Mindfulness for Children, Adolescents, and Families: Integrating Research into Practice (Mindfulness in Behavioral Health) 3031519426, 9783031519420

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Mindfulness in Behavioral Health Series Editor: Nirbhay N. Singh

Herman Hay Ming Lo

Mindfulness for Children, Adolescents, and Families Integrating Research into Practice

Mindfulness in Behavioral Health Editor-in-Chief Nirbhay N. Singh, Medical College of Georgia Augusta University Augusta, GA, USA

Mindfulness-based therapy is one of the fastest evolving treatment approaches in psychology and related fields. It has been used to treat many forms of psychological and psychiatric distress and medical conditions as well as to foster health and wellness. Early empirical studies and meta-analyses of current research suggest that mindfulness-based therapies are effective and long lasting, but much more data from research and training studies are needed to fully understand its nature and effective practice. The Mindfulness in Behavioral Health series aims to foster this understanding by aggregating this knowledge in a series of high-quality books that will encourage and enhance dialogue among clinicians, researchers, theorists, philosophers and practitioners in the fields of psychology, medicine, social work, counseling and allied disciplines. The books in the series are appropriate for upper level undergraduate and graduate courses. Each book targets a core audience, but also appeals to others interested in behavior change and personal transformation.

Herman Hay Ming Lo

Mindfulness for Children, Adolescents, and Families Integrating Research into Practice

Herman Hay Ming Lo Department of Applied Social Sciences Hong Kong Polytechnic University Hunghom, Kowloon, Hong Kong

ISSN 2195-9579     ISSN 2195-9587 (electronic) Mindfulness in Behavioral Health ISBN 978-3-031-51942-0    ISBN 978-3-031-51943-7 (eBook) https://doi.org/10.1007/978-3-031-51943-7 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Preface

This book serves as a reflection on the literature and empirical studies conducted over the past two decades, incorporating my personal involvement in teaching and researching MBPs since 2004. Its purpose is to delve into the role of mindfulness training in promoting the well-being of children and families within a broader context. It is important to acknowledge that mindfulness is not a cure-all solution, but rather a tool with its own limitations and benefits. By being mindful of these factors, we can gain a better understanding of how mindfulness can be beneficial to children and families when implemented properly. I have cherished memories of the International Conference on Mindfulness in 2018, held in Amsterdam, where I had the pleasure of meeting researchers and practitioners from around the world. We gathered alongside the canal, sharing our passion for mindfulness research and practice. However, the COVID-19 pandemic has drastically altered how we connect and gather. Despite the challenges we face, the mindfulness research and practice community continues to thrive. As I bring this book manuscript to completion, my aspiration is for it to serve as a catalyst, fostering further reflection, discussion, and research. In doing so, we can advance our mindfulness teaching and research endeavors, ultimately benefiting children, adolescents, and families globally. Lastly, I would like to express my profound gratitude to Prof. N. Singh for your unwavering encouragement and inspiration. Without your support, this book would not have come to fruition. I am also immensely thankful to Dr. Helen Ma and Dr. Jon Kabat-Zinn, who have played pivotal roles in shaping my mindfulness practice through your guidance and mentorship. Your wisdom, embodiment, and teachings have served as guiding forces throughout my journey of learning, practicing, teaching, and researching mindfulness. Kowloon, Hong Kong October 2023

Herman Hay Ming Lo

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Introduction

After teaching mindfulness to adults for several years, I believe I could adapt my earlier fruitful experiences with adult mindfulness programs to children. Parents who attended my 8-week mindfulness-based stress reduction programs at a family service center in Hong Kong echoed this sentiment. They believed their children could significantly benefit from such programs and asked me to consider what can be offered to this younger demographic. The venture of developing and researching mindfulness-based projects tailored for children turned out to be an intriguing journey. My background as a social worker in foster care and school social work paved the way in this journey. Seeing the distress in many children and adolescents, who hardly vocalized their pain, made me realize the importance of fostering trustworthy relationships with them. Before formally trained to teach mindfulness to children, I had developed a resilience program for children aged 10 to 14 in 2003. This program utilized a cognitive behavioral approach, and the two 10-session protocols were well received by both schoolteachers and students. Having taught mindfulness-­ based programs to adults for several years, it dawned on me that I could harness my previous experience with children to adapt such programs to suit their needs. When I was asked by Ms. Elsa Lau, a seasoned school teacher, to join a school mindfulness project for students struggling with low academic achievement, I accepted without hesitation. At that time, there was a dearth of knowledge and research regarding mindfulness for children. Collaborating with Elsa and Anita, two accomplished child mindfulness teaching fellows, we began teaching mindfulness programs to students in three Hong Kong secondary schools (Lam et al., 2015). My first session in 2010 was memorable. I stood before 40 students aged 12 to 14 who had attended per their teacher's recommendation, only to find the program not interesting. Some chose to nap, others conversed in small groups, while I strived to maintain their attention and lost my voice. By the third session, less than half remained. After the completion of the ten-session mindfulness curriculum, we continued to offer follow-up booster sessions in the second school semester. About ten of the students stayed in the class until the end of the school year. I still remembered a girl vii

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told me that she practiced body scan with my audio file when she could not fall asleep. When I look back, I am so thankful to these young people who have taught me to be humble and open when teaching and researching mindfulness with children. In all mindfulness-based programs, we honor the participant’s intention to learn and practice mindfulness, and there is no exception for children. At the same time, we should be prepared and stay mindful when children say no to you in a mindfulness-based program. It has been my privilege to meet Ms. Eline Snel, the founder and trainer of the Mindfulness Matters a child mindfulness program (Snel, 2015). I joined her first batch of professional training in Hong Kong in 2014, and I went back to the drawing board and experiment with Snel’s program. I taught a few eight-week mindfulness matters programs to preschool and young children. The experience was a bit chaotic, but I learned to adapt the mindfulness exercises with stories, movement activities for children, and other playful and engaging methods. The process of teaching mindfulness to children may not be straightforward. Still, I believe in its potential, especially for children grappling with behavioral and attention disorders. The reflection and insights presented in this book are based on my experiences, ongoing research, and learnings. I feel fortunate to complete the training of .b (the program of Mindfulness in Schools Project), MYMind (the mindfulness program for children with ADHD and ASD developed by Prof. Susan Bogels), and the Soles of the Feet (the mindfulness-based approach in working with aggression for children and adults with disabilities by Prof. Nirbhay Singh) over the years. I am glad that I can learn from these pioneers in the field and join this rapid growing community that we can learn and support each other in the path of teaching and researching child mindfulness. In 2014, I was awarded my first external research grant, which was based on a mindfulness-based program for children diagnosed with attention deficit/hyperactivity disorders (ADHD), and for their parents (Lo et al., 2016). This was the formal beginning of my journey into researching mindfulness for children and families. I'm extremely grateful to my team and, in particular, Eline in offering support in implementing the program. I vividly recall an occurrence during the first program of this project. Two children who were part of my study got into a physical altercation in the waiting area just before the start of the second class. The boy who was suspected of initiating the fight was reported to be extremely restless and had notable issues adhering to the instructor's directions during the class. The fight was so serious that the other boy's white school uniform was left bloodstained. As the principal investigator, I was left contemplating whether the first boy was suitable to continue participating in the program. The following week, the boy and his parents met with the instructor and me prior to the start of the third class. The boy was extremely quiet, eyes lowered, appearing remorseful for his actions the week prior. He did agree to avoid causing harm to others during the program and also to practice mindfulness at home using our audio files. Considering his intention to change and his parents' motivation and persistence to our program, we decided to take a risk and allow him to continue the program despite our doubts about whether mindfulness could help him. Five weeks later, the boy and his both parents completed the program. During

Introduction

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the final joint practice session, all the participants arranged themselves into two circles. Upon completion of the practice, we asked everyone to acknowledge the effort and “performance” of the children. Unexpectedly, the boy that was in question demonstrated his calmness and stability in practice. All the parents and children were in agreement to award him the highest score for his peacefulness during the sitting practice. The research concluded with promising results, suggesting that a family parallel intervention for children with ADHD and their parents may lead to improvements in attention, hyperactivity symptoms, and overall family well-being (Lo et al., 2020). Three months later, the boy's mother attended my talk and stayed behind to chat with me afterward. She revealed that schoolteachers were pleasantly astonished by her son's improvement particularly in school readiness. I was deeply moved by the significant impact of mindfulness on a young child's life, although I am also aware that short mindfulness-based programs may not completely alleviate the struggles faced by many families and children with similar developmental challenges. This book brings together the work of multiple research studies focused on mindfulness-based programs conducted by myself and draws on the knowledge and experience of a multitude of researchers and practitioners worldwide. Following the adaptation of Buddhist-based meditation techniques into a secular mindfulness program suited for adults, this successful model is now experiencing another adaptation to childhood application. Over the last two decades, there has been an uptick in the number of mindfulness-based curricula designed specifically for children, accompanied by substantial research in this field (Butterfield et al., 2020). However, there is still much to learn about how mindfulness can positively impact children. This field is still in its infancy and we are navigating an uncertain path, often clouded by doubt. Comprehensive and rigorous studies will be instrumental in providing evidence into if and how exactly mindfulness can serve children and their families. This book aims to act as a guide for those interested in understanding and contributing to this field. Chapter 1 introduces the concept of mindfulness and outlines its trajectory from a traditional religious teaching to a comprehensive, modern program. Chapter 2 delves into the theoretical foundations of mindfulness-based programs in children and adolescents, focusing on the role of mindfulness in promoting cognitive development and socio-emotional learning, and detailing the essential components of these programs. Chapter 3 explores measurements used in studying mindfulness and the outcomes of these programs. Chapter 4 assesses research on school mindfulness curriculums and critically evaluates issues associated with teaching mindfulness to children in a classroom setting. Chapter 5 focuses on the application of mindfulness-based programs for children with developmental challenges while Chapter 6 looks at the uses of these programs in managing children’s mental health and socio-cultural challenges. Chapter 7 examines the theoretical basis of mindful parenting and discusses the application and adaptation of mindfulness-based programs for parents. Chapter 8 reviews the application of these programs to teachers and their subsequent impact on students and entire school systems. Chapter 9 addresses implementation science, explaining the rationale behind studying the

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delivery processes of mindfulness-based programs for children and adolescents. Lastly, in Chapter 10, ethical considerations specific to the teaching of mindfulness to children and adolescents are explored, alongside discussions on ways to enhance teaching standards.

References Butterfield, K. M., Roberts, K. P., Feltis, L. E., & Kocovski, N. L. (2020). What is the evidence in evidence-based mindfulness programs for children? Advances in Child Development and Behavior, 58, 189–213. Lam, C. C., Lau, N. S., Lo, H. H. M., & Woo, D. M. S. (2015). Developing Mindfulness programs for adolescents: Lessons learnt from an attempt in Hong Kong. Social Work in Mental Health, 13(4), 365–389. Lo, H. H. M., Wong, S. Y. S., Wong, J. Y. H., Wong, S. W. L., & Yeung, J. W. K. (2016). The effect of a family-based mindfulness intervention on children with attention deficit and hyperactivity symptoms and their parents: Design and rationale for a randomized, controlled clinical trial (study protocol). BMC Psychiatry. 16, 65. Lo, H. H. M., Wong, S. W. L., Wong, J. Y. H., Yeung, J. W. K., Snel, E., & Wong, S. Y. S. (2020). The effects of family-based mindfulness intervention in ADHD symptomology in young children and their parents: A randomized control trial. Journal of Attention Disorders, 24(5), 667–680. DOI: 10.1177/1087054717743330. Snel, E. (2014). Mindfulness matters: Mindfulness for children, ages: 5-8. Trainers handbook 1. Author.

Contents

1

Mindfulness-Based Programs: Origins, Emergence, and Adaptations ������������������������������������������������������������������������������������     1 Mindfulness as a Traditional Buddhist Teaching������������������������������������     1 Emergence of Mindfulness-Based Programs in a Secular Context ��������     3 Defining Mindfulness-Based Programs ��������������������������������������������������     5 Adaptations of MBPs and Their Considerations�������������������������������������     7 Framework Informing Program Adaptations and Study Designs������������     9 National Institute of Health Stage Model (Onken et al., 2014) ����������     9 Medical Research Council Guidance on Developing and Evaluating Complex Interventions (Skivington et al., 2021)��������    10 Theory of Change (Breuer et al., 2016) ����������������������������������������������    11 Community-Based Participatory Research (Wallerstein & Duran, 2010)����������������������������������������������������������������������������������������������������    11 Implications for Research������������������������������������������������������������������������    12 Implications for Practice��������������������������������������������������������������������������    12 References������������������������������������������������������������������������������������������������    12

2

 Mindfulness and Developmental Needs of Children��������������������������    15 Mindfulness, Meditation, and Spirituality for Children��������������������������    15 Mindfulness-Based Programs as a Unique Intervention for Children ����    17 Common Mindfulness Practice and Adaptations for Child MBPs����������    19 Mindfulness and Cognitive Development of Children����������������������������    21 Mindfulness and Social and Emotional Development of Children����������    21 Age and Sex Effects on the Outcomes of Child Mindfulness Programs��������������������������������������������������������������������������������������������������    23 Can Mindfulness Programs Benefit Preschool Children?��������������������    23 Can Children and Adolescents Benefit Equally from Mindfulness Programs?��������������������������������������������������������������������������������������������    24 Gender Differences in the Outcomes of Mindfulness-Based Programs����������������������������������������������������������������������������������������������    25 Implications for Research������������������������������������������������������������������������    25 xi

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Implications for Practice��������������������������������������������������������������������������    26 References������������������������������������������������������������������������������������������������    26 3

 Measurements Used in Studying Mindfulness-Based Programs������    31 Measuring Mindfulness in Children��������������������������������������������������������    31 The Child and Adolescent Mindfulness Measure (CAMM)����������������    31 The Mindful Attention and Awareness Scale (MAAS)������������������������    32 The Comprehensive Inventory of Mindfulness Experiences-­Adolescents (CHIME-A)������������������������������������������������    32 Five-Facet Mindfulness Questionnaire Adolescent-Short Form (FFMQ-­A-­SF)��������������������������������������������������������������������������������������    33 Adolescent and Adult Mindfulness Scale (AAMS) ����������������������������    33 Relaxation-Mindfulness Scale for Adolescents (EREMIND-A) ��������    34 Mindful Student Questionnaire (MSQ) ����������������������������������������������    34 Behavioral Measurements, Biomarkers, and Other Measures That Can Be Used in Evaluating MBPs��������������������������������������������������    35 Breath Counting Task��������������������������������������������������������������������������    35 Attention Network Test������������������������������������������������������������������������    36 Ecological Momentary Analysis����������������������������������������������������������    36 Salivary Cortisol����������������������������������������������������������������������������������    37 Photovoice��������������������������������������������������������������������������������������������    38 The Head–Toes–Knees–Shoulders (HTKS) Task��������������������������������    39 Test for Creative Thinking Drawing Production (TCT-DP)����������������    39 Stroop Task������������������������������������������������������������������������������������������    40 Difficulties in the Emotion Regulation Scale������������������������������������������    41 Implications for Research������������������������������������������������������������������������    41 Implications for Practice��������������������������������������������������������������������������    42 References������������������������������������������������������������������������������������������������    43

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 Mindfulness in School-Based Curricula����������������������������������������������    49 MindUP����������������������������������������������������������������������������������������������������    50 Learning to BREATHE����������������������������������������������������������������������������    52 Mindful School����������������������������������������������������������������������������������������    54 . b and Paws b ������������������������������������������������������������������������������    55 Other Curricula Worldwide����������������������������������������������������������������������    56 Major Findings of Recent Systematic Reviews and Meta-­analyses on School-­Based Mindfulness Curriculum����������������������������������������������    58 The Findings of the MYRIAD Project and Its Impact����������������������������    61 Implications for Research������������������������������������������������������������������������    63 Implications for Practice����������������������������������������������������������������������    63 Appendix: Useful Websites for School-Based Mindfulness Projects������    64 References������������������������������������������������������������������������������������������������    65

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 Mindfulness-Based Programs for Children with Developmental Challenges����������������������������������������������������������������������������������������������    69 Attention-Deficit/Hyperactivity Disorder (ADHD) ��������������������������������    69

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Autism Spectrum Disorder (ASD)����������������������������������������������������������    75 Intellectual Disability (ID) and Specific Learning Difficulties (SLDs) ��    77 Implications for Research������������������������������������������������������������������������    79 Implications for Practice��������������������������������������������������������������������������    80 References������������������������������������������������������������������������������������������������    82 6

Mindfulness-Based Program for Children Facing Mental Health and Sociocultural Challenges����������������������������������������������������������������    87 Anxiety����������������������������������������������������������������������������������������������������    87 Depression������������������������������������������������������������������������������������������������    90 Aggression and Disruptive Behaviors������������������������������������������������������    92 Transdiagnostic Psychiatric Conditions��������������������������������������������������    94 Suicide������������������������������������������������������������������������������������������������������    96 Substance Use������������������������������������������������������������������������������������������    97 Other Health Challenges��������������������������������������������������������������������������    98 Chronic Pain����������������������������������������������������������������������������������������    98 HIV������������������������������������������������������������������������������������������������������    99 Cancer��������������������������������������������������������������������������������������������������   100 Cardiac Diagnoses ������������������������������������������������������������������������������   100 Diabetes������������������������������������������������������������������������������������������������   101 Obesity ������������������������������������������������������������������������������������������������   101 Psychosocial Challenges��������������������������������������������������������������������������   102 Racial Minorities, Low-Income Children from Disadvantaged Families������������������������������������������������������������������������������������������������   102 Children of Divorced Parents and from Migrant Families������������������   104 Sexual and Gender Minorities ������������������������������������������������������������   105 Implications for Research������������������������������������������������������������������������   106 References������������������������������������������������������������������������������������������������   107

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Mindful Parenting and Mindfulness-Based Programs on Parents ����������������������������������������������������������������������������������������������   115 Evolution of the Construct of Mindful Parenting������������������������������������   115 Assessment of Mindful Parenting������������������������������������������������������������   117 Interpersonal Mindfulness in Parenting (IM-P) ����������������������������������   117 Mindfulness in Parenting Questionnaire (MIPQ)��������������������������������   118 Bangor Mindful Parenting Scale (BMPS) ������������������������������������������   118 Mindful Parenting Inventories for Parents (MPIP) and Children (MPIC) ������������������������������������������������������������������������������������������������   118 Behavioral Observation: Mindful Parenting Observation Scale (MPOS)������������������������������������������������������������������������������������������������   119 Adapting MBPs for Parents ��������������������������������������������������������������������   119 Programs for Parents of Children with Developmental Challenges��������   120 Programs for Parents of Children with Mental Health Challenges����������   123 Programs for Parents Encountering Social Challenges���������������������������   125 Parents of Children in Nonclinical Samples��������������������������������������������   125 Online MBPs for Parents ������������������������������������������������������������������������   126

