How can interventions based on mindfulness be used for children and adolescents? - Chapter 24

What is this chapter about?

Mindfulness-based interventions, or mindfulness training, are referred to as MFT. MFT is an umbrella term for all forms of such interventions, such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). MFT for children and adolescents with psychopathology is growing rapidly and worldwide. For adults, there is a medium effect size of MFT on psychological health and stronger effect sizes for MBCT for anxiety disorders and depression. The research on (the effectiveness of) MFT for children and adolescents is still in its infancy. The studies were carried out within three psychopathologies: autism spectrum disorders (ASD), internalizing disorders (anxiety and mood) and externalizing disorders (ADHD, ODD and [other] behavioural disorders).

How does MFT work for children and adolescents with an ASD?

According to the ToM hypothesis (Theory of Mind hypothesis), people with an ASD have difficulty in understanding others’ mental states, which may explain the flaws in social interactions (such as little empathy). MFT improves the ability to express empathy. Very little research has been done on the effectiveness of such an intervention – only one study conducted by Singh and colleagues (2006) (in which only three children were included) shows modest but promising results.

How does MFT work for children and adolescents with internalizing disorders?

In most anxiety disorders, attention problems play a (major) role. Think of the attention bias for threatening stimuli, the self-focused attention, the low concentration as a symptom of GAD, and the avoidance of social cues in a social anxiety disorder. According to Semple and colleagues (2005), mindfulness-based techniques can already be taught to children from the age of 7. According to an RCT by Semple and colleagues (2010), MFT leads to a reduction in attention problems, behavioural problems and anxiety symptoms. According to another study (no RCT) by Biegel and colleagues (2009), MFT is a promising addition to outpatient health care for adolescents with mood disorders, to reduce levels of anxiety, depression and somatic symptoms and to improve self-esteem and quality of sleep!

How does MFT work for children and adolescents with externalizing disorders?

Externalizing disorders such as ADHD, ODD and behavioural disorders all have the characteristics that there are problems in attention and impulsivity. MFT can help to fix these attention problems.

An important challenge is that studies on the effectiveness of MFT for children and adolescents with psychopathology have many methodological flaws, such as very small samples, few objective outcome measurements (they mainly use self-reports), a lack of measurements that can really notice changes in the underlying mechanisms of the disorders, and also a lack of RCTs! Almost all supporting evidence now comes from pilot studies or uncontrolled studies.

How does MFT work for children with ADHD?

It is clear from the following that new treatments for ADHD are needed. Currently, there are two evidence-based treatments for children with ADHD: medications, and behavioural treatments. The long-term effect of medications is still unclear, there are often side effects, and treatment loyalty is often low. The most commonly used behavioural treatment is to train the parents in their parenting style. However, part of ADHD is hereditary and the training does not affect this. CBT treatments for ADHD are not empirically proven: coping skills and other skills learned are often not permanent in the long term and generalization of the learned skill of the therapy setting to other settings is often low. Mindfulness training is promising: it focuses on the core problems of ADHD, namely the prolonged focus of attention is addressed directly (by focusing attention on breathing, or the body), and an impulsive response is inhibited (by seeing thoughts as thoughts, and not as the beginning of an action).

The program of the authors of the book is Mindfulness Training (MFT) for children with ADHD and parallel mindful parenting (MP) for their parents. The program consists of eight group sessions of one and a half hours with 4 to 6 children (between 9-12 years) or 6 to 8 adolescents (between 13-17 years) diagnosed with ADHD, and eight parallel group sessions for the parents (presence of both parents is best), with one follow-up session 8 weeks after the training.

What are the eight sessions of MFT for the child?

• Session 1: The Martian male. In the first half hour the children, parents and trainers are in one room and do the "weather forecast" for 2 minutes, i.e., meditating while sitting and focusing on how they feel (and talk about this in one or two words afterwards). Then the "raisin exercise" in which everyone talks about what they see, hear, feel, smell, and taste during meditation. The third half hour is used to increase motivation. Then parents and children split up and the session for the children involves stretching, breath-focused meditation, setting group rules and providing psycho-education.
• Session 2: At home in our bodies. The general structure of sessions 2 through 7 is as follows: a short sedentary meditation, repeat the theme of the previous session and what has been learned, introduce and learn the new theme, discuss the homework done and provide new homework. The theme of this session is to learn to listen to one's own body so that the child becomes aware of restless moments (the body is an alarm clock), but also how this awareness can help him or her to concentrate.
• Session 3: Breathing. The theme "breathing" teaches children what happens to their breathing in case of hyperactivity or intense emotions, and how this can be controlled so to calm down.
• Session 4: Distractors. This theme revolves around both external distractors (such as noise) and internal distractors (e.g. tired), and how meditation can help to stay focused.
• Session 5: Highway, sidewalk. The first 20 minutes involve the parents and the children together, so they perform the sedentary meditation together. Everyone is given a moment to talk what they have learned so far. "Highway" refers to the times when the child feels uncontrollable, "sidewalk" refers to the way focused breathing can lead the child off the highway and into quieter lanes.
• Session 6: What we learned. All central concepts are reflected in a quiz. In this session, the ‘seeing-meditation’ is also introduced (follow a soap bubble) as well as the ‘hearing-meditation’ (listen to the meditation bell).
• Session 7: Practice with difficult situations. In these sessions, meditation is practiced when all kinds of difficult situation occur (such as, when there is a mountain of candy in front of the meditating child).
• Session 8: And now alone. Most of the sessions involve both the parents and the children. Six meditation sessions are performed together, in which the child learns the meditation together with the parent. Also, each child will learn what the parent has learned, and the parent will learn what the child has learned. Each family also creates a plan for meditation exercises for the next eight weeks (until the follow up session).

Does the parallel session of mindful parenting exist for parents?

In mindful parenting (MP) parents learn the following things:

1. To be fully aware of the here-and-now with your child, in a non-judgmental way.
2. Take good care of yourself, as this is the basis for a good upbringing.
3. Accept your child's problems.
4. Be careful to deal with difficult behaviour, rather than reacting impulsively/automatically in difficult situations.

What can be concluded?

Mindfulness trainings combined with MP are promising. A warning is in place in the case of MFT in children with anxiety disorders. CBT programs for anxious children are often twice as effective as CBT treatments for adults, so it's not clear whether MFT is as effective within this context as a CBT treatment. CBT treatments for depression in children are less impressive, and given the success of MFT for treating depression in adults, it is a good idea to develop such programs for children with depression.

Mindfulness-based interventions, or mindfulness training, are referred to as MFT. MFT is an umbrella term for all forms of such interventions, such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). MFT for children and adolescents with psychopathology is growing rapidly and worldwide. For adults, there is a medium effect size of MFT on psychological health and stronger effect sizes for MBCT for anxiety disorders and depression. The research on (the effectiveness of) MFT for children and adolescents is still in its infancy. The studies were carried out within three psychopathologies: autism spectrum disorders (ASD), internalizing disorders (anxiety and mood) and externalizing disorders (ADHD, ODD and [other] behavioural disorders).