) reducing the
impact of dysfunctional upbringing schemas and habits; (e) increasing self-nourishing attention; and (f)
improving marital functioning and co-parenting. In a
recent cross-sectional study of Duncan et al.Õs (2009a)
model, Parent et al. (2011) investigated the relationship
between parental mindfulness, parental depression,
positive and negative parenting practices (based on
observations of parent-child interactions) and child
outcomes (internalizing and externalizing problems).
Correlational analyses carried out on the results of 180
families involving 242 children aged 9–15 showed that
parental mindfulness was associated with both internalizing and externalizing problems of the children.
Regression analyses failed to find that parental
depressive symptoms or positive or negative parenting
behaviors acted as intervening variables to explain
the significant association. While this might suggest
mindfulness has a direct effect on child outcomes, the
Mindfulness-based therapies for families
11
authors speculated that other variables not measured
in their study, possibly parental emotion regulation or
adaptive coping skills, might be candidates to explain
the relationship. This conclusion is consistent with the
model of mindful parenting put forward by Duncan
et al.Õs (2009a) and the mechanisms proposed by Bögels et al. (2010); specifically that heightened parental
awareness of their own and their childÕs emotional
states and enhanced parental emotional regulation
skills allow the parent to respond more flexibly to the
child, as opposed to responding with a ÔmindlessÕ
automated negative reactivity.
Placing mindfulness within a broader context
While the ÔmindfulnessÕ of children and parents is a
variable that may prove to be a key factor in adaptive
functioning, there is a danger that a focus on mindfulness in isolation from other variables influencing the
development of children and functioning of families
could limit consideration of the full range of variables
that potentially mediate outcomes in treatment. We
suggest the benefits of mindfulness-based interventions
targeting families would be better considered within the
context of an integrated framework of family functioning, one that is itself informed by existing models of
child development and family functioning (Cicchetti &
Cohen, 2006; Sameroff, 2010). That is, we suggest that
mindfulness-based interventions may be better considered as one strategy for obtaining positive outcomes
when working with children and their families rather
than an endeavor in its own right. We present here an
integrated framework (Figure 2) for working with families and consider below how mindfulness-based interventions can sit within and complement other
intervention strategies. Indeed an important implication of the integrated framework is that changes in
mindfulness can be tested as mediators and moderators of change across multiple domains of functioning.
The integrated framework we propose takes, as its
starting point, the aim of promoting positive child
developmental outcomes across multiple domains of a
childÕs functioning and across time. This is achieved by
targeting both proximal and more distal domains of
family functioning. Those influences most proximal to
a child are (a) the quality of the parent child relationship and (b) how the parent behaves in their parenting
role. In regards to the quality of the parent child relationship, the framework draws on BiringenÕs work on
emotional availability (Biringen, 2000, 2004). This
model delineates the dimensions of the parent-child
relationship that predict the quality of parent-child
attachment and other child developmental outcomes.
Four dimensions describe the behavior of the parents –
the ability to respond sensitively to the child (sensitivity), provide structure to help the child manage their
emotions and behaviors (structuring), promote autonomy (non-intrusiveness); and minimize angry and
hostile interactions (non-hostility). In addition to being
emotionally available, the integrated framework highlights the importance of parental values and expectations of the child as major influences on the choices a
parent make about issues such as their style of discipline, level of child monitoring and importance of
family routines.
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
12
Paul H. Harnett & S. Dawe
Child Adolesc Ment Health 2012; *(*): **–**
Figure 2. Integrated framework
Critically, however, and an area that typically
receives less focus in many traditional family focused
interventions, the integrated framework suggests that
the extent to which the parentsÕ capacity to be emotionally available and ability to consistently implement
parenting practices based on fair and reasonable values
and expectations is directly influenced by the parentÕs
emotion regulatory capacities. Parents create a social
and emotional climate to which children must learn to
self-regulate, as well as provide the safety net when selfregulation fails (Sameroff, 2010). High levels of parental
emotional dysregulation results in a high stress environment and impairs the parentÕs capacity to be emotionally available. Thus a significant contribution that
mindfulness can make is to provide a therapeutic
approach that may directly enhance this self-regulatory
capacity. However, the integrated framework acknowledges parental functioning and a childÕs development
are affected by multiple influences, including the
resources (or lack of) available to the family, schools,
neighborhoods, culture and economic and political
climate (e.g., Bronfenbrenner, 1986; Sameroff, 2010).
Thus, the ecological context in which the family is
embedded is an important target for therapy – by
helping parents manage those aspects of the social
ecology that are amenable to change, such as managing
life stressors and engaging support.
Mindfulness and the integrated framework
A common theme of the articles reviewed was that
mindfulness leads to greater acceptance of problem
child behavior by parents, carers and teachers that
leads to an increase in the quality of the relationship
with the children in their care. For example, Singh et al.
(2010) speculated that mindfulness training might
produce a transformational change in carers that does
not occur following training in contingency management and specific methods of behavior management.