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Contents

Evidence of MBPs for Parents in Systematic Reviews and Meta-­Analyses����������������������������������������������������������������������������������   127 Implications for Research������������������������������������������������������������������������   128 Implications for Practice��������������������������������������������������������������������������   129 References������������������������������������������������������������������������������������������������   129 8

 Mindfulness in Teaching and Education����������������������������������������������   135 The Role of Mindfulness in Teaching and the Role of Teachers in Mindfulness Teaching��������������������������������������������������������������������������   135 Assessing Mindfulness in Teaching��������������������������������������������������������   136 Mindfulness-Informed Programs for Teachers����������������������������������������   137 CARE for Teachers����������������������������������������������������������������������������������   137 SMART Program ������������������������������������������������������������������������������������   138 .begin����������������������������������������������������������������������������������������������������   138 More Evidence About Students’ Benefits from MBPs for Teachers ������   139 A Whole-School Approach: An Answer for Effective Promotion of Mindfulness in Schools?����������������������������������������������������������������������   140 Implications for Research������������������������������������������������������������������������   142 Implications for Practice��������������������������������������������������������������������������   142 Appendix: Information About Teacher Mindfulness Programs��������������   143 References������������������������������������������������������������������������������������������������   143

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 Implementing Mindfulness-Based Programs for Children����������������   147 A Growing Attention in Implementation Science������������������������������������   147 Factors Contributing to Effective Implementation of an MBP����������������   148 Consolidated Framework for Implementation Research (CFIR)��������   148 The School-Based Mindfulness Program Implementation Framework (SBMP-IF)������������������������������������������������������������������������   149 Who Implements SMBP Better? The Roles and Outcomes of Schoolteachers vs External Instructors��������������������������������������������   153 Implications for Research������������������������������������������������������������������������   155 Implications for Practice��������������������������������������������������������������������������   156 References������������������������������������������������������������������������������������������������   157

10 Ethical  Issues in Teaching Mindfulness to Children and Adolescents��������������������������������������������������������������������������������������   161 Ethics from the Perspectives of Religious and Psychological Practice ��   161 Common Ethical Issues in MBPs������������������������������������������������������������   164 Ethical Considerations Relating to Program Development of MBPs ����������������������������������������������������������������������������������������������   164 Ethics Relating to the Implementation of the MBPs ��������������������������   166 Teacher Training and Development ����������������������������������������������������   167 Awareness of the Impact of Mindfulness Practices on Participants Who May Misapply ����������������������������������������������������������������������������   168

Contents

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Implication for Research��������������������������������������������������������������������������   170 Implications for Practice��������������������������������������������������������������������������   171 References������������������������������������������������������������������������������������������������   172 Index����������������������������������������������������������������������������������������������������������������   175

Chapter 1

Mindfulness-Based Programs: Origins, Emergence, and Adaptations Mindfulness as a Traditional Buddhist Teaching

Mindfulness and dharma are best thought of as universal descriptions of the functioning of the human mind regarding the quality of one’s attention in relationship to the experience of suffering and the potential for happiness. They apply equally wherever there are human minds, just as the laws of physics apply equally everywhere in our universe … Kabat-Zinn (2009: 11)

“Mindfulness” is the translation of the Pali term sati, which also conveys the meaning “to remember,” as to remember to maintain awareness, or a skillful intention to reorient our awareness and attention to current experience, instead of using memory (Thera, 1962). The term sati is best translated as “to be mindful,” instead of “mindfulness,” which is a noun and normally implies a fixed trait. Buddhist texts primarily refer to mindfulness not as a mental function or trait (Bodhi, 2000) but as a practice or process involving at least four distinct phases, as mentioned in the Satipatthana Sutta (one of the oldest Buddhist discourses on mindfulness), ranging from ­mindfulness of bodily sensations to awareness of more expansive mental content and processes, such as emotion and altered view of self. Gunaratana (2012) sees mindfulness as a nonjudgmental observation, with emphasis on the qualities of impartiality, without any conceptual and perceptual process. Mindfulness allows one to see the true nature of all phenomena with an awareness that things are ever-changing. In classical Buddhist discourse, Satipatthana, the four foundations of mindfulness, can be cultivated through body, feelings, mind, and dhamma. Separate techniques have been developed for these four targets (Gunaratana, 2012; Thera, 1962). Mindfulness of the body starts with the awareness of breathing and bodily sensations arising in different bodily postures, including walking, standing, sitting, and lying down. One should have a clear comprehension of what is beneficial and of suitability.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_1

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Mindfulness of feelings is cultivated through a nonconceptual awareness of feelings arising from moment to moment, regardless of whether the feeling is pleasant, unpleasant, or neutral in nature. One should have an awareness of their manifestation, arising, and disappearance. Mindfulness of the mind is about the awareness of the quality of the mind and three unwholesome roots: namely, greed, hatred, and delusion. One should also recognize the mental states of whether the mind is distracted, exalted, supreme, concentrated, liberated, or not. With mindfulness practice, one can be aware of their manifestation, arising, and disappearance. Mindfulness of the dhamma is a deeper investigation of all mental activities and can embrace all factors in Buddhist teachings, including mental hindrances, aggregates of clinging, internal and external sense bases, factors of enlightenment, and the noble truths that contribute to enlightenment. In other words, it is the way to verify the interdependent nature of reality and emphasizes how reality is constructed in the modes of thought and perception of human beings. Mindfulness is grounded in two traditional Buddhist teachings, which are the Four Noble Truths and the Noble Eightfold Path (Hanh, 1999): The First Noble Truth is suffering or unsatisfactoriness. We all suffer or feel dissatisfaction to some extent in our body and our mind. Unless we recognize and acknowledge the presence of this suffering, the suffering will be overarching and endless. The Second Noble Truth is the origin or arising of suffering. After we recognize our suffering, we need to look deeply into it to see how it came to be. We need to recognize the craving for sensual pleasures, existence, and extermination that are causing us to suffer. The Third Noble Truth is the cessation of creating suffering by attachment or craving. Ending suffering is possible and can be achieved by enlightenment through the extinction of the fire of greediness, hatred, and ignorance. The Fourth Noble Truth is the path that leads to the cessation of suffering, which is called the Noble Eightfold Path. Such teaching of the Four Noble Truths provides a frame for all mindfulness-based programs (MBPs) in contemporary societies. I shall discuss later that mindfulness is specifically developed for the cessation of human suffering. Among the Noble Eightfold Path, three of them are related to meditative practice. Skillful effort is about the noticing of fetters and hindrances that can prevent and overcome negative states of mind and cultivate and maintain positive states of mind. Skillful concentration is wholesome, that is free of greed, hatred, and delusion, and the five hindrances. It is also a teaching of one-pointedness and full concentration, which integrate with mindfulness. Skillful mindfulness is a teaching about looking clearly toward awareness and grants individuals insight into impermanence, aversion, and the nonexistence of an unchanging self. There are another five ethical teachings in the Noble Eightfold Path, which are related to wisdom and morality (Gunaratana, 2002). Skillful understanding is the teaching about comprehension of cause and effect and the four Noble Truths.

Emergence of Mindfulness-Based Programs in a Secular Context

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Skillful thinking: Some translated this teaching as skillful intention, which is related to one’s purpose or role in life, including generosity, loving-friendliness, and compassion. Skillful speech refers to the ethical teaching that one should not lie or use malicious words, harsh language, and useless talk. Skillful action refers to the ethical teaching of five precepts, including not killing, not stealing, no false speech, no sexual misconduct, and not using drugs or alcohol. Skillful livelihood refers to a job or a living that should not be harmful to others or oneself, not to break any moral precepts, or make it difficult for the mind to settle down.

 mergence of Mindfulness-Based Programs E in a Secular Context Mindfulness and other types of meditation have been classified as religious activities, with many of them not adopted into Western medical and psychological practices until the 1980s (Burke, 2012; Richards & Bergin, 2005). Interest in Eastern meditations such as Zen meditation and transcendental meditation grew in the United States after the end of World War II, in the late 1960s. However, integrating meditation into rigorous clinical and research studies took much longer. In fact, Spilka et al. (1981) found that only 27.5% of introductory psychology texts published in the 1970s included religion as a topic, indicating a minimal interfacing between psychology and religion or spirituality. A bibliography of scientific studies on meditation theory and research by Murphy and Donovan (1983) featured only four entries out of 776 that included the word “mindfulness.” This evidence highlights the lack of mindfulness and mindfulness-­ based program applications before the 1980s. The four entries, all published after 1975, were based on adult populations and included the doctoral dissertation by Jack Kornfield who was a prestigious Buddhist monk with training in clinical psychology in 1976 and the first scientific study on the Mindfulness-Based Stress Reduction (MBSR) program for chronic pain patients in 1982. All papers were based on adult populations. Jon Kabat-Zinn pioneered the Stress Reduction and Relaxation Program in 1979, later renamed the Mindfulness-Based Stress Reduction (MBSR) program, at the University of Massachusetts Medical School (Kabat-Zinn, 2013). His intention was to incorporate the teachings of Buddhist meditation and yoga into the curriculum without using explicitly religious terminology, thereby making it more broadly applicable. MBSR was specifically created as a complementary program in health care for individuals dealing with stress due to pain or illness. When MBSR evolved, the term “mindfulness” was used to convey “the heart of Buddhist meditation,” encompassing ideas about wakefulness, compassion, wisdom, and being universally human, qualities referred to in the word dharma. Kabat-Zinn (1994:4) offered a secular definition of mindfulness for a secular context as “paying attention in a particular way: on purpose, in the present moment.”

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Among the diversity of Buddhist teachings, Kabat-Zinn (2013) acknowledges the origins of MBSR in Theravada traditions, Mahayana traditions, and Zen traditions, incorporating the yogic Vedanta traditions and the teachings of Krishnamurti and Ramana Maharshi. In addition, being influenced by his primary Zen teacher, Seung Sahn, the broad use of koans and the exchanges between teacher and student have contributed to the establishment of a unique interaction and exchanges in the MBSR classroom between instructors and participants. Such dialogs encompass the participant’s first-person experience with the practice and its personal applications in everyday life. They also create a relational space for the emergence and additional unfolding of the participant’s meditative experiences. Such unique features of MBSR and other MBPs have been termed “inquiry” (Kabat-Zinn, 2005; Segal et al., 2013). Inquiry is also an invitation for program participants to actively engage in their journey toward better health and well-being. In his work, Kabat-Zinn clarified that the word mindfulness in the MBSR program is a comprehensive term to describe his efforts to transform many traditional teachings into a secular program while retaining their essence. This program, which he views as a universal dharma, encapsulates a multitude of meanings and traditions concurrently and aligns with Buddhist teachings (Kabat-Zinn, 2013). The MBSR program is conducted as an 8-week course for groups of up to 30 participants who meet weekly for 2–2.5 h for instruction and practice in mindfulness meditation skills, together with inquiry, psychoeducation of stress and coping, and homework assignments. An all-day 7-h intensive mindfulness session is usually held around the sixth week. Three formal mindfulness meditations, including body scan, mindful stretching, and mindful sitting, are based on the teaching of four foundations of mindfulness. Another informal mindfulness practice is taught that facilitates participants in bringing their mindfulness into daily living. Participants in MBSR are instructed to practice mindfulness at home for at least 45 min per day, 6 days per week, with the audio files as guidance. Participants are guided to focus attention on the target of observation, including breathing, bodily sensation, or other sensory experiences in each moment. When emotions, sensations, or cognitions arise, participants learn to observe them nonjudgmentally. When they notice that the mind has wandered into thoughts, memories, or fantasies, the nature or content of them is noted, and then, attention is returned to the present moment but not to become absorbed in their content. Consistent with the traditional teaching of Buddhist meditation and impermanence, participants learn to realize that most sensations, thoughts, and emotions fluctuate or are transient (Kabat-Zinn, 2013). After decades of empirical investigation, studies of MBSR have reported significant improvements in psychological distress and mental health symptoms for people with chronic health conditions (Bohlmeijer et  al., 2010) and stress management among healthy individuals (Chiesa & Serretti, 2009). Later, three scholars, namely John Teasdale, Zindel Segal, and Mark Williams, jointly explored a maintenance form of cognitive-behavioral therapy for preventing individuals from relapsing into major depression. Based on their earlier studies of the information processing theory of depressive relapse, individuals who have experienced major depressive episodes are vulnerable to recurrence whenever mild

Defining Mindfulness-Based Programs

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dysphoric states are encountered, and these states may reactivate the depressive thinking patterns present during the previous episode and precipitate a new episode (Teasdale et  al., 1995). They gradually recognized that meditation-related procedures would be helpful for people to take a decentralized perspective on their patterns of thinking (see Segal et al., 2013, for a detailed description of the process). Mindfulness-based cognitive therapy (MBCT) has been developed with a similar format to MBSR in its structure, lasting for 8 weeks and each session with 2 h plus a day retreat, by integrating MBSR with many common features and strategies in cognitive-behavioral therapy (Segal et al., 2002/2013). It includes similar mindfulness practices (body scan, mindful stretching, mindful sitting, and other informal practices) and format (combining experiential in-class practice with inquiry and psychoeducation of relapse prevention). In MBCT, participants are taught to observe their thoughts and feelings nonjudgmentally and to view them simply as mental events that come and go instead of accurate reflections of reality. After two decades of studies, MBCT has demonstrated its efficacy in the prevention of depressive relapse (Kuyken et al., 2016) and in many other mental health conditions, including current depressive symptoms (Goldberg et al., 2019), generalized anxiety disorder (Ghahari et al., 2020), bipolar disorder (Bojic & Becerra, 2017), and many other healthcare contexts (Demarzo et al., 2015). Despite initially being developed for adults dealing with healthcare needs and to prevent depression relapses, mindfulness-based stress reduction (MBSR) and mindfulness-­based cognitive therapy (MBCT) have paved the way for the development of mindfulness-based programs (MBPs) for diverse populations and clinical conditions. A recent systematic review of 44 meta-analyses of randomized controlled trials (RCTs) investigated the empirical status of MBPs (Goldberg et  al., 2022). MBPs were found to have not only shown superior results to passive controls (effect sizes ds = 0.10 to 0.89), but they also outperformed active controls in certain populations and clinical problems (effect sizes ds  =  0.13 to 0.54). These include depression, substance use, smoking, and psychiatric symptoms, with very small to small effect sizes. With the establishment of a preliminary evidence base for mindfulness-­based approaches, international scholars of MBPs have offered specific guidance on program adaptation and implementation. This guidance aims to ensure the quality of training and the successful dissemination of mindfulness to diverse populations, including children, adolescents, and families.

Defining Mindfulness-Based Programs As the efficacy of the MBSR and MBCT programs in reducing stress and suffering arising from chronic health and mental health conditions has been corroborated by a mounting body of evidence, other mindfulness programs, structured and modeled around MBSR and MBCT, have emerged. These new programs are targeted toward specialized needs across different contexts, including hospitals, schools, and

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corporate environments. Essentially, most of these programs share a few common and distinguishing features centered around mindfulness training. Overall, all these programs endeavor to establish a scientifically grounded, educationally informed methodology to manage mental and physical well-being and promote overall health. These programs have found application across a variety of mainstream public institutions and varied cultures, ensuring accessibility to individuals with diverse values and religious inclinations. However, adaptations have been made to mindfulness training, leading to the formulation of diverse curricula, each with its own unique structure and content (Crane et al., 2017). The essential and core elements of these programs have been identified within the family of “mindfulness-based programs” (MBPs) (Crane et al.; 2017; Loucks et al., 2022): 1. MBPs are informed by combinations of theories and practices that encapsulate contemplative meditative traditions, scientific research, and a variety of models from medicine, psychology, and education. These programs have their roots in a broad array of spiritual teaching, including practices across Buddhist and other traditions, focusing on the awareness of habitual reactive patterns embedded in the mind’s habits, and the development of skillful ways to relate to experiences with freedom from reactivity. MBPs have adapted their format of practices and frameworks to cater to the different needs and contexts, such as enhancing social–emotional learning for children and alleviating parenting stress, ensuring their cultural inclusivity. The delivery of these programs consistently employs an invitational approach, as individuals are encouraged to apply mindfulness in whichever manner best aligns with their intentions and aspirations. Drawing on educational principles, MBPs are designed to be experiential, interactive, participatory, student-centered, and relationship-centered (Kabat-Zinn, 2013). 2. MBPs are grounded in a model that explicates stress and human responses to it, proposing pathways to mitigate this stress. Continued practice of mindfulness enables individuals to cultivate awareness and glean insight into the creation and perpetuation of stress. These insights in managing stress, coupled with the application of mindfulness techniques, can engender improved mental health and overall well-being (Kabat-Zinn, 2013; Segal et al., 2013). 3. MBPs foster a novel relationship with our experience, which is present-focused, decentering, and a willingness to approach difficulties and distress. A decentering approach is described as the skill to observe the arising and leaving of thoughts and feelings, which can be a beneficial strategy to tackle many problems and disorders in human living. 4. MBPs encourage the development of attentional, emotional, and behavioral self-­ regulation, fostering positive qualities, including compassion, wisdom, and equanimity. These capacities stem from an elaborated intention to cultivate a friendly attitude toward experiences, be they pleasant or unpleasant, and an understanding that pain is an inevitable part of human existence. 5. In MBPs, instructors engage participants in intensive mindfulness practice characterized by experiential, inquiry-based learning. They facilitate awareness and

Adaptations of MBPs and Their Considerations

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insights. Such experiential, systematic, and intensive engagement in formal and informal practices forms the core mechanisms of MBPs. Such training contributes to developing an understanding of mind and body and how to regulate and optimize attention. The above five characteristics help distinguish MBPs from other intervention approaches. In addition, MBPs typically include three formal mindfulness practices: body scan, mindful movement, and sitting meditation. These practices are not just taught in class but are also encouraged to be enacted at home with the assistance of recorded guidance materials, fostering an environment for regular practice. Participants are encouraged to transfer these skills to everyday activities through informal practice. Another integral part of the learning process in MBPs is “inquiry,” a process of personal and collective exploration. Inquiry is a dialog between MBP instructors and participants that seeks to deepen their awareness of the direct experiences in mindfulness practice, habitual patterns of relating to these experiences, and the implications of such understanding. MBPs also comprise other important psychoeducational activities. For example, they delve into the exploration of both pleasant and unpleasant moments, which can be enlightening in recognizing reactivity patterns and enabling a different way of response (Kabat-Zinn, 2013; Segal et al., 2013).

Adaptations of MBPs and Their Considerations While it is crucial to remain true to the core curriculum of MBPs, adaptations are often necessary or even desirable depending on the specific context and population involved (Crane et al., 2017; Loucks et al., 2022). However, there is a distinct` difference between an MBP designed for adults in a healthcare setting and one tailored for schoolchildren, leading to a constant tension between maintaining fidelity to the MBP and catering to the unique needs of children and parents (Kemp, 2016). Notwithstanding, such adaptations should not be random but should be aligned with the understanding of distress across MBPs and the needs of the target population in specific contexts. Underpinning these modifications is a nuanced understanding of general vulnerability (the universal human condition that leads to distress) and specific vulnerabilities (particular traits, tendencies, or patterns of a target population). Adaptations may involve altering the program structure, length, and delivery to fit the population and context. For instance, the number of sessions may be increased, but the duration of each session is reduced to accommodate the physical stamina of the participants. Low-intensity and self-help programs may be suitable for nonclinical populations, and online or app-based programs may be beneficial for those with irregular work schedules or busy lifestyles. The following chapters of this book delve further into how MBPs have been adapted for use in schools (Chap. 4), children with various developmental

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challenges (Chap. 5), children with mental health and other social or cultural challenges (Chap. 6), parents (Chap. 7), and teachers (Chap. 8). However, before broaching these topics, it is imperative to clarify the principals involved in adapting MBPs (Loucks et al., 2022). 1. The program developers should reflect on their understanding of the core components of the MBP, the etiology of the target outcome, evidence of interventions for the given outcome, demographic, and other contextual factors, and the specific culture and communication habits of the target groups and ascertain whether an adaptation is necessary to the existing MBP. 2. Clarifying the aim and intention of the adaptation, the foundational theory of the adapted MBP could be beneficial for a particular population or context. 3. Collaboratively with MBP instructors, stakeholders that include individuals with personal experience of the issues of concern, people engaged in the delivery context, and experts in the targeted population and setting generate and develop ideas for the adaptations. 4. Assess the acceptability and feasibility of the newly adapted MBP through qualitative interviews with individuals from the target population or context and small single-arm pilot trials of the MBP. Based on these data, the program developers can evaluate the impact on outcomes and mechanisms. 5. Repeat steps 3 and 4 until an acceptable, feasible, safe, effective, and theoretically sound adaptation is ready for the pilot study. 6. Carry out a pilot clinical trial with key measures capturing acceptability, feasibility, possible adverse effects, mechanisms, and effectiveness, with a selected control group for comparison. 7. Undertake a randomized controlled trial with an adequately sized sample and pre-registration to assess the outcome and mechanisms of MBP, in accordance with the CONSORT guidelines (Boutron et al., 2008). 8. If the results of step 7 are positive, proceed to replication drawing from models in implementation science, notably in research focusing on diffusion in actual communities and settings where the MBP should be implemented (Dimidjian & Segal, 2015; Onken et al., 2014). Finally, there may be cases where adaptation alone is not enough for certain demographics and settings, and an innovative program based on mindfulness is needed. For instance, Mindfulness in the Soles of the Feet can be uniquely administered on an individual basis (Singh, 2003). This program does not incorporate three major mindfulness practices. Instead, it includes only one mindfulness practice aimed at reducing aggressive behavior in children and adolescents. Given the clinical risks associated with delivering a group program to children with severe aggressive behaviors, Mindfulness in the Soles of the Feet offers specific benefits to this particular target group. Similar innovations should be encouraged in some unique contexts and populations. The reasons for such innovations, as outlined by Sanghvi et al. (2019), include:

Framework Informing Program Adaptations and Study Designs

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1. The intention to include specific groups of people, including participants from special cultural, economic, and ethnic backgrounds, individuals with particular learning styles, and vulnerable groups with prior traumatic experiences, such as abused children, refugees, and prisoners. These groups may need tailored interventions to support their mindfulness practice. 2. The need to address societal issues in light of critiques arguing that MBPs neglect broader structural factors contributing to human suffering such as racism, inequality, and work or study cultures. 3. The expansion and deepening of practice possibilities, including developing more elaborate programs for practice following mainstream MBPs. The use of informal practices that can be incorporated into daily lives, particularly speaking to the needs of people from specific cultures or lifestyles. 4. Integrating MBPs with emerging technology could optimize the utilization of communication technology, particularly, though not exclusively, in online or app-based programs and artificial intelligence.

 ramework Informing Program Adaptations F and Study Designs In order to bridge the divide between well-monitored clinical trials and real-world implementation, several models for behavioral intervention development have been introduced. These models help guide the study design of behavioral interventions and outline pathways for refinement, enhancement, and innovation. This offers researchers a comprehensive framework to pinpoint crucial areas and future directions for future developments and improvements of MBPs.

National Institute of Health Stage Model (Onken et al., 2014) The stage model proposes that the creation of a new behavioral intervention should aim to maximize its potential by targeting its implementation outcomes with the largest number of people within the intended population. Notably, the model is not linear, and program developers can begin at any stage, moving back and forth as needed to meet this goal. The six-stage model is as follows: Stage 0 involves any basic science studies aimed at informing the development of behavioral interventions. It spans studies that uncover mechanisms of action, mediators, and moderators. Stage I is subdivided into 1A (involving the creation, modification, or adaptation of an existing intervention) and 1B (focusing on feasibility and pilot testing). Stage I research involves the development, modification, refinement, adaptation, or pilot testing of a behavioral intervention. The primary goal is to obtain scientific

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knowledge of the processes for triggering behavior change and its outcomes and ascertain its feasibility. Stage II entails the testing of promising behavioral interventions in research settings, predominantly using randomized controlled trials. Other adaptive designs such as multiple-baseline single-case designs and A-B-A designs can also be used. Stage III focuses on translating the intervention from a research control setting to a community setting. The intervention is tested in a well-regulated but internally valid study in a community setting, with the inclusion of community-friendly fidelity monitoring and enhancement procedures. Stage IV assesses the empirically supported behavioral intervention in community settings with community-based providers, aiming to optimize external validity. Preparation for a stage IV study involves validated measures and training for community providers. Stage V revolves around the methods and delivery system required to implement scientifically supported interventions in community settings. It encompasses the distribution of information and material resources about the programs to stakeholders.

 edical Research Council Guidance on Developing M and Evaluating Complex Interventions (Skivington et al., 2021) The UK’s Medical Research Council outlines a framework to deliver programs suitable for real-world application. This approach ensures the programs are implementable, cost-effective, transferable, and scalable and engages users, practitioners, and policymakers. The intervention research is divided into four phases: Stage 1: Developing or Identifying the Interventions  – This could either involve developing a new intervention or adapting an existing one for a new context, based on research evidence and theoretical understanding of the problem. An existing or planned intervention already in policy or practice can be selected and its evaluation options explored. Stage 2: Feasibility – This stage involves conducting research to evaluate feasibility and acceptability and the design of evaluation to inform progression to the next stage of study. Stage 3: Evaluation – This stage aims to assess an intervention using the most suitable method to address the research questions. Stage 4: Implementation – This stage aims to enhance impact and apply successfully tested innovative programs. Across all stages, core elements of studies include understanding the context, developing, refining, and testing program theory, engaging stakeholders, identifying key uncertainties, refining the intervention, and evaluation cost-effectiveness.

Framework Informing Program Adaptations and Study Designs

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Theory of Change (Breuer et al., 2016) This model outlines how a program achieves specific long-term results through a series of logical, intermediate outcomes. The model is commonly developed using a backward mapping approach that begins with the long-term outcome and then identifies the process of change and the short- and medium-term outcomes necessary for its achievement. Additional components include beneficiaries, research evidence supporting the theory of change, actors within the context, sphere of influence, strategic choices and interventions, timelines, and indicators. The model is typically developed in collaboration with stakeholders through workshops or interviews, although the extent of stakeholder participation can vary. It embraces a broad spectrum of stakeholders, including service users, and can involve evaluators and funders in utilizing program documentation. This approach does not favor any particular research methods, with options ranging from qualitative interviews to randomized controlled trials.

 ommunity-Based Participatory Research (Wallerstein & C Duran, 2010) Community-based participatory research (CBPR) is a transformative research approach that bridges the divide between research and practice through community engagement and social actions. This approach is beneficial for the implementation sciences as it allows them to develop, apply, and disseminate effective interventions across a range of communities. CBPR uses strategic ways to confront power imbalances and foster mutual benefits between community and academic partners, while advocating for reciprocal knowledge translation, incorporating community theories into the research process. To handle the challenges associated with research knowledge into real-world applications, the CBPR model involves community stakeholders in the adaptation process within complex organizational and cultural systems. It facilitates the creation of hybrid knowledge, which includes culturally supported interventions, indigenous theories, and community advocacy. This model aims to expand shared understandings and values in community relationships and brings about power shifts through shared learning and resources, collective decision-making, and outcomes beneficial to the community. It aims to integrate existing programs, promote local ownership, and develop capacity, with the ultimate goal of achieving program sustainability. It encourages co-learning and empowering processes to address social inequalities and ensures that research findings and knowledge are disseminated across all partners. Parallel to these frameworks, the field of mindfulness for children, adolescents, and families has seen a significant surge over the last two decades in response to the changing needs of different developmental stages in children. Similar models and

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reviews have been carried out, guiding mindfulness researchers and practitioners working with children to translate MBPs developed for adults into specific populations and contexts (Escoffery et  al., 2019; Moullin et  al., 2019; Movsisyan et al., 2019).

Implications for Research To strengthen and maintain the credibility and integrity of MBPs, it is essential that ongoing scientific research continues to evidence their efficacy. The guidelines provided in this chapter offer roadmaps for the future development and adaptation of MBPs to suit various populations and contexts. The works of Crane et al. (2017) and Loucks et al. (2022) provide concise definitions for MBPs, setting them apart from other interventions. These clearly defined parameters are necessary for ensuring the future of mindfulness as a distinctive approach within the fields of medicine, psychology, and education. Potential avenues for improvement and development have been highlighted for researchers to consider in their planning of proposals for future MBPs.

Implications for Practice This chapter offers grounding knowledge for MBP instructors for children and adolescents. Given the diverse backgrounds of these instructors, who may range from school teachers, experienced MBP teachers for adults, or other clinical practitioners specializing in child work, the chapter can serve as a valuable resource. Over the past two decades, there has been a rapid growth in the creation of MBPs and associated curricula for children and adolescents with varied needs, spanning both healthcare and educational settings. As further programs are developed, it is vital that all program developers, MBP instructors, and stakeholders retain an awareness of the integrity of MBPs and the recommendations for program adaptation, as detailed within the implementation science.

References Bodhi, B. (2000). The connected discourses of the Buddha: A translation of the Samyutta Nikaya. Wisdom Publications. Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). The effects of mindfulness-based stress reduction therapy on mental health of adults with a chronic medical disease: A meta-analysis. Journal of Psychosomatic Research, 68(6), 539–544. Bojic, S., & Becerra, R. (2017). Mindfulness-based treatment for bipolar disorder: A systematic review of the literature. Europe’s Journal of Psychology, 13(3), 573.

References

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Boutron, I., Moher, D., Altman, D.  G., Schulz, K.  F., & Ravaud, P. (2008). Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: Explanation and elaboration. Annals of Internal Medicine, 148(4), 295–309. Breuer, E., Lee, L., De Silva, M., & Lund, C. (2016). Using theory of change to design and evaluate public health interventions: A systematic review. Implementation Science, 11, 63. Burke, A. (2012). Comparing individual preferences for four meditation techniques: Zen, Vipassana (mindfulness), qigong, and mantra. Explore, 8(4), 237–242. Chiesa, A., & Serretti, A. (2009). Mindfulness-based stress reduction for stress management in healthy people: A review and meta-analysis. The Journal of Alternative and Complementary Medicine, 15(5), 593–600. Crane, R. S., Brewer, J., Feldman, C., Kabat-Zinn, J., Santorelli, S., Williams, J. M. G., & Kuyken, W. (2017). What defines mindfulness-based programs? The warp and the weft. Psychological Medicine, 47(6), 990–999. Demarzo, M. M. P., Cebolla, A., & Garcia-Campayo, J. (2015). The implementation of mindfulness in healthcare systems: A theoretical analysis. General Hospital Psychiatry, 37(2), 166–171. Dimidjian, S., & Segal, Z. V. (2015). Prospects for a clinical science of mindfulness-based intervention. American Psychologist, 70, 593–620. Escoffery, C., Lebow-Skelley, E., Udelson, H., Böing, E.  A., Wood, R., Fernandez, M.  E., & Mullen, P. D. (2019). A scoping study of frameworks for adapting public health evidence-based interventions. Translational Behavioral Medicine, 9(1), 1–10. Ghahari, S., Mohammadi-Hasel, K., Malakouti, S. K., & Roshanpajouh, M. (2020). Mindfulness-­ based cognitive therapy for generalised anxiety disorder: A systematic review and meta-­ analysis. East Asian Archives of Psychiatry, 30(2), 52–56. Goldberg, S.  B., Tucker, R.  P., Greene, P.  A., Davidson, R.  J., Kearney, D.  J., & Simpson, T.  L. (2019). Mindfulness-based cognitive therapy for the treatment of current depressive symptoms: A meta-analysis. Cognitive Behaviour Therapy, 48(6), 445–462. Goldberg, S.  B., Riordan, K.  M., Sun, S., & Davidson, R.  J. (2022). The empirical status of mindfulness-­based interventions: A systematic review of 44 meta-analyses of randomized controlled trials. Perspectives on Psychological Science, 17(1), 108–130. Gunaratana, B. (2002). Mindfulness in plain English. Wisdom. Gunaratana, B. (2012). The four foundation of mindfulness in plain English. Wisdom. Hanh, T. N. (1999). The Heart of the Buddha’s Teaching Transforming Suffering into Peace, Joy, and Liberation. Random House. Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. Hyperion. Kabat-Zinn, J. (2005). Dialogues and discussion. In J. Kabat-Zinn (Ed.), Coming to our senses: Healing ourselves and the world through mindfulness (pp. 448–450). Hyperion. Kabat-Zinn, J. (2009). Dhama. In B. Boyce (Ed.), In the face of dear: Buddhist wisdom for challenging times. Shambhala. Kabat-Zinn, J. (2013). Some reflections on the origins of MBSR, skillful means, and the trouble with maps. In J. M. G. Williams & J. Kabat-Zinn (Eds.), Mindfulness: Diverse perspectives on its meaning, origins and applications (pp. 281–306). Routledge. Kemp, L. (2016). Adaptation and fidelity: A recipe analogy for achieving both in population scale implementation. Preventive Science, 17, 429–438. Kuyken, W., Warren, F.  C., Taylor, R.  S., Whalley, B., Crane, C., Bondolfi, G., et  al. (2016). Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An individual patient data meta-analysis from randomized trials. JAMA Psychiatry, 73(6), 565–574. Loucks, E.  B., Crane, R.  S., Sanghvi, M.  A., Montero-Marin, J., Proulx, J., Brewer, J.  A., & Kuyken, W. (2022). Mindfulness-based programs: Why, when, and how to adapt? Global Advances in Health and Medicine, 11, 21649561211068805. Moullin, J. C., Dickson, K. S., Stadnick, N. A., Rabin, B., & Aarons, G. A. (2019). Systematic review of the exploration, preparation, implementation, sustainment (EPIS) framework. Implementation Science, 14(1), 1–16.

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Movsisyan, A., Arnold, L., Evans, R., Hallingberg, B., Moore, G., O’Cathain, A., Pfadenhauer, L.  M., Segrott, J., & Rehfuess, E. (2019). Adapting evidence-informed complex population health interventions for new contexts: A systematic review of guidance. Implementation Science, 14, 105. https://doi.org/10.1186/s13012-­019-­0956-­5 Murphy, M., & Donovan, S. (1983). A bibliography of meditation theory and research: 1931-1983. Journal of Transpersonal Psychology, 15(2), 181–228. Onken, L. S., Carroll, K. M., Shoham, V., Cuthbert, B. N., & Riddle, M. (2014). Reenvisioning clinical science: Unifying the discipline to improve the public health. Clinical Psychological Science, 2(1), 22–34. Richards, P. S., & Bergin, A. E. (2005). A spiritual strategy for counseling and psychotherapy (2nd ed.). American Psychological Association. Sanghvi, M., Bell, R., Bristow, J., & Stanway, J.-P. (2019). Fieldbook for mindfulness innovators. The mindfulness initiative. Available from www.themindfulnessinitiative.org. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression. Guilford Press. Singh, N. N., Wahler, R. G., Winton, Adkins, A. D., Myers, R. E., & The Mindfulness Research Group. (2003). Soles of the feet: a mindfulness-based self-control intervention for aggression by an individual with mild mental retardation and mental illness. Research in Developmental Disabilities, 24, 158–169. Skivington, K., Matthews, L., Simpson, S. A., Craig, P., Baird, J., Blazeby, J. M., et al. (2021). A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. BMJ, 374, n2061. https://doi.org/10.1136/bmj.n2061 Spilka, B., Comp, G., & Goldsmith, W. M. (1981). Faith and behavior: Religion in introductory psychology texts of the 1950s and 1970s. Teaching of Psychology, 8(3), 158–160. Teasdale, J.  D., Segal, Z.  V., & Williams, M.  G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness training) help? Behaviour Research and Therapy, 33, 25–39. Thera, N. (1962). The heart of Buddhist meditation: A handbook of mental training based on the Buddha’s way of mindfulness. Buddhist Publication Society. Wallerstein, N., & Duran, B. (2010). Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. American Journal of Public Health, 100(S1), S40–S46.