On the contrary, mindfulness training leads to
nonjudgmental acceptance of problem behavior that is
responded to more favorably by the children in their
care, improving the quality of the carer–child interactions. This was echoed by Coatsworth et al. (2010) who
found changes in parental discipline and monitoring by
mothers in the standard Strengthening Families Program was not received well by the youth in their study.
Children whose mothers received mindfulness training
in addition to SFP reported their mothers to be more
consistent in their use of discipline and more likely to
monitor where they were and who they were with.
Children from the SFP group reported slight increases
in motherÕs negative affect directed toward them, while
MSFP children reported a decrease in negative affect
(despite positive affect remaining high throughout).
Mothers in the MSFP condition perceived their children
to display more positive and less negative affect,
whereas mothers in the SFP condition perceived less
positive affect and more negative affect from their children. The authors suggested that when disciplinary
strategies are taught in conjunction with mindful parenting, parents are able to modulate their emotional
reactivity to their childrenÕs behavior and this may have
contributed to building a closer and more loving relationship between parent and children (Coatsworth
et al., 2010). Within the school environment Gold et al.
(2010) noted that teachers described the intervention to
be helpful in controlling their stress because they
became more accepting and nonjudging. The authors
report that ÔResponding, not reacting, teaches us to take
controlÕ (p. 188). There is some empirical support for
this suggestion. Two studies by Bluth and Wahler
(2011a,b) tested the hypotheses that mothersÕ everyday
mindfulness would covary inversely with the effort they
put into parenting, that mothersÕ mindfulness will covary inversely with their reports of their childrenÕs
problem behavior, and that mindfulness would mediate
or moderate the correlation between their effort and
their reports of their childrenÕs problem behavior. Parenting effort was described as emotionally taxing
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.
doi:10.1111/j.1475-3588.2011.00643.x
struggles parents have when trying to handle challenging situations with their children, such as reacting
emotionally in the moment rather than disciplining in a
manner more in line with their values. Bluth and
Wahler found that mothers reporting high mindfulness
were less intrusive and more able to avoid the escalation of conflicts with their adolescents (Bluth & Wahler,
2011a) and pre-schoolers (Bluth & Wahler, 2011b)
compared to mothers who were classified as low mindfulness. The authors argued that parental mindfulness
has the potential to interrupt or de-escalate a chaotic or
emotionally charged situation. Mindful parents can be
more aware of their habitual patterns of parent-child
interaction, leading to a less reactive and more nuanced
responses, that requires less effort.
Our integrated framework acknowledges the important influence of the social ecology within which the
family is embedded. At this level mindfulness-based
therapeutic techniques have a potentially important
role to play. Duncan and Bardacke (2010) in a study of
pregnant women reported that mindfulness training
helped the women cope with stressful aspects of pregnancy and family life post-intervention, expanding their
repertoire of skills to cope with contextual demands
such as poverty, major life events, work related stress
and interpersonal tensions (Duncan & Bardacke,
2010). The ability to employ mindfulness skills to protect against such adversity is worthy of increased
attention given the negative impact of stressors associated with low SES on individual and family functioning (McEwen & Gianaros, 2010). In a recent study
Sturge-Apple, Skibo, Rogosch, Ignjatovic, and Heinzelman (2011) found that mothers facing the stress of
extremely low social economic status displayed abnormal sympathovagal activity (hyporarousal). This physiological reaction, the result of the need to adjust to
chronic stress, was associated with disengaged and
insensitive interactions with their children during
observations of free play. Importantly, Ganzel, Morris,
and Wethington (2010) have presented evidence pointing to the potential of mindfulness-based therapies to
significantly influence the physiological processes
associated with individuals physiological adjustment to
ongoing stress – raising the hope that mindfulnessbased therapies can potentially promote improved
family functioning and child outcomes in socially and
economically disadvantaged families (see Repetti,
Robles, & Reynolds, 2011).
Conclusion
The results of the research conducted thus far suggest
that mindfulness-based techniques have the potential
to improve aspects of individual and family functioning
that are associated with better developmental outcomes
for children and families. However, we argue that the
outcomes of interventions targeting children, adolescents, and families will be most informative if the
mindfulness-based therapeutic techniques are integrated into existing programs that address multiple
domains of family functioning rather than pursued as
an independent endeavor. It is important that the field
avoids continued proliferation of programs and focuses
more on understanding the mechanisms responsible
for change. ÔMindfulnessÕ is emerging as an active
Mindfulness-based therapies for families
13
ingredient of interventions, but is unlikely to be the sole
variable responsible for the changes in outcome.
Acknowledgement
This review article was commissioned by the Editors of the
journal, for which the first author received a small honorarium towards expenses. The authors have both declared
that they have no competing or potential conflicts of interest arising from the publication of this article.
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Accepted for publication: 9 November 2011
2012 The Authors. Child and Adolescent Mental Health 2012 Association for Child and Adolescent Mental Health.