Chapter 2

Mindfulness and Developmental Needs of Children

Mindfulness, Meditation, and Spirituality for Children Mindfulness and spirituality, though distinct, often overlap in many ways in their intention and practice. While mindfulness promotes presence and acceptance, spirituality also encapsulates these aspects and acknowledges a deeper and broader connection with self, others, and the universe. Children may develop their own spiritual lives, without or without the influence of their parents (Mahoney, 2021). Benson et al. (2012) define spirituality as a composite of beliefs, practices, and experiences that surpass religious rituals, tenets, and orthodoxy. This definition appreciates spirituality as an engaged and deliberate process where individuals construct and live their ways of understanding – with or without religious affiliation. It ranges from self-discovery and self-knowledge to exploring the cosmos and pondering life’s purpose. This conceptualization identifies three primary dimensions of spirituality: (1) awareness of self and the world: This involves recognizing and appreciating the goodness within oneself and the beauty of the universe. (2) Connecting/belonging: This encapsulates the understanding that life is interconnected and interdependent. (3) Life of meaning and contribution: This embodies an orientation entrenched in hope, purpose, and gratitude. Spiritual development involves psychological processes, such as fostering connections with others based on prosocial beliefs and actions and the uncovering of meaning and mindfulness across diverse values and actions. Mindfulness, like spirituality, offers tools for self-­ exploration and understanding and a sense of interconnectedness. The promotion of mindfulness in secular settings over the past two decades aligns closely with children’s inherent capacity for spiritual understanding. Michaelson et  al. (2016) underscore the importance of relational domains of spirituality, which refer to connections with self, others, nature, and a larger meaning in life. Spirituality is perceived as a unique state of being that promotes awareness and appreciation for the sacred aspects of life. Based on the conception of © The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_2

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spirituality, Gomez and Fisher (2003) developed an eight-item well-being scale specifically for adolescents to measure their spirituality. Items include the importance of feeling that your life has meaning or purpose and experiencing joy in life (connections to self); being kind to other people and being forgiving of others (connections to others); feeling connected to nature and caring for the natural environment (connections to nature); and feeling a connection to a higher spiritual power and meditating or praying (connections to the transcendent). This suggests that spirituality and mindfulness are interconnected concepts. Particular attention has been given to children with chronic health conditions regarding the impact of spirituality on their outcomes (Iannello et al., 2022). Chronic illnesses interfere with children’s normal growth and developmental processes and require changes in lifestyles and relationships that can negatively impact psychosocial well-being and quality of life. Spiritual coping mechanisms can boost morale, offer a novice and positive outlook, and buffer against internal and external problems. When they face uncertainties about the future, spirituality can offer a source of comfort and perspective by answering existential questions. A few common trends in mindfulness and spirituality can be identified, regarding their shared values and practice in meeting human needs in search of connection, meaning, and transcendence. Parallel evidence about spirituality and MBPs for children that may inform researchers and practitioners about the future development and studies of MBPs is as follows: 1. Spirituality is associated with child well-being and mental health, as a resource in support, belief, coping, and connection to God or higher power (Hardy et al., 2019; Kaeakus et al., 2021; Michaelson et al., 2019), as mindfulness has also shown similar associations with well-being and positive coping (Dunning et al., 2022; Sheinman et al., 2018); 2. There is a decline in spirituality in adolescence across the years from 11 to 15 years old (Michaelson et al., 2016), and similarly, in some recent large-scale MBP studies for early adolescents, positive outcomes were not found in this particular age population (Frank et  al., 2021; Kuyken et  al., 2022; Volanen et al., 2020). 3. Girls reported higher levels of spirituality than boys (Desrosiers & Miller, 2007; King & Boyatzis, 2015; Michaelson et al., 2019), while girls often reported more benefits than boys after MBPs (Johnson et al., 2016; Kang et al., 2018). In the scoping review conducted on the literature of meditation from 1931 to 1983 (Murphy & Donovan, 1983), only four studies of meditation were based on children. Notably, a study conducted by Linden (1973) was probably the first RCT of meditation for children. The trial involved 26 participants who underwent meditation practice over an 18-week period. Results demonstrated that children in the meditation group became more independent and reported a reduction in test anxiety compared to those in the control group. These scattered studies of meditation and spirituality align with the development of MBPs, as they share common concerns about children’s well-being. Both mediation and mindfulness are intervention

Mindfulness-Based Programs as a Unique Intervention for Children

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strategies aimed at promoting awareness and resilience in the face of adversity. In addition, both spirituality and mindfulness can cater to the needs of children and families from diverse cultural and religious backgrounds. In the subsequent section, a detailed examination of the content and structure of MBPs is discussed.

 indfulness-Based Programs as a Unique Intervention M for Children Numerous MBPs for children have gained popularity around the world. These programs have been adapted for various contexts, including school-based curricula for classroom implementation, specific clinical contexts, and flexible models fit for diverse settings. Like MBPs for adults, MBPs for children combine mindfulness practices with psychoeducation on stress reduction aiming to promote coping skills. Many MBPs involve group learning, where participants are trained in specific formal mindfulness practices. These include the body scan, mindful movement, mindfulness of breath, sounds, and thoughts, as well as informal mindfulness practices for daily activities such as walking and eating (Kabat-Zinn, 2013; Segal et  al., 2013). Despite the diversity in program structures and activities, several key elements have been identified as common to all MBPs designed for children. Four main objectives are common to all MBPs for children (Knowles et  al., 2015), aligning with those of adult MBPs. First, MBPs for children aim to foster present-focused awareness. Multisensory mindfulness exercises that engage all senses (sight, sound, taste, smell, and touch) are used to encourage an appreciation of the novelty and richness of the present moment. Continuous mindfulness practice within an MBP enhances the quality of attention and promotes curiosity, openness, and a nonjudgmental acceptance of life experiences. For instance, MBP instructors may begin and end each class with a sitting practice with a bell, encouraging children to focus on the sounds in the room and the silence and to bring curiosity to the less-often-noticed sensory experiences. Certain activities, common in adult MBPs, may be particularly engaging for children. One such activity involves watching a snow globe. Observing the settling now in the globe creatively illustrates the clarity of the mind and the importance of slowing down during stressful moments. Some instructors may also guide children in creating a “mind jar” filled with glitter or sand, providing a tangible reminder of the value of mindfulness practice that they can take home. Second, MBPs for children can facilitate the recognition of thoughts, feelings (emotions), and bodily sensations and their impacts. After learning to focus on a single object, such as the breath, children are encouraged to broaden their awareness to other experiences linked to their stress and well-being. This increased awareness of inner experiences, including thoughts, feelings, and bodily sensations, can help children recognize automatic stress-related reactions. Activities such as mapping strong emotional experiences in the body and mind in relation to stressful life events

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can gradually enhance children’s understanding of the interplay between feelings, thoughts, bodily sensations, and behaviors, leading to greater awareness of automatic responses to stress. Third, MBPs help children distinguish between noticing and judging. In these programs, children learn to observe their experiences objectively, resisting the urge to quickly judge a situation. It is also crucial to cultivate nonjudgmental acceptance of all experiences, including uncomfortable and unpleasant ones. Through the guidance of instructors and mindfulness exercises, children understand that it is okay to experience difficult emotions and learn to approach such feelings with kindness and compassion. Mindful games, such as the melting ice game, are used to simulate experiences common in extended mindful sitting exercises in MBP for adults. These games, designed for the shorter duration of children’s exercises, often elicit amusing experiences that children enjoy. In the melting ice game, children hold an ice cube in their palm for as long as they can. They name the sensations they feel, such as cold, burning, stinging, and numbness, and learn to observe these changing experiences without physically reacting (see Greenland, 2010, for detailed guidance on the activity). Finally, MBPs for children can teach them to make choices mindfully. Children learn to pause and reflect before reacting in stressful situations, promoting conscious decision-making, inhibiting socially inappropriate behaviors, encouraging empathic communication, and improving self-regulation of emotional distress. This approach allows for mindful decision-making between triggering events and the children’s response. Different MBPs use unique strategies to help children manage their reactions. For instance, the .b program uses an activity called feet on floor, body on chair (FOFBOC) to help children feel more grounded in stressful moments (Mindfulness in Schools Project, 2014). In the Mindfulness Matters program, children are encouraged to press their “pause button,” giving themselves time and space to observe their emotions and bodily sensations in response to unpleasant events (Snel, 2013). A recent study aimed to pinpoint the core program components of MBPs for young people. The research employed the Delphi method to gather consensus from researchers and practitioners of child MBPs worldwide (Felver et al., 2022). The study conducted in three rounds identified 22 core program components for MBPs for young people. Of these, nine categories of mindfulness met or exceeded a consensus endorsement threshold of 75% among MBP researchers and instructors. These core components are: 1. Acceptance: This refers to open-mindedness toward internal and external experiences without the need for change. It involves letting things be as they are, without avoidance. 2. Compassion: This involves a concern for alleviating suffering for oneself and others. 3. Decentering: This is the process of developing an experiential understanding that thoughts and feelings are transient and not lasting.

Common Mindfulness Practice and Adaptations for Child MBPs

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4. Focused Attention: This involves maintaining attention on a targeted internal or external experience for an extended period and noticing when the attention drifts away from the target and then redirecting it back. 5. Nonjudging: This refers to observing internal and external experiences without classifying them as good/positive or bad/negative. It involves practicing nonjudgmental perceptions of thoughts, feelings, and sensations. 6. Non-Reacting: This is the ability to observe pleasant and pleasant experiences without immediately interfering or reacting, allowing for more space between stimulus and response. 7. Orienting to the Present Moment: This involves moment-to-moment awareness of internal and external experiences. 8. Self-Awareness: This refers to the experiential understanding and awareness of thoughts, actions, and emotional states, and the interrelation between these experiences. 9. Somatic Awareness: This involves awareness of bodily sensations and movements. MBP practitioners endorsed two other components, loving kindness and skillful responding, but these did not reach a consensus among researchers. Additional components, including gratitude and open monitoring, failed to meet the 75% consensus threshold among the experts.

 ommon Mindfulness Practice and Adaptations C for Child MBPs MBPs for children, like those for adults, incorporate similar formal and informal mindfulness practices that aim to achieve the program’s aims. After two decades of adapting MBSR/MBCT into age-appropriate practices, some general principles for these adaptations have been identified (Saltzman, 2020; Semple & Lee, 2014). Adaptation in formal practice for child MBPs includes the following: Mindful Sitting: Modify the duration of practices to suit children’s memory and attention capacities. While there is no fixed rule regarding the length of sitting practice, most mindfulness trainers agree that many children can practice for about 3–5 min. Some adolescents may be able to engage in a 15-min practice with appropriate support. As children mature, they can engage in longer practice sessions with the aid of their instructor. Using ongoing verbal guidance with less silence can help engage children and keep them attentive during the practice. Mindful Movement: Incorporate movement practices in all sessions, if possible. Most children and adolescents enjoy moving their bodies and need to do so. A variety of simple movement practices can be beneficial for bringing attention to the body and adjusting energy levels by increasing or decreasing momentum energy levels, depending on the timing of a program and the integration with different practices.

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Body Scan: Contrary to adult MBSR/MBCT where the first body scan is conducted in the first session, most MBPs for children and adolescents introduce the body scan practice later in the curriculum. For many young people, the practice of scanning their bodies for over 10 min or longer can be challenging. Instructors are recommended to start with a shorter version of the body scan practice and gradually extend it to a full version. Once children can acknowledge and accept a practice that may feel challenging and experience some feelings and sensations, such as boredom and agitation, they can experiment with a longer body scan practice. Home Practice: Like adult MBPs, it is beneficial for child MBP instructors to prepare and record audio practice files for participants to use at home. If parents are not involved in a parallel MBP, it is strongly recommended to encourage their involvement in supporting their children’s home practice. Instructors may provide simple instructions for engaging parents in joint mindfulness exercises at home, which can strengthen children’s cultivation of mindfulness awareness. In other contexts, teachers may also provide support to develop children’s regular mindfulness practice in daily life. Other adaptations relating to the program design and materials include the following: 1. Using In-Class Repetition to Enhance Learning. Unlike the MBPs for adults, the time spent in each mindfulness practice is shorter for children, but repetition can be built into the session structure and help children practice under the instructor’s supervision. 2. Separating Different Objects of Practice: In MBP for adults, different objects (such as body, thoughts, and other participants) are incorporated into a single-­ sitting practice. However, children and adolescents benefit from having these practices offered separately. 3. Playfully Adapting Practices for Younger Children. Some mindfulness concepts may be too abstract for children. Using fun activities such as stories, rhythms, or other playful expressions can help cultivate awareness and learning. 4. Incorporating the Educational and Reflective Exercises into the Sessions: In MBPs for adults, the inquiry is a significant extension of mindfulness practice, fostering awareness, and insights. However, children and adolescents may struggle with abstract thinking and logical analysis. They can learn and reflect more effectively through activities, games, and stories. For MBPs for children, worksheets, or structured activities, including Q&A about stress and socioemotional well-being, can consolidate learning. 5. Promoting Active Participation in Most Activities: Activities like drawing pictures, listening to or making music, smelling or touching a variety of objects, and mindful eating can serve as informal practice and directly involve children. Activities providing specific sensory modes (sight, sound, touch, taste, smell, and kinesthetics) can enhance the program’s fun and energy. 6. Considering Participant Composition in Small Group MBPs: If possible, grouping children within 3 years of age can help instructors tailor the program content

Mindfulness and Social and Emotional Development of Children

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according to their cognitive and socioemotional development. Older children can be more sensitive to peer dynamics, which can lead to attraction or rejection by other participants and result in withdrawal from the MBP.

Mindfulness and Cognitive Development of Children Attention and executive function are core components of most cognitive and neuropsychological tasks. Lezak et  al. (2004) suggest that attention is the process of selecting specific information for processing while excluding other details, due to the system’s inherited limited capacity. According to its theory, there are five key components of attention (Anderson et al., 2002): (1) suppressing attention: the ability to inhibit immediate, prepotent responses or to suppress impulsive actions; (2) sustaining attention: the capability to maintain focus and stay alert for extended periods, also known as vigilance; (3) focusing attention: the capacity to select specific, targeted information from a group for more detailed processing; (4) shifting attention: the ability to change the focus of attention with flexibility; and (5) divided attention: the skill to perform two or more tasks simultaneously. Experimental studies have consistently demonstrated that mindfulness training can enhance the regulation of attention across these dimensions (Jha et al., 2007; Zeidan et al., 2010). Another crucial cognitive function is the executive function, which Lezak et al. (2004) define as a collection of mental abilities used for setting goals, planning how to achieve those goals, and effectively executing those plans. The careful processing of information before responding underpins the flexible and selective control of attention (Zelazo, 2015). The development of executive function accelerates during the preschool years but continues to grow into adolescence and beyond, coinciding with the structural and functional evolution of the prefrontal cortex (Zelazo & Calson, 2012). Studies further revealed that training programs, such as MBPs, can improve children’s executive function. By practicing regularly and repeatedly, executive functions can be enhanced for tasks that test these skills, thereby expanding the boundaries of executive functioning capabilities (Diamond, 2013).

 indfulness and Social and Emotional Development M of Children The framework of social and emotional development outlines the processes by which children grow and learn to become knowledgeable, responsible, caring, and socially competent individuals in their families and society. The Collaborative for Academic, Social, and Emotional Learning (CASEL) in the United States endorses this framework, which includes five domains (Weissberg et al., 2015):

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1. Competence in Self-Awareness: This domain involves understanding and recognizing one’s emotions and thoughts and how they influence behavior. It promotes the ability of children to evaluate their own strengths and weaknesses, fostering positive mindsets, self-efficacy, and optimism. 2. Competence in Self-Management: This area refers to the ability to effectively regulate emotions, thoughts, and behaviors across situations. It includes managing stress management, delaying gratification, and persevering to achieve personal goals and overcome challenges. 3. Competence in Social Awareness: This domain involves the ability to empathize with and comprehend the perspective of individuals from diverse backgrounds or cultures. It also involves understanding social and ethical norms in daily social interactions and recognizing resources and support from family, school, and community. 4. Relationship Skills in Social Communication: They are necessary for establishing and maintaining healthy and rewarding relationships with individuals from a variety of backgrounds and cultures. They include clear communication, active listening, cooperation, assertiveness in response to social pressure, constructive conflict negotiation, and seeking and offering help when needed. 5. Competence in Responsible Decision-Making: This domain involves the knowledge, skills, and attitudes necessary for making constructive decisions about personal behavior and social interactions in various settings. It includes considering ethical standards, safety concerns, and social norms for risky behaviors, realistically evaluating the consequences of actions, and promoting the health and well-­ being of oneself and others. Many MBPs for children incorporate mindfulness exercises with social–emotional learning to foster psychological wellness. Focusing on mindful awareness development, MBPs also emphasize care for others, personal growth, and positive self, social, and emotional understanding that aligns with children’s developmental needs. However, the integration of mindfulness exercises with social–emotional development might require a more distinct theoretical, empirical, and practical elucidation, as the program design varies from adult-focused programs (Lawlor, 2016). The aims of self-awareness and self-management in both the MBP and CASEL frameworks significantly overlap in the education context. The remaining three domains may also be viewed as an adaptation of MBP in schools and developmental contexts, aiming for healthy psychosocial growth for all children and adolescents. How instructors embody a healthy lifestyle and social relationships within and beyond an MBP can provide valuable learning opportunities for children to strengthen their abilities in these areas of social and emotional development. In addition, children with developmental, mental health, and social challenges may require additional support for their social and emotional development, as they are more likely to demonstrate deficits in social and emotional competence. Due to their unique conditions or issues, a more intensive MBP, such as selective or indicated prevention programs, can be delivered in small groups or individually to cater to their specific needs (Felver et al., 2013; Wiley & Siperstein, 2015).

Age and Sex Effects on the Outcomes of Child Mindfulness Programs

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Until 2009, fewer than 10 studies were published annually on MBPs for children and adolescents. However, the volume of research has surged rapidly recently, with 164 papers being published by 2019, and evidence supporting the efficacy of MBPs in children continues to accumulate (Saunders & Kobers, 2020). In the latter half of this chapter, some general practice and research issues will be discussed. A common question in this field is who can benefit (more) from mindfulness.

 ge and Sex Effects on the Outcomes of Child A Mindfulness Programs Can Mindfulness Programs Benefit Preschool Children? A recent systematic review has focused on studies on the application of MBPs in preschool-aged children (Sun et al., 2021). Although many studies reported positive improvements in certain domains of child development, the methodological quality of these studies has often been a concern, with many showing a moderate-to-high overall risk of bias. Viglas and Perlman (2018) conducted an RCT on the effects of an MBP on 127 preschool children aged 4–6 years. Eight kindergarten classrooms were randomly assigned to either an MBP or a control condition. Students from the mindfulness group reported significant improvements in self-regulation, prosociality, and hyperactivity, compared with those in the control condition. In another RCT, Flook et al. (2015) evaluated the effects of an MBP on 68 preschool students from higher-­ income families. This curriculum integrates mindfulness practices with gratitude and compassion to cultivate prosocial behavior over 12  weeks, including two 20–30-min lessons each week. The students in the mindfulness group showed greater improvements in prosocial behavior, social competence as reported by their teachers, and academic grades at the end of the school year compared to the control group. Both the mindfulness and control groups demonstrated large effect sizes and between-group differences in prosocial behavior and emotion regulation. Jackman et al. (2019) evaluated an MBP, which combines mindfulness practices with social–emotional learning, and their RCT involved 262 children aged 3–5 years. The students from the mindfulness group showed larger improvements in self-­ regulation, compared to the active control group. However, the mindfulness group showed a decline in cognitive flexibility and no significant differences in inhibitory self-control, metacognition, or overall executive functioning when compared with the active control group. The same program called OpenMind has been translated into Korean, and an RCT was conducted to evaluate its effectiveness (Kim et al., 2020). Two of the four preschools were randomly assigned to the intervention condition (n = 42) and two to the control condition (n = 41). Preschoolers in the intervention group showed slightly larger improvements in emotion regulation, although these did not reach statistical significance.

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Thierry et  al. (2018) conducted a study of an MBP in a preschool sample of African American and Latino students (n = 157) with a matched control group. By the end of the school year, the students in the mindfulness group demonstrated greater improvements in executive functions than those in the control group. Crooks et  al. (2020) recruited 261 preschool children and evaluated the program, with a comparison group of 323 children, in districts characterized as high social risk and disadvantaged. Students who received the program demonstrated improvements in adaptive skills, reductions in behavioral problems, and enhanced executive functioning relative to their control group counterparts. However, more rigorously designed studies are needed to determine the benefits of MBPs in preschool children. Although the findings of these studies suggest that mindfulness is a promising approach for preschool-age children, they should be interpreted with caution due to two limitations: first, limited sample sizes: The sample sizes of these studies were relatively small, likely due to the greater resources required when conducting evaluation research for preschool children. Also, some studies reported teachers’ ratings but did not include parents’ ratings, creating a limitation in generalizing such positive findings from school to home and the community. Second, adaptation for younger participants: The younger the program participants are, the more modifications are required in the intervention components to adapt to the young population. It becomes a delicate question to judge whether a program is mindfulness-based, as mindfulness practice is only a small proportion of the total program content.

 an Children and Adolescents Benefit Equally C from Mindfulness Programs? A few large-scale clinical trials provide insight into the current state of research on the application of MBPs among adolescents. Gómez-Odriozola and Calvete (2021) conducted a waitlist RCT of an MBP on 300 students aged 13–21 years. Older adolescents in the control group showed significant increases in depression and somatic symptoms, suggesting that the program may have a preventive effect. Interpersonal difficulties decreased among older adolescents who completed the program. However, younger adolescents in the program group showed increases in depression and somatic symptoms, whereas no significant changes in those factors were observed in the control group. These findings highlighted the challenges in studying the program effect among healthy adolescents: First, there is a need for age-­ appropriate adaptation of mindfulness programs. Satisfaction survey results suggest that students expect a program that is more enjoyable and stimulating (Gómez-­ Odriozola & Calvete, 2021). In addition, the relevance of mindfulness practice in younger adolescents without serious health or mental health issues should be rigorously evaluated for better program efficacy. A recent meta-analysis by Carsley et al. (2018) investigated the effects of age on the outcomes of school-based MBPs. Studies conducted in late adolescents

Implications for Research

25

(g = 0.28) revealed larger effects on mental health and well-being outcomes than those conducted in middle childhood (g = 0.20). The program effects on early adolescents were not significant (g = 0.11). However, a meta-analysis (Odgers et al., 2020) of studies on anxiety found significantly larger effect sizes in studies on children (d = 0.41) than in studies on adolescents (d = 0.21). In further studies, it is crucial to be more precise in age range, and outcomes can also be specific to problems (such as general stress or depression or other health indicators) and contexts (clinical population or school-based curriculum). The transition period in early adolescents may also be a contraindication for delivering mindfulness programs. This important practice issue will be further discussed in Chap. 4 after reviewing the findings of a recent large-scale school-based mindfulness curriculum.

 ender Differences in the Outcomes G of Mindfulness-Based Programs Most previous findings suggest that adult women benefit more than adult men from MBPs (Katz & Toner, 2013). Tudor et al. (2022) conducted a moderation analysis based on school-based mindfulness training. Among the six studies that investigated the potential moderating effect of sex on the outcomes of MBPs, two  reported greater benefits in female students than in male students in terms of emotional regulation, anxiety, and positive affect (Johnson et  al., 2016; Kang et  al., 2018), one indicated greater benefits in male students than in female students in terms of physical activity (Salmoirago-Blotcher et al., 2018), and two reported no significant differences between the sexes in terms of depression, body concerns, well-being, and mindfulness (Johnson et  al., 2017; van der Gucht et  al., 2017). Sheinman et  al. (2018) investigated the perception of mindfulness practice among 646 students aged 9–12 years in Israeli public schools that had implemented a whole-school mindfulness curriculum. They reported that girls were more likely than boys to apply mindfulness strategies in coping with stress, regardless of their age. In conclusion, girls are more likely to benefit from an MBP than boys, but such gender differences in outcomes are domain-specific and are subject to the context of individual studies, such as factors relating to the location of the MBP and target population.

Implications for Research Two major areas of research relating to child development emerge from this chapter. First, cognitive and socioemotional development: elementary school-age children experience rapid growth in cognitive and socioemotional development. The ways in

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which mindfulness can benefit these domains of child development should be the focus of rigorous longitudinal studies. Second, core components of MBPs and implementation of MBPs: Once the aims and core components of MBPs have been defined, further research should investigate the connection between these components and the levels of implementation intensity across various contexts. Earlier studies of child MBPs have primarily followed the success of the benchmark MBPs for adults, such as MBSR and MBCT. However, these may not be suitable for school contexts or children in diverse situations. Based on these core components, adapted or creative MBPs may be developed to meet the specific needs of children for flexible implementation. In the last section of this chapter, the age and gender effects are discussed. There are relatively less studies conducted for younger children. More rigorous studies should be conducted to address the limitations of existing literature. Concerning the gender effect on MBPs, further studies are warranted to explore the moderating effect of sex in different age ranges and with different clinical problems.

Implications for Practice In real-world implementation, many practitioners creatively integrate mindfulness with expressive arts, drama, music, and a variety of other creative intervention forms. These are seen as potential strategies to engage children and enhance their intentions to learn and practice mindfulness. Experienced practitioners are encouraged to collaborate with researchers, sharing their wisdom to advance not only the practice knowledge and program dissemination, but also to compare the effects of a pure form of MBP with these innovative approaches. This collaboration between practitioners and researchers will be key to navigating the complexities of implementing MBPs to diverse environments and formats.

References Anderson, V., Northam, E., Hendy, J., & Wrennall, J. (2002). Developmental neuropsychology: A clinical approach. Psychology Press. Benson, P. L., Scales, P. C., Syvertsen, A. K., & Roehlkepartain, E. C. (2012). Is youth spiritual development a universal developmental process? An international exploration. The Journal of Positive Psychology, 7(6), 453–470. Carsley, D., Khoury, B., & Heath, N.  L. (2018). Effectiveness of mindfulness interventions for mental health in schools: A comprehensive meta-analysis. Mindfulness, 9, 693–707. Crooks, C. V., Bax, K., Delaney, A., Kim, H., & Shokoohi, M. (2020). Impact of MindUP among young children: Improvements in behavioral problems, adaptive skills, and executive functioning. Mindfulness, 11, 2433–2444. Desrosiers, A., & Miller, L. (2007). Relational spirituality and depression in adolescent girls. Journal of Clinical Psychology, 63(10), 1021–1037. Diamond, A. (2013). Executive functioning. Annual Review of Psychology, 64, 135–168. https:// doi.org/10.1146/annurev-psych-113011-143750

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Dunning, D., Tudor, K., Radley, L., Dalrymple, N., Funk, J., Vainre, M., et  al. (2022). Do mindfulness-­based programmes improve the cognitive skills, behaviour and mental health of children and adolescents? An updated meta-analysis of randomised controlled trials. Evidence-­ Based Mental Health, 25(3), 135–142. https://doi.org/10.1136/ebmental-­2022-­300464 Felver, J. C., Doerner, E., Jones, J., Kaye, N. C., & Merrell, K. W. (2013). Mindfulness in school psychology: Applications for intervention and professional practice. Psychology in the Schools, 50, 531–547. Felver, J.  C., Cary, E.  L., Helminen, E.  C., Schutt, M.  K. A., Gould, L.  F., Greenberg, M.  T., Roser, R.  W., Baelen, R.  N., & Schussler, D.  L. (2022). Identifying Core program components of mindfulness-based programming for youth: Delphi approach consensus outcomes. Mindfulness. https://doi.org/10.1007/s12671-­022-­02015-­1 Frank, J. L., Broderick, P. C., Oh, Y., et al. (2021). The effectiveness of a teacher-delivered mindfulness-based curriculum on adolescent social-emotional and executive functioning. Mindfulness, 12, 1234–1251. https://doi.org/10.1007/s12671-021-01594-9 Flook, L., Goldberg, S. B., Pinger, L., & Davidson, R. J. (2015). Promoting prosocial behavior and self-regulatory skills in preschool children through a mindfulness-based kindness curriculum. Developmental Psychology, 51, 44–51. Gomez, R., & Fisher, J. W. (2003). Domains of spiritual well-being and development and validation of the Spiritual Well-Being Questionnaire. Personality and Individual Differences, 35(8), 1975–1991. Gómez-Odriozola, J., & Calvete, E. (2021). Effects of a mindfulness-based intervention on adolescents’ depression and self-concept: The moderating role of age. Journal of Child and Family Studies, 30, 1501–1515. Greenland, S. K. (2010). The mindful child: How to help your kid manage stress and become happier, kinder, and more compassionate. Free Press. Hardy, S. A., Nelson, J. M., Moore, J. P., & King, P. E. (2019). Processes of religious and spiritual influence in adolescence: A systematic review of 30 years of research. Journal of Research on Adolescence, 29(2), 254–275. Iannello, N. M., Inguglia, C., Silletti, F., Albiero, P., Cassibba, R., Lo Coco, A., & Musso, P. (2022). How do religiosity and spirituality associate with health-related outcomes of adolescents with chronic illnesses? A scoping review. International Journal of Environmental Research and Public Health, 19(20), 13172. https://doi.org/10.3390/ijerph192013172 Jackman, M. M., Nabors, L. A., Mcpherson, C. L., Quaid, J. D., & Singh, N. N. (2019). Feasibility, acceptability, and preliminary effectiveness of the OpenMind (OM) Program for Pre-School Children. Journal of Child and Family Studies, 28, 2910–2921. Jha, A. P., Krompinger, J., & Baime, M. J. (2007). Mindfulness training modifies subsystems of attention. Cognitive, Affective, & Behavioral Neuroscience, 7(2), 109–119. https://doi. org/10.3758/cabn.7.2.109 Johnson, C., Burke, C., Brinkman, S., & Wade, T. (2016). Effectiveness of a school-based mindfulness program for transdiagnostic prevention in young adolescents. Behaviour Research and Therapy, 81, 1–11. Johnson, C., Burke, C., Brinkman, S., & Wade, T. (2017). Development and validation of a multifactor mindfulness scale in youth: The Comprehensive Inventory of Mindfulness Experiences— Adolescents (CHIME-A). Psychological Assessment, 29(3), 264–281. Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness (Revised and updated ed.). Bantam. Kaeakus, M., Ersozlu, A., Usak, M., & Yucel, S. (2021). Spirituality and well-being of children, adolescent, and adult students: A scientific mapping of the literature. Journal of Religion and Health, 60, 4296–4315. https://doi.org/10.1007/s10943-­021-­01435-­y Kang, Y., Rahrig, H., Eichel, K., Niles, H.  F., Rocha, T., Lepp, N.  E., Gold, J., & Britton, W. B. (2018). Gender differences in response to a school-based mindfulness training intervention for early adolescents. Journal of School Psychology, 68, 163–176. Katz, D., & Toner, B. (2013). A systematic review of gender differences in the effectiveness of mindfulness-based treatments for substance use disorders. Mindfulness, 4, 318–331.

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Kim, E., Jackman, M.  M., Jo, S., Oh, J., Ko, S., McPherson, C.  L., Hwang, Y., & Singh, N.  N. (2020). Effectiveness of the mindfulness-based OpenMind-Korea (OM-K) Preschool Program. Mindfulness, 11, 1062–1072. King, P. E., & Boyatzis, C. J. (2015). Religious and spiritual development. In R. M. Learner (Ed.), Handbook of child psychology and developmental science (7th ed.). Wiley. Knowles, L. M., Goodman, M. S., & Semple, R. J. (2015). Mindfulness with elementary-school-­ age children: Translating foundational practices from clinic to the classroom. In C. Willard & A. Saltzman (Eds.), Teaching mindfulness skills to kids and teens. Guilford Press. Kuyken, W., Ball, S., Crane, C., Ganguli, P., Jones, B., Montero-Marin, J., et al. (2022). Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting wellbeing in adolescence: The MYRIAD cluster randomised controlled trial. Evidence-Based Mental Health, 25(3), 99–109. https://doi.org/10.1136/ebmental-2021-300396 Lawlor, M. S. (2016). Mindfulness and Social Emotional Learning (SEL): Conceptual framework. In K. Schonert-Reichl & R. Roeser (Eds.), Handbook of mindfulness in education. Mindfulness in behavioral health. Springer. https://doi.org/10.1007/978-­1-­4939-­3506-­2_5 Lezak, M. D., Howieson, D. B., Loring, D. W., & Fischer, J. S. (2004). Neuropsychological assessment. Oxford University Press. Linden, W. (1973). Practicing of meditation by school children and their levels offield dependence-independence, test anxiety, and reading achievement. Journal of Consulting & Clinical Psychology, 41(1), 139–143. Mahoney, A. (2021). The science of children’s religious and spiritual development. Cambridge University Press. Michaelson, V., Brooks, F., Jirásek, I., Inchley, J., Whitehead, R., King, N., et  al. (2016). Developmental patterns of adolescent spiritual health in six countries. SSM-Population Health, 2, 294–303. Michaelson, V., King, N., Inchley, J., Currie, D., Brooks, F., & Pickett, W. (2019). Domains of spirituality and their associations with positive mental health: A study of adolescents in Canada, England, and Scotland. Preventive Medicine, 125, 12–18. Murphy, M., & Donovan, S. (1983). A bibliography of meditation theory and research: 1931–1983. Journal of Transpersonal Psychology, 15(2), 181–228. Mindfulness in Schools Project. (2014). .b teacher’ notes. Mindfulness in Schools Project. Odgers, K., Dargue, N., Creswell, C., Jones, M. P., & Hudson, J. L. (2020). The limited effect of mindfulness-based interventions on anxiety in children and adolescents: A meta-analysis. Clinical Child and Family Psychology Review, 23, 407–426. Salmoirago-Blotcher, E., Druker, S., Frisard, C., Dunsiger, S. I., Crawford, S., Meleo-Meyer, F., Bock, B., & Pbert, L. (2018). Integrating mindfulness training in school health education to promote healthy behaviors in adolescents: Feasibility and preliminary effects on exercise and dietary habits. Preventive Medicine Reports, 9, 92–95. Saunders, D., & Kobers, H. (2020). Mindfulness-based intervention development for children and adolescents. Mindfulness, 11, 1868–1883. Saltzman, A. (2020). Still quiet place: Sharing mindfulness with children and adolescents. In I. Ivtzan (Ed.), Handbook of mindfulness-based programmes (pp. 267–281). Routledge. Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse (2nd ed.). Guilford Press. Semple, R. J., & Lee, J. (2014). Mindfulness-based cognitive therapy for children. In Mindfulness-­ based treatment approaches (pp. 161–188). Academic Press. Sheinman, N., Hadar, L. L., Gafni, D., & Milman, M. (2018). Preliminary investigation of whole-­ school mindfulness in education programs and children’s mindfulness-based coping strategies. Journal of Child and Family Studies, 27, 3316–3328. Snel, E. (2013). Sitting still like a frog: Mindfulness exercises for kids (and their parents). Shambhala.

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Sun, Y., Lamoreau, R., O’Connell, S., Horlick, R., & Bazzano, A. N. (2021). Yoga and mindfulness interventions for preschool-aged children in educational settings: A systematic review. International Journal of Environmental Research and Public Health, 18, 6091. Thierry, K.  L., Vincent, R., Bryant, H., Kider, M.  B., & Wise, C.  L. (2018). A self-oriented mindfulness-­ based curriculum improves prekindergarten students’ executive functions. Mindfulness, 9, 1443–1456. Tudor, K., Maloney, S., Raja, A., Baer, R., Blakemore, S. J., Byford, S., et al. (2022). Universal mindfulness training in schools for adolescents: A scoping review and conceptual model of moderators, mediators and implementation factors. Prevention Science, 1–20. https://doi. org/10.1007/s11121-­022-­01361-­9 Van der Gucht, K. V., Takano, K., Kuppens, P., & Raes, F. (2017). Potential moderators of the effects of a school-based mindfulness program on symptoms of depression in adolescents. Mindfulness, 8, 797–806. https://doi.org/10.1007/s12671-­016-­0658-­x Viglas, M., & Perlman, M. (2018). Effects of a mindfulness-based program on young children’s self regulation, prosocial behavior and hyperactivity. Journal of Child and Family Studies, 27, 1150–1161. Volanen, S.-M., Lassander, M., Hankonen, N., Santalahti, P., Hintsanen, M., Simonsen, N., Raevuori, A., Mullola, S., Vahlberg, T., But, A., & Suominen, S. (2020). Healthy learning mind – Effectiveness of a mindfulness program on mental health compared to a relaxation program and teaching as usual in schools: A cluster-randomised controlled trial. Journal of Affective Disorders, 260(1), 660–669. Weissberg, R. P., Durlak, J. A., Domitrovich, C. E., & Gullotta, T. P. (2015). Social and emotional learning: Past, present, and future. In J. A. Durlak, C. E. Domitrovich, R. P. Weissberg, & T. P. Gullotta (Eds.), Handbook of social and emotional learning: Research and practice (pp. 3–19). The Guilford Press. Zeidan, F., Johnson, S. K., Diamond, B. J., David, Z., & Goolkasian, P. (2010). Mindfulness meditation improves cognition: Evidence of brief mental training. Consciousness and Cognition, 19(2), 597–605. https://doi.org/10.1016/j.concog.2010.03.014 Zelazo, P. D., & Carlson, S. M. (2012). Hot and cool executive function in childhood and adolescence: Development and plasticity. Child Development Perspectives, 6(4), 354–360. https:// doi.org/10.1111/j.1750-8606.2012.00246.x Zelazo, P. D. (2015). Executive function: Reflection, iterative reprocessing, complexity, and the developing brain. Developmental Review, 38, 55–68.

Chapter 3

Measurements Used in Studying Mindfulness-Based Programs

Due to the intricate nature of mindfulness as a construct, assessing it and the outcome of MBP present considerable challenges. There are fewer measurements available to measure mindfulness and MBP outcomes for children and adolescents compared to adults. When evaluating mindfulness in children, factors to consider include the age appropriateness of the items, perceived understandability (e.g., abstract vs. concrete), limitations relating to self-reflection, and adapting the complexity and structure of the factors to align with the developmental stage of the respondents (Potts et al., 2021). The Five-Facet Mindfulness Questionnaire (FFMQ, Baer et al., 2006), the most commonly used mindfulness scale in adults, has multiple subscales assessing an individual’s present awareness across five facets: describing, observing, acting with awareness, nonreactivity, and nonjudgment. However, some of these subscales necessitate more developed metacognitive skills. As a result, many of the measurement tools employed to assess mindfulness in children are unidimensional (Potts et al., 2021).

Measuring Mindfulness in Children The Child and Adolescent Mindfulness Measure (CAMM) The Child and Adolescent Mindfulness Measure (CAMM; Greco et al., 2011) is the first mindfulness scale specifically for children and adolescents aged 10–17 years. The CAMM assesses trait mindfulness, defined as acting with awareness rather than instinctively responding and accepting without judgment (Greco et al., 2011, p. 2). Many CAMM items are based on the Kentucky Inventory of Mindfulness Scale, an adult mindfulness measure (Baer et al., 2004). It was initially developed to assess three factors: observation, lack of awareness of the ongoing activity and judgmental

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_3

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responses to thoughts and feelings, and non-accepting and avoidance of unpleasant thoughts and feelings. However, the confirmatory factor analysis did not adequately support the CAMM, despite it demonstrating good reliability in single-factor analysis (Kuby et al., 2015). There are 20-item and 10-item versions of the CAMM, and both have empirical backing. The CAMM has been translated into several languages, including Dutch (de Bruin et al., 2014), Spanish (Guerra et al., 2019), French (Dion et al., 2018), Chilean Spanish (García-Rubio et al., 2019), Italian (Chiesi et al., 2017), Greek (Theofanous et al., 2020), and Chinese (Lo, 2021).

The Mindful Attention and Awareness Scale (MAAS) The Mindful Attention and Awareness Scale (MAAS; Brown & Ryan, 2003) is a 15-item unidimensional measure that assesses trait mindfulness, defined as the tendency to pay attention to and be conscious of life experiences. It has been adapted for children aged 9–13 years (MAAS-C; Lawlor et al., 2014) and adolescents aged 14–18  years (MAAS-A; Brown et  al., 2011). The MAAS-A has demonstrated strong internal consistency across different populations, including secondary school students, psychiatric patients, and incarcerated adolescents. Unlike the CAMM, the MAAS-A and MAAS-C focus more on the present aspect quality of mindfulness. The MAAS has been translated into many languages and adapted for adolescents in various countries and cultures. Some researchers have even developed shorter versions of the MAAS for the younger populations, such as a 5-item version for Norwegian adolescents (Smith et al., 2017).

 he Comprehensive Inventory of Mindfulness T Experiences-­Adolescents (CHIME-A) The Comprehensive Inventory of Mindfulness Experiences-Adolescents (CHIME-A; Johnson et al., 2017) is a 25-item trait mindfulness tool developed for use in adolescents aged 12–14 years. Adapted from the CHIME for adults (Bergomi et al., 2015), the CHIME-A assesses mindfulness across eight domains: awareness of internal experiences, awareness of external experiences, acting with awareness, accepting and nonjudgmental orientation, decentering and nonreactivity, openness to experiences, relativity of thoughts, and insightful understanding. A study in Belgium recently utilized the CHIME-A to explore mindfulness in adolescents with chronic conditions (Kock et al., 2021). While this tool may be useful for measuring specific components of mindfulness, the use of its total score is not recommended due to the unsatisfactory internal consistency. The CHIME-A has been translated into Portuguese and Dutch and validated (Cladder-Micus et al., 2019; Magalhães & Limpo, 2022). More studies are needed to further validate this measure’s psychometric properties and external validity.

Measuring Mindfulness in Children

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 ive-Facet Mindfulness Questionnaire Adolescent-Short Form F (FFMQ-A-SF) The FFMQ has been utilized to assess mindfulness in adolescents; however, its length has been a limitation when applied to research on children and adolescents. To address this, a shorter version suitable for ages 10–18 years, based on the adult short form (Tran et al., 2013), was developed. The FFMQ-A-SF contains 25 items, both positively and negatively worded. The response format is a Likert scale from 1 (Never or Very Rarely True) to 5 (Very Often or Always True). Similar to the FFMQ, the scale covers five domains: awareness, observe, describe, nonjudging of inner experience, and nonreactivity to inner experience. Both the total scale and the subscales demonstrated evidence of discriminant and convergent validity (Cortazar et al., 2020). A validation study was conducted based on 829 adolescents in Spain. The FFMQ-A-SF showed adequate internal consistency (α = 0.82 to 0.85) across multiple time points, with subscales ranging from α = 0.61 to 0.88. Confirmatory factor analysis supported the five-factor structure (Cortazar et al., 2020). However, a separate confirmatory factor analysis based on a sample in the United States suggested a four-factor structure, with the removal of the observe construct and one item from the describe construct (Abujaradeh et al., 2020).

Adolescent and Adult Mindfulness Scale (AAMS) The Adolescent and Adult Mindfulness Scale (AAMS; Droutman et al., 2018) was designed to offer a self-reported, multifaceted measure of mindfulness that is applicable to both adolescents and adults. The AAMS has 19 items that assess mindfulness across four dimensions: present-moment awareness (e.g., “I notice changes in my body, such as whether my breathing (or heartbeat) slows down or speeds up.”), nonreactivity (e.g., “when you realize that you missed something important in a class or during a lecture or a work meeting how often do you get angry with yourself?”), nonjudging (e.g., “I make judgments about whether my thoughts are good or bad. How true is it for you?”), and self-acceptance (e.g., “I tell myself that I shouldn’t be feeling the way I am feeling.”). Respondents are required to score each item on a 5-point scale, ranging from 1 (never) to 5 (always). This scale has been validated across four age groups from early adolescents to adults, enabling researchers to compare levels of mindfulness between adolescents and adults using the same tool. The AAMS has been translated into Turkish and validated (Arslan et  al., 2020), and a Dutch version is also available (Droutman et al., 2023).

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Relaxation-Mindfulness Scale for Adolescents (EREMIND-A) The 18-item Relaxation-Mindfulness Scale for Adolescents (EREMIND-A) was specifically developed to evaluate the outcomes of MBPs, designed for adolescents in an educational context, with a focus on attention, breathing, posture, movement, and energy (López-González et  al., 2018). The scale encompasses three factors identified through exploratory factor analysis: attention and concentration in the present moment (e.g., “I know how to enjoy what I have to do at every moment”), relaxation (skills and attitudes; e.g., “I am scared of relaxing totally”), and sensory awareness/contemplation/interiority (e.g., “I seek sensations of peace, calm, and tranquility”). Higher scores denote levels of mindfulness. The scale was validated with a Spanish-speaking ample, and an English translation of the Spanish items was provided. EREMIND-A is suitable for children aged 12 or above. While the scale has been used in a few studies for further validation, all these studies are based on samples from Spain (López-González et al., 2019).

Mindful Student Questionnaire (MSQ) The Mindfulness in Schools Questionnaire (MSQ) was developed to assess self-­ reported mindfulness levels among young people in the school context (Renshaw, 2017). The MSQ was designed to address some limitations of existing mindfulness scales by using exclusively positively phrased items and focusing on mindfulness rather than mindlessness, thereby addressing issues related to content validity. The MSQ items were crafted to target a theoretically grounded multidimensional measurement model that includes the first-order processes of mindful attention (e.g., “When I am at school, I notice when my feeling change from good to bad”) and mindful acceptance (e.g., “when I am feeling bad at school, I am still kind to myself”), as well as the higher-order process of approach and persistence behavior (e.g., “when I doing something hard at school, I try to do the best I can”). This structure helps to avoid the potential for construct underrepresentation and enhances the measure’s utility for informing MBP research and practice. The item content was designed to be specific to the school setting, ensuring that the scores derived from the measure would be directly relevant to educational settings and school-based MBP. A scale validation study was conducted with 278 adolescents in grades 6 to 8, and the three-factor latent structure received adequate support with internal consistency (α = >0.70). The MSQ also showed positive associations with subject well-­ being and academic achievement and has been used in evaluating school-based MBP. Despite the limited number of assessment scales for measuring mindfulness in children and adolescents, each available scale possesses strengths and exhibits solid psychometric properties. More research is needed to foster the development of more refined mindfulness scales for younger populations (Pallozzi et al., 2017). Future research should aim to clarify the factor structure and content assessed by these mindfulness scales. This task is challenging in children, as single-factor solutions

Behavioral Measurements, Biomarkers, and Other Measures That Can Be Used…

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often function better, but the content of these single factors varies, and the scales may lack items relevant to the definitions of mindfulness in adults. It is also worth exploring whether the factor structure of a mindfulness scale should vary by the respondent’s developmental stage. There is a noticeable lack of scales for measuring state mindfulness in the younger population, indicating another potential direction for future research. Overall, it is crucial to assess mindfulness in children and adolescents using adapted scales to enhance our understanding of mindfulness and encourage the application of MBPs in these age groups.

 ehavioral Measurements, Biomarkers, and Other Measures B That Can Be Used in Evaluating MBPs The utilization of behavioral evaluations and biomarkers is a common practice in studying the outcomes of MBPs in adults. The use of behavioral measurements and biomarkers is less frequent in child MBP studies, largely due to the increased costs and administration time these methods require. Researchers should consider their potential value, as these measures may capture changes that children are unable to express due to their cognitive development stage.

Breath Counting Task Most mindfulness practice involves focusing on the breath. A variant of this involves counting one’s breaths, which can help an individual anchor their attention and notice moments of distraction. The Breath Counting Task (BCT) is an objective method of mindfulness, which operationalizes mindfulness of the breath (Levinson et al., 2014). The task’s instructions resemble meditation guidance: to pay attention to the experience of the breath (by counting breaths from 1 to 9) and to be aware when the mind has wandered from focusing on the breath. The BCT has been validated in two published studies and shown to have good convergent, discriminant, and incremental validity. Higher accuracy on the BCT was found to correlate with higher self-reported mindfulness, reduced mind wandering, improved mood, higher levels of nonattachment, and sustained attention (Levinson et al., 2014; Wong et al., 2018). Furthermore, BCT accuracy was found in long-term meditators (Levinson et al., 2014) and negatively correlated with self-reported cognitive failures (Wong et al., 2018). The BCT takes approximately 20 min to administer. It has been programmed in E-Prime (Psychology Software Tools, Pittsburgh, PA) and Psychtoolbox 3.0.10 in MATLAB version R2012A (http://www.mathworks.com). The scripts for these are available at https://github.com/NECLdukenus/BCT. The BCT should be conducted individually and in a distraction-free environment. Before starting the task, ensure participants are seated comfortably upright and can easily rest both hands on the response device.

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While BCT studies have primarily been conducted with adult samples, it has also been used in an adolescent study (unpublished data by Cousins et al., 2018, cited in Lim & Doshi, 2023). Although adolescents performed worse than undergraduate samples, BCT accuracy in the adolescent group was significantly correlated with sustained attention but not self-reported mindfulness. Further investigation may be needed to validate the BCT’s feasibility in adolescent populations.

Attention Network Test The Attention Network Test (ANT), originally developed by Posner and Petersen in 1990, is a tool used to assess attention efficiency. The test involves presenting a row of five fish, either above or below a fixation point. Children are instructed to press a key indicating the direction in which the central fish is pointing, while ignoring the surrounding or flanker fish. Completion of the task allows for the calculation of three scores, each related to a different aspect of attention efficiency. Alerting: This is measured by comparing the response time with no clue to the response time when a cue is given. The cue informs the child that a target will appear shortly. Orienting: This is measured by subtracting the reaction time to a central cue from the time taken to respond to a cue at the target location. Conflict Monitoring: This is measured by assessing the ability to prioritize cognitive attentional resources among competing stimuli. Research by Federico et al. (2017) found that younger children had more errors, slower reaction times, and greater conflict than older children when completing the ANT. Additionally, the ANT has been used in other studies of MBPs for children as an outcome measure. This is because the test can detect whether children display improvements in attention regulation after participating in the MBPs (Felver et al., 2017; Lo et al., 2020).

Ecological Momentary Analysis With the proliferation of smartphones and portable devices, research methodologies are evolving and expanding. Increasingly, researchers are exploring within-person variations in state mindfulness over time using intensive longitudinal designs and real-time data capture methods, such as Ecological Momentary Assessment (EMA) (Enkema et al., 2020). EMA is a method involving frequent and intensive data collection from individuals as they conduct their daily lives in their natural environment. It uses technologies such as personal digital assistants, smartphones, or wearable biosensors to assess behaviors, such as physical activity, and experiences such as thoughts, feelings, beliefs, urges, pain, and cardiac activity, as they occur or shortly thereafter. In EMA studies, participants receive prompts throughout the day to complete brief questionnaires. These can cover a range of topics, from the

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frequency of behavior during a given time frame, the context of the behavior, the emotions felt during the behavior, to any other information the researcher aims to collect (McDevitt-Murphy et al., 2018). EMA also facilitates the analysis of patterns occurring both within and across time periods, making it a powerful tool for investigating temporal sequences of events or experiences and recording temporal antecedents and consequences of events, behaviors, and experiences (Shiffman et al., 2008). EMA can significantly enhance our understanding of the benefits individuals gain from MBPs. It may reveal individual differences and responses between MBP sessions, serve as a reminder for individuals to observe different aspects of their experience and behavioral patterns, and help participants monitor their progress as part of an intervention strategy in MBPs (Grégoire et al., 2023). EMA has been frequently used with children and adolescents, including those with psychopathology (Thunnissen et  al., 2022), mood disorders (Baltasar-Tello et al., 2018), and emotional impulsivity (Rosen & Factor, 2015). However, despite these advantages, EMA also presents ethical and methodological challenges. These include difficulties in identifying confounders in natural settings, potential participant dropouts due to the intense involvement required, privacy concerns from constant monitoring of participants’ conditions or symptoms, and issues of social desirability and reactivity due to repeated self-reporting (Grégoire et al., 2023).

Salivary Cortisol Many participants in MBPs experience chronic physiological stress, which impacts the functions of the hypothalamic–pituitary–adrenal (HPA) axis, resulting in dysregulated cortisol (Obradovic et al., 2010). The activation of the HPA axis is connected with increased cortisol secretion, a vital behavioral response to stress perception that is crucial for adaptation to environmental stimuli (Jessop & Turner-­ Cobb, 2008). Salivary cortisol serves as a biomarker of stress response due to its minimally invasive method of collection. The typical diurnal pattern of cortisol – characterized by a peak in the early-morning rise after waking up followed by a steady decrease throughout the day – provides essential information about an individuals’ physiological stress over time (Chida & Steptoe, 2009). This diurnal cortisol pattern can be summarized using various indicators: wake-up cortisol, evening cortisol, mean cortisol, and diurnal cortisol slopes (Vreeburg et al., 2009). Disrupted diurnal cortisol patterns, such as flatter diurnal slopes, lower wake-up cortisol, and higher evening and mean cortisol, have been linked to poorer immune/inflammation outcomes (Adam et  al., 2017). Saliva samples can be collected at participants’ homes on a regular weekday at the beginning and end of the intervention using Salivette tubes. Biomarkers like salivary cortisol have been utilized for additional evidence in evaluating the outcomes of MBPs (Sanada et al., 2020). In a recent study involving economically disadvantaged families with children aged 5–7 and their

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parents, salivary cortisol was chosen along with other parent-reported scales as outcome scales for outcome assessments (Ho et al., 2020). Compared to the control group, children in the mindfulness group displayed significant increases in morning cortisol and significant decreases in diurnal cortisol slopes following the MBP. Parents in the mindfulness group displayed significant decreases in evening cortisol compared to the control group after MBP. Given the limitations and biases in self-reported mindfulness measures for children and adolescents, the use of salivary cortisol as a biomarker can be further encouraged in outcome studies of MBPs.

Photovoice Photovoice is a qualitative and participatory research method that empowers individuals, especially those in disadvantaged groups, to capture and reflect on their strengths and concerns. It fosters dialogs about personal experiences through sharing and discussing photographs and has been applied in various health (Baker & Wang, 2006) and community research projects (Ho et al., 2011; To et al., 2022). The original goals of photovoice include facilitating community advocacy participation, enhancing awareness of community needs, and boosting individuals’ sense of empowerment. Photographs also become a means to delve into their daily realities, exploring self-defined meanings and significance. As a participatory research method, photovoice allows participants to convey their worlds through photography and their own verbal responses to the images. The unique advantage of photographs is their ability to capture lived experiences. Participants in MBPs are taught to take photographs mindfully and creatively, enhancing their awareness and insights (Kurtz, 2015). MBP instructors can use these photographs to prompt participants to reflect on their experiences and deepen their inquiry within MBPs. Smartphone cameras empower participants to seize meaningful moments in their lives and proactively share their photographs. Based on themes suggested by MBP instructors, participants can contribute to creating or co-constructing knowledge about the benefits of mindfulness on their families in a contextualized and equal environment (Liebenberg, 2022). A recent study integrated photovoice into an MBP for caregivers of young adults with psychosis (Lo et al., 2022). The use of photographs aimed to develop a unique contextual understanding of the MBP program process and outcomes. It encouraged generating new ideas, insights, suggestions, and questions based on participants’ perceptions. Photographs taken by caregivers and their discussions with MBP instructors were transcribed and analyzed together. Themes were developed to understand the lived experience of caregivers participating in the MBP. Given its potential, the use of photovoice should be further promoted among researchers and practitioners. Its potential value in integration with MBPs for children and adolescents warrants further investigation.

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The Head–Toes–Knees–Shoulders (HTKS) Task The Head–Toes–Knees–Shoulders (HTKS) task is a measure of a child’s behavioral regulation, based on their responses to a sequence of 31 commands (Ponitz et al., 2009). Initially, children are acclimated to two oral commands (e.g., “touch your head” and “touch your toes”). They are then asked to respond in a counterintuitive manner to two types of paired behavioral commands during 16 trials and then four types in the subsequent 15 trials. For instance, if the administrator says, “Touch your toes,” the correct response is for the child to touch his or her head. Similarly, in response to “Touch your knees,” the child should touch his or her shoulders. Correct responses receive 2 points; incorrect responses earn 0 points; and if the child initially responds incorrectly but self-corrected to perform the correct action, 1 point is awarded. Scores can range from 0 to 62. The commands are given in a consistent, non-random order, and higher scores denote higher levels of behavioral regulation. The HTKS task is particularly suitable for younger children as a measure of self-­ regulation. In a study of an MBP conducted by Viglas and Perlman (2018) involving 127 children aged 4–6 in kindergarten classrooms, it was found that children in the mindfulness group demonstrated greater improvement in self-regulation as gauged by the HTKS task. The HTKS task was also chosen as an outcome measure in an MBP for children and parents from economically disadvantaged families (Lo et al., 2019). Families were randomly assigned to either the MBP or a waitlist control. The intervention group showed a more significant positive improvement after the program than the waitlist control, and the effect was further enhanced at the 3-month follow-up. The effect size at follow-up was d  =  0.72, indicating a moderate size improvement in self-regulation.

Test for Creative Thinking Drawing Production (TCT-DP) The literature has indeed demonstrated that mindfulness can foster creativity, particularly in educational contexts. The theoretical foundations for this assertion lie in the role mindfulness plays in enhancing skills and habits of mind conducive to creativity. Mindfulness promotes observation and understanding of the world, fostering an open-mindedness that enables the recognition of a broader range of possibilities. It also supports deliberate mind wandering, a state often associated with creative insights (Henriksen et  al., 2020). The Test for Creative Thinking Drawing Production (TCT-DP) is an assessment tool developed by Jellen and Urban (1986) to evaluate the creative thinking abilities of children aged 6 and above. It adopts a componential approach and a social-psychological model of creativity, assessing a variety of aspects, including divergent thinking and acting, general knowledge and thinking base, specific knowledge base and area-specific skills, focusing and task commitment, motivation and motives, and openness and tolerance of ambiguity (Jellen & Urban, 1986; Urban & Jellen, 1996).

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In the TCT-DP, an individual’s creative thinking is assessed through a drawing task. Participants are given an A4-sized paper featuring six figural fragments (a semicircle, a point, a 90° angle, a curved line, a broken line, and a small open square) and are asked to create a drawing using any combination of these six fragments within a 10-min timeframe. The TCT-DP is deemed a promising tool for assessing creative thinking through a componential and holistic approach (He & Wong, 2011). According to the test manual (Urban & Jellen, 1996), creative thinking is scored based on nine criteria, including continuations, completion, new elements, connections by line, connections by theme, boundary breaking, perspective, humor and affectivity, and unconventionality, with a potential total score range of 0–66 points. A higher composite score denotes higher creative functioning. Several studies on meditation and mindfulness for children have chosen the TCT-DP as a measurement tool. For example,  So and Orme-Johnson (2001) conducted three studies examining the effects of the regular practice of transcendental meditation on high school and postsecondary vocational school students in Taiwan. In two of these studies, students from meditation groups showed greater improvements in creativity, as indicated by their TCT-DP total scores. Similarly, Luong et al. (2019) conducted a waitlist-controlled study of a 2-h MBSR program for students in Germany. Although no significant improvement in creativity was reported, small-to-medium effect sizes were found on self-reported measures, including depression, self-regulation, and perceived stress. Cheung and Hui (2023) evaluated an art-based mindfulness program for school-aged children aged 7–10. After six sessions, children showed improvements in self-reported mindfulness and creativity in TCT-DP, particularly in the subscales of Composition, Perspective and Speed, and New Element.

Stroop Task The Stroop Task, named after its creator, J. Ridley Stroop, is a widely used assessment tool in cognitive science. This task presents participants with stimuli that have two dimensions, requiring them to focus on one aspect while disregarding the other. In the classic version of the Stroop task (Stroop, 1935), participants are shown a list of color words (e.g., “red” and “blue”) that are printed in different colored inks. Participants are asked to name the color of the ink, ignoring the actual word. This creates a conflict or interference because our brains are wired to recognize words more quickly than colors. Better cognitive functioning is indicated by shorter reaction times and improved response accuracy. This “Stroop interference” is considered a measure of cognitive control, reflecting an individual’s capacity for sustained attention or cognitive inhibition (Wimmer et  al., 2016). The Stroop task is often used to assess the effects of MBPs on cognitive functioning. It is a brief measure, taking only 5 min to administer, and it is suitable for children aged 5 and above (Golden & Freshwater, 2002). This task has been used to investigate whether

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cognitive changes resulting from mindfulness practice are the mechanisms mediating the effects of mindfulness practice on mental health (Tarrasch, 2017). The Stroop task is commonly considered a measure of executive function (Scarpina & Tagini, 2017), which refers to a set of cognitive processes believed to be performed by the prefrontal cortex of our brains (Nyongesa et al., 2019). These processes include attentional control, working memory, inhibitory control of competing cognitive processes, flexibility in adapting to changing task demands, self-­ regulation, planning, problem-solving, and decision-making. However, it is important to note that there is no standardized version of the Stroop Task, and its convergent validity has been questioned. Furthermore, many studies have found no correlation between mindfulness practice and improved Stroop performance (Paap et al., 2020). Therefore, while the Stroop Task can provide valuable insights into cognitive control and executive function, its limitations should be taken into account when interpreting results or designing studies.

Difficulties in the Emotion Regulation Scale The Difficulties in Emotion Regulation Scale (DERS) is a well-regarded tool for assessing an individual’s ability to regulate emotions (Gratz & Roemer, 2004). The full version of the DERS consists of 36 items, which are grouped into six factors: (1) nonacceptance of emotional response (six items), (2) difficulties in engaging in goal-directed activity (five items), (3) impulse control difficulties (six items), (4) lack of emotional awareness (six items), (5) limited access to emotion regulation strategies (eight items), and (6) lack of emotional clarity (five items). Each item is scored on a 5-point Likert-type scale, ranging from 1 (almost never) to 5 (almost always), with higher scores indicating difficulty in emotion regulation. A shorter 18-item version of the DERS has been developed and validated for use with adolescents (Kaufman et al., 2016). The DERS has been extensively used to evaluate the outcomes of MBPs for children. For instance, Metz et al. (2013) reported that students showed significant improvements in their overall emotional regulation scores, as well as in the three subscales (emotional awareness, access to regulation strategies, and emotional clarity) after participating in an MBP.

Implications for Research The number of self-reported measures of mindfulness for children and adolescents has indeed been growing, with varying dimensions across different scales. Some, like the CAMM and MAAS, are unidimensional, while others, such as the FFMQ-­ A-­SF, CHIME-A, and AAMS, incorporate multiple subscales. This diversity reflects the lack of consensus on how to best measure mindfulness in younger populations.

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Each scale has different strengths and limitations, and researchers should select the one most suitable for their particular study. However, many of these scales are only available in English, limiting their applicability in non-English-speaking contexts. Further validation and replication studies are needed to refine these scales and ensure their utility across diverse settings. A recent systematic review reported that while awareness and mindfulness have often been selected as outcome measures in MBPs, fewer than half of the studies showed an increase in these factors post-­ intervention. This highlights the urgent need to improve these self-reported measures in terms of validity and sensitivity to changes following MBPs. Advancements in the measures can contribute to the evidence base of child MBPs, facilitate mediating analysis, and aid in the development of MBP models. Importantly, they may help answer questions about the specific factors of MBPs that contribute to outcomes, such as the extent to which outcomes are mediated by the learning and teaching of mindfulness, as opposed to other common factors such as instructor care or peer support. However, the current self-reported mindfulness scales for children may have significant limitations in capturing children’s experiences during and after MBPs. Younger children and adolescents may struggle to summarize information over extended periods and accurately report their mindfulness experience. Furthermore, these self-reports are unlikely to be validated due to the variable and dynamic nature of mindfulness experiences. In addition, there is often a discrepancy between self-, parent, and teacher reports of a child’s behavior, which could be attributed to rater bias or social desirability effects. When MBPs involve both parents and children, it is crucial to distinguish between parents’ ratings of children’s behavior and changes in the parents’ own behaviors, especially as their awareness and acceptance levels increase. Ultimately, it is recommended to use multiple measures, including behavioral measures or biomarkers, in order to triangulate and improve the validity of the outcomes, particularly in studies involving younger children. This approach can provide a more comprehensive understanding of the effects of MBPs on children and adolescents.

Implications for Practice Measurements play a crucial role in assessing MBPs. With an increasing number of measurement options suitable for children and adolescents, practitioners can incorporate straightforward program evaluation procedures into their regular practice. Research conducted in real-world settings can contribute to the advancement of practical knowledge, enhance the quality of program implementation, and deepen our understanding of the effectiveness of MBPs and their target audience.

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Nyongesa, M. K., Ssewanyana, D., Mutua, A. M., Chongwo, E., Scerif, G., Newton, C. R., et al. (2019). Assessing executive function in adolescence: A scoping review of existing measures and their psychometric robustness. Frontiers in Psychology, 10, 311. Obradovic, J., Bush, N. R., Stamperdahl, J., Adler, N. E., & Boyce, W. T. (2010). Biological sensitivity to context: The interactive effects of stress reactivity and family adversity on socioemotional behavior and school readiness. Child Development, 81, 270–289. Paap, K. R., Anders-Jefferson, R., Zimiga, B., Mason, L., & Mikulinsky, R. (2020). Interference scores have inadequate concurrent and convergent validity: Should we stop using the flanker, Simon, and spatial Stroop tasks? Cognitive Research: Principles and Implications, 5, 7. https:// doi.org/10.1186/s41235-­020-­0207-­y Pallozzi, R., Wertheim, E., Paxton, S., & Ong, B. (2017). Trait mindfulness measures for use with adolescents: A systematic review. Mindfulness, 8, 110–125. Ponitz, C. C., McClelland, M. M., Matthews, J. S., & Morrison, F. J. (2009). A structured observation of behavioral self-regulation and its contribution to kindergarten outcomes. Developmental Psychology, 45, 605–619. Potts, S. A., Twohig, M. P., Butcher, G. M., & Levin, M. E. (2021). Assessment of mindfulness in children and adolescents. In N. N. Singh & S. D. Singh Joy (Eds.), Mindfulness-based interventions with children and adolescents: Research and practice. Routledge. Renshaw, T. L. (2017). Preliminary development and validation of the Mindful Student Questionnaire. Assessment for Effective Intervention, 42(3), 168–175. Rosen, P. J., & Factor, P. I. (2015). Emotional impulsivity and emotional and behavioral difficulties among children with ADHD: An ecological momentary assessment study. Journal of Attention Disorders, 19(9), 779–793. Sanada, K., Montero-Marin, J., Barceló-Soler, A., Ikuse, D., Ota, M., Hirata, A., et  al. (2020). Effects of mindfulness-based interventions on biomarkers and low-grade inflammation in patients with psychiatric disorders: A meta-analytic review. International Journal of Molecular Sciences, 21(7), 2484. https://doi.org/10.3390/ijms21072484 Scarpina, F., & Tagini, S. (2017). The Stroop color and word test. Frontiers in Psychology, 8, 557. Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Ecological momentary assessment. Annual Review of Clinical Psychology, 4, 1–32. Smith, O. R. F., Melkevik, O., Samdal, O., Larsen, T. M., & Haug, E. (2017). Psychometric properties of the five-item version of the Mindful Awareness Attention Scale (MAAS) in Norwegian adolescents. Scandinavian Journal of Public Health, 45, 373–380. So, K. T., & Orme-Johnson, D. W. (2001). Three randomized experiments on the longitudinal effects of the Transcendental Meditation technique on cognition. Intelligence, 29(5), 419–440. Stroop, J. R. (1935). Studies of interference in serial verbal reactions. Journal of experimental psychology, 18(6), 643. Tarrasch, R. (2017). Mindful schooling: Better attention regulation among elementary school children who practice mindfulness as part of their school policy. Journal of Cognitive Enhancement, 1, 84–95. https://doi.org/10.1007/s41465-­017-­0024-­5 Theofanous, A., Ioannou, M., Zacharia, M., Georgiou, S. N., & Karekla, M. (2020). Gender, age, and time invariance of the Child and Adolescent Mindfulness Measure (CAMM) and psychometric properties in three Greek-speaking youth samples. Mindfulness, 11, 1298–1307. Thunnissen, M. R., aan het Rot, M., van den Hoofdakker, B. J., & Nauta, M. H. (2022). Youth psychopathology in daily life: Systematically reviewed characteristics and potentials of ecological momentary assessment applications. Child Psychiatry & Human Development, 53, 1129–1147. https://doi.org/10.1007/s10578-­021-­01177-­8 To, P. D. N., Huynh, J., Wu, J. T. C., Vo Dang, T., Lee, C., & Tanjasiri, S. P. (2022). Through our eyes, hear our stories: A virtual photovoice project to document and archive Asian American and Pacific islander community experiences during COVID-19. Health Promotion Practice, 23(2), 289–295.

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Tran, U. S., Glück, T. M., & Nader, I. W. (2013). Investigating the Five Facet Mindfulness Questionnaire (FFMQ): Construction of a short form and evidence of a two-factor higher order structure of mindfulness. Journal of Clinical Psychology, 69(9), 951–965. https://doi. org/10.1002/jclp.21996 Urban, K.K., & Jellen, H.G. (1996). Test for creative thinking - drawing production (TCT-DP). Swets Test Services. Viglas, M., & Perlman, M. (2018). Effects of a mindfulness-based program on young children’s self regulation, prosocial behavior and hyperactivity. Journal of Child and Family Studies, 27, 1150–1161. Vreeburg, S. A., Kruijtzer, B. P., van Pelt, J., van Dyck, R., DeRijk, R. H., Hoogendijk, W., et al. (2009). Associations between sociodemographic, sampling and health factors and various salivary cortisol indicators in a large sample without psychopathology. Psychoneuroendocrinology, 34(8), 1109–1120. Wimmer, L., Bellingrath, S., & von Stockhausen, L. (2016). Cognitive effects of mindfulness training: Results of a pilot study based on a theory driven approach. Frontiers in Psychology, 7. https://doi.org/10.3389/fpsyg.2016.01037 Wong, K. F., Massar, S. A. A., Chee, M. W. L., & Lim, J. (2018). Towards an objective measure of mindfulness: Replicating and extending the features of the breath-counting task. Mindfulness, 9(5), 1402–1410. https://doi.org/10.1007/s12671-­017-­0880-­1

Chapter 4

Mindfulness in School-Based Curricula

Educational goals extend beyond academic achievements and encompass the fostering of children’s positive human qualities, including kindness, compassion, and generosity. With this holistic perspective, mindfulness has gained prominence as a tool in social-emotional learning within school environments (Roeser et al., 2023; Schonert-Reichl, 2023). The rise in school-based mindfulness programs (SBMPs) for students from students aged 4 to 18 years, particularly after 2014, aligns with the development of social–emotional learning curricula. These curricula aim to promote resilience, coping skills, and social-emotional well-being in children (Roser et al., 2023). Such growth is in line with the parallel development of a social–emotional learning curriculum, offering a counterforce to cultures and educational systems often skewed toward competition, aggression, and violence rather than peacefulness and cooperation (Mohoney & Weissberg, 2019). A rudimentary search I conducted on the Web of Science database yielded 415 articles and early-access publications. The search criteria included “mindfulness,” “schools,” and “students,” while excluding “yoga” and “college.” The aim was to ensure that the selected studies did not include studies that were based on yoga intervention or targeted at college and university students. Figure  4.1 shows an interesting trend: The annual number of articles between 2001 and 2010 was 2 or less. However, there has been a significant surge in publications since 2014. Most notably, there was a sharp increase from 2015 to 2016, with the number of articles rising from 17 to 39. From 2019 and onwards, over 60 articles have been published each year. The articles published between 2016 and 2022 accounted for 85.3% of the total during this period. This surge in publications indicates that most of the evidence base in this field has accumulated in the past decade. As Roeser et  al. noted, “the science of mindfulness in schools and for students does not yet appear to be very developmental in nature” (2023: 241). Feuerborn and Gueldner (2019) observed that 23 manualized MBPs designed for children are being implemented in school settings worldwide. These programs exhibit considerable diversity in their types, implemented practices, and the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_4

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Number of arcles between 2000 to 2022 80 70 60 50 40 30 20 10 0

Fig. 4.1  Research publications on mindfulness, schools, and students from 2000 to 2022. Notes: N = 415 from Web of Science search

expertise of the program instructors. In this chapter, we commence with an examination of several renowned SMBPs that were initially introduced in their country of origin before being translated and disseminated across cultures. Pilot studies and large-­scale trials associated with each SMBP are reviewed. Given that we are now a decade into the collective effort of implementing SMBPs, it is an appropriate time to review their outcomes. Several systematic reviews and meta-analyses have been carried out in recent years. The significant findings from these reviews and their implications for further research and practice are discussed toward the end of this chapter.

MindUP MindUP is a mindfulness-based social and emotional learning program consisting of fifteen 45-min lessons, with one lesson delivered each week. The program is designed for children from prekindergarten to eighth grade and has been adapted into three versions for different age groups: prekindergarten to grade 2, grades 3 to 5, and grades 6 to 8. Each lesson in this program integrates mindfulness practices with classroom activities that convey knowledge about the brain, how thoughts and feelings influence actions, and strategies for fostering empathy and care. The core practices last for 3  min and are repeated three times a day, comprising mindful breathing and attentive listening exercises. Children learn that cultivating focused awareness provides a self-regulatory strategy to soothe themselves when they are

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emotionally overwhelmed. One lesson in the MindUP program specifically teaches children about the brain, particularly the amygdala and the prefrontal cortex, and their roles in emotions and cognition. This knowledge helps children understand the connections between brain neurology, positive psychology, and mindfulness practices and motivates them to engage in these practices to enhance their attention and calmness. Studies have shown the MindUP program’s effectiveness in promoting mindfulness and positive development in children and young adolescents. Schonert-Reichl and Lawlor (2010) conducted the first study using a waitlist-controlled design with 246 early adolescents from the fourth to seventh grades. The adolescents in the mindfulness group demonstrated significant increases in optimism, teacher-rated attention, and socially competent behaviors in the classroom compared to the control group. The program was also found to positively impact affect though no significant effects were observed on negative affect. A second study conducted by Schonert-Reichl et al. (2015) involved the random assignment of 99 fourth and fifth graders to either the MindUP program or a standard social responsibility school program. This study utilized multiple outcome assessments, including objective cognitive tasks, salivary cortisol testing, self, peer, and teacher ratings of social–emotional competence, and end-of-year math grade evaluation. Compared to the control group, the mindfulness group children exhibited significantly shorter average response times in cognitive control tasks, indicative of improvements in inhibition, working memory, and selective attention. They also demonstrated higher cortisol secretion in the morning and a stable diurnal pattern, suggesting healthier stress physiology. Furthermore, the mindfulness group children showed significant improvements in optimism, emotional control, empathy, perspective-taking, prosocial behaviors, and mindful attention, as well as a decrease in depressive symptoms. They also reported increased school self-concept (i.e., perceived academic abilities and interest) and a 15% average gain in teacher-­ reported math grades. Both studies utilized rigorous designs, including waitlist or active control groups, and employed multi-component assessments capturing various aspects of child development. MindUP also offers a version for preschool children. Two studies examining this version (Crooks et al., 2020; Thierry et al., 2018) reported positive outcomes. The study by Thierry et al. (2018) included 157 four-year-old students from four schools. At the end of the school year, students in the mindfulness schools demonstrated small-to-moderate effect sizes of increases in executive functions, as measured by two behavioral tests, and greater improvements than students in the business-as-­ usual control schools. However, no between-group difference was identified in teachers’ ratings of students’ prosocial behaviors and preschool children’s self-­ assessment of academic skills. In the study by Crooks et al. (2020), teacher delivered the MindUP program to 23 classrooms, while 19 classrooms received regular instruction as the comparison group. Students who received the intervention showed an increase in adaptive skills and reductions in behavioral symptoms, including internalizing and externalizing

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symptoms. In addition, a significant decrease in executive functioning deficits was observed among students who participated in MindUP.  Nevertheless, it remains unclear whether the mindfulness component of this program offers additional benefits for children relative to the other social–emotional learning programs. Moreover, these studies lacked follow-up time points, leaving the long-term effects of the program uncertain. The MindUP program has been translated into different languages and implemented in countries including China, Finland, and Qatar. A quasi-experimental study in Portugal (de Carvalho et al., 2017) reported the effects of the program on 454 third and fourth graders. The experimental group received MindUP, and their outcomes were compared with those in the waitlist control group. Over 50% of the children in the SMBP scored above the control group mean in emotion regulation capacity, positive affect, and self-compassion, and over 50% scored lower in negative affect. In Northern Ugandan, a region previously engulfed in violent civil conflict where many experienced and witnessed extreme violence, local researchers collaborated with the local research team to train schoolteachers to deliver SMBP. After a feasibility test of 200 fifth and sixth graders, some lessons were culturally adapted – for instance, using a mango to illustrate brain regions. During mindful eating and smelling exercises, white ants, mangos, sugar, and soap were used. Significant improvements in prosocial behaviors, empathic concern, and depressive symptoms were observed (Matsuba & Williams, 2020). A follow-up study adopted a quasi-­ experimental design to compare 46 SMBP students with 36 students from a waitlist comparison group. Between-group differences were found in self-reported anger, loneliness, perceived hostility, perceived rejection, empathic concern, and teachers’ ratings of positive affect and empathic behavior. This study demonstrated that the SMBP curriculum could be adapted to different cultural contexts that have experienced social unrest and resource limitations.

Learning to BREATHE The Learning to BREATHE (L2B) curriculum is a program designed to teach adolescents mindfulness, focusing on present-moment awareness, reducing self-­ judgment, and everyday mindfulness practice (Broderick, 2013). The program can be implemented in 6-, 12-, or 16-week versions in a group setting. Each 45-min lesson incorporates core practices common to most MBPs, such as body scan, mindfulness of thoughts and emotions, and mindful movement. In addition, the program includes loving-kindness practice, where students are encouraged to wish well for themselves and others. Students are provided with workbooks and CDs for mindfulness practice at home. Pilot and feasibility studies have been conducted to investigate the effects of the L2B programs in high schools, particularly in ethnically and economically disadvantaged school populations (Bluth et  al., 2016; Eva & Thayer, 2017; ­

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Felver et al., 2019; Fung et al., 2016). These studies, discussed in detail in Chap. 6 (the application of MBP in children with psychosocial challenges), reported positive changes after the SMBP, suggesting that L2B has the potential for improving adolescents’ well-being and mental health. The impact of the L2B program was further investigated in two large-scale studies. The first study, conducted by Metz et  al. (2013), used a quasi-experimental pretest–posttest comparison design on 244 students in grades 10 to 12 from a middle- to high-income U.S. population. The program was delivered during the time originally for choir courses. Students demonstrated improvements in emotional regulation, particularly in emotional regulation strategies, psychosomatic symptoms, and self-regulation strategies. The program received high satisfaction ratings, with 89% of the students indicating that they would recommend the program to others. The second study, conducted by Frank et al. (2021), involved 251 students from an urban high school district, who was randomly assigned to a teacher-delivered L2B program or the usual health curriculum (the control group). The L2B program group students did not show significant improvements in any self-reported measure of mindfulness, emotion regulation, mental health symptoms, or social connectedness. Unexpectedly, they reported higher levels of rumination and difficulties in goal-directed behavior (a subscale of emotion regulation) compared with the control group students. However, when assessed on executive functioning, the mindfulness group reported better reaction times in cognitive interference and working memory tasks than the control group. The study further investigated the effects of uptake, defined as students practicing mindfulness at least once per month. Based on students’ self-reports, one-third of the students met this standard, and a moderating effect of practice was found on outcomes in emotion regulation, emotional awareness, emotional clarity, impulse control, and social connectedness. In the study conducted by Frank et  al. (2021), several implementation factors were identified as potential mediators for the outcome of the L2B program. Firstly, despite the extensive support provided to teachers, including supervision, love observations, and weekly feedback calls, none of the teachers achieved a high level of implementation fidelity in delivering the program. This indicates the challenge of transforming teachers into competent mindfulness instructors after a short training period, suggesting the need for further research and development in teacher training methodologies for MBPs. Secondly, the effects of the MBPs on clinical symptoms were not detected in the majority of the students in the study samples, as they were relatively healthy (Greenberg & Abenavoli, 2017). This implies that the impact of mindfulness programs may be more pronounced or easier to detect in populations dealing with specific mental health or stress-related challenges. Lastly, only one-­ third of the adolescents reported practicing mindfulness at least once a month, despite efforts to integrate mindfulness practice into the regular school day. This suggests a need for strategies to encourage and remind students to incorporate mindfulness practice mindfulness into their daily lives. Without regular practice, the potential benefits of the MBPs may be limited.

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The L2B program has also been tested among adolescents with specific health challenges, including those at risk of obesity (Shomaker et al., 2019) and those at risk of diabetes (Shomaker et al., 2017). The findings from these studies, which are included in Chap. 6 (covering the use of MBP for children encountering health challenges), demonstrate the potential of the L2B program in addressing specific healthrelated issues. This suggests the potential for the L2B program to have a far-­reaching impact on student well-being, beyond its initial target group of high school students to improve students’ well-being within a broader school context and across age groups.

Mindful School The Mindful School program comprises 18 lessons, each lasting 20 min. These lessons are scheduled three times a week, spanning 6 weeks. To ensure uniformity in delivery, teachers are given a manual to guide each lesson. The program includes exercises focused on breathing, walking, eating, and seeing, with students practicing attention focusing during each activity. In addition, lessons on “heartfulness” are included, which encourage students to explore themes of self-care and kindness toward others. After each lesson, students are invited to write or draw in journals, reflecting on what they learned from the mindfulness practice. They are also encouraged to practice this learning at home, share the experiences, and teach their family members. On the project’s website, it is claimed that the Mindful School program has reached millions of youths and over 50,000 educators worldwide (http://www. mindfulschools.org). A pilot study was conducted to examine the effects of the program on 18 children attending a summer camp, compared to those who received a health education program. The results indicated that minority children who attended the program reported a lower level of depressive symptoms (Liehr & Diaz, 2010). Another study involving 409 children from kindergarten to grade 6 was conducted. In this study, 83% of participants were enrolled in a free lunch program, and 95.7% were ethnic minorities (Black & Fernando, 2014). Teachers reported improved classroom behavior among their students in terms of attention, self-control, participation in activities, and respect for others. These effects were sustained at the 7-week follow­up post-program. However, this study did not include a control group. A more recent study focuses on preschool children conducted by Viglas and Lerlman (2018). This study evaluated the effects of the program on self-regulation, prosocial behavior, and hyperactivity among 127 kindergarten children aged 4–6 years. The mindfulness group showed greater improvements in self-regulation, prosocial behavior, and hyperactivity with moderate effect sizes, compared to the control group. Similar to many studies of the MindUP program, this study involved children from low-income households, raising questions about the generalizability of the findings to children from other socioeconomic backgrounds.

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.b and Paws b The Mindfulness in Schools Project, based in the UK, has developed a range of child MBPs, beginning with the .b (pronounced as “dot-be”) for secondary school students. Originally, the program was designed to be delivered weekly during regular lesson time. Activities incorporated into the program include mindfulness of breath, body, and thoughts, mindful eating, mindful walking, and stress management techniques. The program is supplemented with home practice, a teacher’s guide manual, a script for teachers, and a student booklet. To make the content engaging for teenagers, the designers have also created interactive PowerPoint presentations featuring video clips and interesting activities. Four separate curricula have been developed to cater to different age groups: 1. Dots: Designed for children aged 3–6 years in preschool settings. It consists of 30 sessions that can be delivered in 10- to 20-min segments and can be repeated over a week or several weeks. 2. Paws b: Aimed at children aged 7–11 years. It can be delivered as twelve 30- to 60-min lessons or can be grouped into six sessions. 3. . breath: For children aged 9–14 years. It is a brief course of four sessions and includes fewer mindfulness practices than .b or Paws .b. 4. .b: For adolescents aged 11–18 years in secondary schools. It encompasses more extensive mindfulness training. Research has been conducted to assess the feasibility and effectiveness of the .b program. An initial cohort-controlled study involved 522 secondary school students aged 12–16 years from 12 schools. These students participated in either the .b program or the usual school curriculum, which acted as the control group. Some of the participating schools used the program universally, while one school only offered it to one class during the lunch break. Students who participated in the program reported fewer depressive symptoms post-program, and these improvements were sustained at the 3-month follow-up. Significant improvements in stress and well-­ being were found at follow-up (Kuyken et al., 2013). Although the study did not employ a randomized controlled design, the use of a comparison group suggested that the SMBP as a universal intervention was feasible and effective. In an RCT, Johnson et al. (2016) evaluated the effects of the .b program on 132 Australian students in years 8 and 10, comparing them with 176 students who received regular school curriculum. The students came from diverse socioeconomic backgrounds, and both students attending public and private schools were involved. Following the program, students reported nonsignificant positive changes in outcome measures, including depression, body concerns, and well-being. Unexpectedly, anxiety symptoms rose after the MBP, compared with the control group for males and those of both genders with low baseline levels of weight/shape concerns or depression. No significant differences were found between the groups in any outcome measures at the posttest or the 11-week follow-up. A large-scale cluster RCT in Finland assessed the effects of the .b program on 3519 adolescents aged 12–15  years (Volanen et  al., 2020). Students were

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randomized into a 9-week .b program, a relaxation program, or standard teaching (control group). The “.b” program did not show substantial benefits on most outcomes compared with the control treatment, except for resilience at post-­intervention, compared to the relaxation group. Girls in the mindfulness group showed reduced depressive symptoms at the 26-week follow-up compared to the control group, but this was not seen in boys, possibly due to their low baseline depression scores. Improvements in social–emotional functioning were observed at two time points among grade 7 students only. Sanger and Dorjee (2016) used a neuroscientific approach to explore the effects of MBP. Post-program, students demonstrated more negative N2 amplitudes in response to color-deviant and standard nontarget stimuli in a visual oddball paradigm, potentially linked with self-reported control over negative thoughts and reduced self-criticism. While Paws .b can be seen as a modified version of .b, there is surprisingly little empirical on this SMBP, likely due to the difficulties of conducting large-scale intervention studies for younger children. Vickery and Dorjee (2016) conducted a non-RCT to assess the acceptability and emotional well-being outcomes of the Paws .b program in 71 children aged 7–9  years. Post-program, students showed significant decreases in self-reported negative affect at follow-up and improved teacher-rated metacognition. However, these findings are limited by the small sample size, lack of randomization, and potential bias as the teachers who delivered the program also rated the students’ metacognition. These improvements were not supported by parental ratings. Thomas and Atkinson (2016) conducted a mixed-methods study of 30 students aged 8 to 9 years in a UK location where most participants spoke Urdu or Bengali as their first language. Paws .b were delivered in 61 h weekly sessions. Teacher-­ reported attention increased from pretest to posttest, and although such improvement was not maintained at the 8-week follow-up, it was seen again at the 14-week follow-up. Two additional attention tests showed significant improvements post-­ program, but only the naming total errors task showed differences between groups. A follow-up qualitative study using focus groups and teacher interviews post-­ program reported that most students enjoyed Paws .b, and improvements in metacognition and socioemotional functioning were observed. Although the program was found to be feasible and acceptable for school-aged children, its small sample size makes it uncertain whether these positive findings can be generalized to other schools and cultural contexts. In summary, the application of Paws b is limited, and the benefits of such a program for young children are still uncertain.

Other Curricula Worldwide The Mindfulness for Adolescents (Mindfulness voor jongeren) program was developed by the Institute for Attention and Mindfulness in Belgium (Dewulf, 2013) and tailored for teenagers. Spanning 8 weeks, each session lasted 100  min and

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incorporated mindfulness exercises and psychoeducation, with homework assignments requiring 15 min of practice. An RCT involving 408 secondary school students (years 3 to 6, mean age of 14) were randomly assigned to a mindfulness program or a control group. The study showed a significant reduction in depression from baseline to postgroup and at the 6-month follow-up (Raes et al., 2014). A follow-­up study reported comparable results in another RCT with 553 students and found no moderation effects of gender, age, or school track, suggesting that SMBP could be upscaled up (van der Gucht et al., 2017). In Australia, a study investigated an adapted eight-week MBP by Dewulf (2013) to a 75 min per class version but failed to replicate the positive outcomes. The RCT involved 434 students aged between 13 and 15 (Johnson & Wade, 2021). For younger students, no differences were found post-intervention between the mindfulness and control groups. However, at the 3-month follow-up, slight deteriorations in well-being and in two aspects of mindfulness (awareness of the external environment, decentering, and nonreactivity) were observed. This raised questions regarding the appropriateness of formal meditation for teenagers. Studies on the effects of SMBPs on younger children are less frequent. A recent study focused on children in kindergarten to grade 2 (Sciutto et al., 2021). The curriculum in this study integrated Mindful Schools and MindUP, with a focus on mindfulness of change and kindness for the development of prosocial behavior. Conducted over 8 weeks with 16 sessions, the study involved 136 children, 94% of whom were receiving free or reduced lunch, and 90% identified as either Hispanic or African American. Significant improvements were found in teacher ratings of externalizing and prosocial behaviors. Outcomes were not associated with child sex or race/ethnicity. School-aged children benefited more in externalizing problems than preschoolers in kindergarten. However, the study had two major limitations: the lack of a control group and reliance on a single, external instructor across all classrooms. In Brazil, an indigenous SMBP initiative integrated mindfulness with a social– emotional learning program for 132 grade 5 students from three public schools (Waldemar et  al., 2016). Students who received up to 12 sessions of MBP for 5 months were compared with a waitlist control group. Compared with the control group, children showed significant improvements in most self-reported measures of emotional, conduct, relationship, prosocial behavior, and quality of life, except attention-deficit and hyperactivity symptoms, which were administered by teachers, at post-intervention. These results suggest the potential psychological contribution of an MBP in developing countries with limited resources for large-scale SMBP implementation. However, it should be highlighted that the SMBP study was delivered in small groups rather than in regular classrooms. The study’s main limitations were that all positive outcomes were based on self-reported ratings and that there was a lack of data on children’s home practice and program satisfaction, making it impossible to attribute the outcome to mindfulness training specifically.

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 ajor Findings of Recent Systematic Reviews M and Meta-­analyses on School-Based Mindfulness Curriculum The development of the SMBP curriculum and a decade’s investigation on the effects of the SMBP have led to various findings in recent systematic reviews, and meta-analyses are discussed (Dunning et al., 2022; Feuerborn & Gueldner, 2019; Phan et al., 2022; Tudor et al., 2022). Because of the variations in research questions and different inclusion criteria, these reviews’ findings and recommendations differ significantly and warrant careful attention. Many SMBPs use the framework of social and emotional learning (SEL) as their basis for development, implementation, and evaluation (CASEL, 2015). Feuerborn and Gueldner (2019) developed a core research question in their exploratory study: To what extent have the five SEL competency areas been reflected in the SMBP? Interestingly, they found that the five competency areas of SEL received varied attention and were unevenly represented in the measures selected in SMBP studies. Based on their coding and the 40 selected studies, 128 measures were classified into self-management, 29 into self-awareness, and 12 into relationship skills. Only six and three of the included studies investigated the effects on responsible decision-­ making and social awareness, respectively. In addition, the number of studies with significant findings varied among the five competency areas. Based on their results, 67% of the studies (n = 3) reported significant improvement in responsible decision-­ making, 62% (n = 24) showed positive results in self-management, and 50% (n = 1) indicated positive changes in social awareness. Only 40% of the studies (n  =  6) reported improvements in relationship skills, and 33% (n = 6) reported improvements in self-awareness. The focus on self-management competency likely reflects the concern of most MBP researchers with emotional and behavioral symptoms and problems, rather than strengths and assets. Feuerborn and Gueldner (2019) also observed that studies evaluating SMBP often use similar outcome measures as those studies used in non-SMBP studies. This raises questions about whether SMBP and SEL are similar constructs. In particular, although it is suggested that mindfulness can bring positive changes to all these child developmental domains, the primary intentions of MBP are to promote self-awareness and self-management. The application of MBP to other areas is less straightforward, especially when SMBP is time-limited. Phan et  al. (2022) conducted a comprehensive approach that included various study designs such as RCTs, quasi-experimental designs with or without a control group, case series, case studies, and A-B-A designs. Seventy studies were included with a total sample of 12,358 students across five continents. The findings of these studies were categorized into 11 domains and were graded by their quality, ranging from grade A (highest quality) to grade D (lowest quality): 1. Well-Being: Among the 12 selected studies that targeted well-being as an outcome, 50% reported improvements, 42% showed no difference, and 8% showed deterioration. Four grade A studies showed improvements and four grade A studies showed no difference, making the outcome in this domain inconclusive.

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2. Self-Compassion and Self-Concept: Only five selected studies included self-­ compassion/self-concept as an outcome. None of them received was scored as having grade A. 3. Social Functioning: Fifteen studies selected social functioning as their program outcome. Most studies (86%) reported positive improvements in social functioning, social participation, and reduction in social bias. However, only two studies were grade A. 4. Mental Health: Nineteen studies included mental health outcomes. Promising results were found in this category, with 71% reporting a reduction in depressive symptoms and 80% of them reporting a reduction in anxiety symptoms. However, none of these were grade A studies. All four grade A studies reported no change in depressive symptoms. Five grade A studies reported a reduction in anxiety, worry, psychosomatic complaints, or internalizing problems. Studies reporting outcomes in suicidality, trauma, and eating disorders were classified as grade B or C only. 5. Self-Regulation and Emotionality: Thirty-one studies selected self-regulation and emotionality as outcomes. Most studies (97%) reported improvements in this domain, including five grade A studies reporting positive changes in executive functioning. Two studies indicated improvements in positive mood but received grade B only. 6. Mindful Awareness: All 11 studies that included mindful awareness as their outcomes reported improvements in perspective-taking or a positive outlook. Among them, 73% showed an improvement in mindfulness, including five grade A studies. 7. Attentional Focus: Twenty studies selected attentional focus as their outcome. Most studies showed improvements in attention and reduced impulsivity, including 12 grade A studies. 8. Psychological and Physiological Stress: Fifteen studies included outcomes related to psychological or physiological stress. Most studies (73%) showed an improvement in stress, but none was classified as a grade A study. 9. Problem Behaviors: All nine studies that included problem behaviors as their study outcomes reported a reduction in problem behaviors, including four grade A studies. 10. Academic Performance: Sixteen studies included outcome measures for academic performance. Most studies (94%) reported improvements in this domain, but none of them were classified as grade A, indicating uncertain effects on academic performance. 11. Acceptability: Only four studies reported acceptability as their outcomes, and none of them was classified as a grade A or B study. Phan et al. (2022) provided valuable insights into the benefits and limitations of MBPs. The areas showing the most evidence of positive impact from MBPs include attention focus, mindful awareness, and self-regulation. There is also some support for MBPs reducing anxiety, internalizing problems, and problem behaviors, but the evidence is less robust. Two important issues are identified from these findings:

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Firstly, many of the included studies had small sample sizes, often less than 50 students (Phan et  al., 2022). This raises concerns about the transferability of these findings to other cultural contexts. Secondly, there was a regional bias in the studies, with over half (51.9%) based on student samples in the United States. Only two studies were from Asia, and both had small sample sizes (the one in China had 20 students and the one in Vietnam had only 10 students). There was only one from South America (n = 132), and there was a lack of study from Africa (Phan et al., 2022). Studies on school-based mindfulness training outside North America and Europe are warranted. It is uncertain whether programs developed in developed countries can transfer to other corners of the world without culturally appropriate adaptation. Dunning et  al. (2022) conducted a systematic review and meta-analysis of 66 RCTs, involving 20,138 children and adolescents below 18 years of age. Compared with passive controls, MBPs were found to be effective in improving anxiety or stress, attention, executive functioning, and negative and social behavior, with small effect sizes of d from 0.12 to 0.35, but not in depression. However, when compared with active controls, MBPs were only found to be more effective in reducing anxiety/stress and improving mindfulness, with small effect sizes of d = 0.11 and 0.24, respectively, but not in attention, depression, executive functioning, and negative behavior. In studies with a follow-up, there were no significant positive effects of MBPs. It suggested the role of SMBP in supporting youth mental health and preventing them from developing mental disorders is uncertain. In addition, the study conducted a subgroup analysis and an analysis for universal prevention (n = 18). Compared with controls, SMBPs were more effective in reducing negative behavior and social behavior (d = 0.31 and 0.20, respectively) and improving attention and executive functioning (d = 0.16 and 0.19, respectively) but not in reducing anxiety/stress, depression, mindfulness, or well-being. Most moderator analyses did not show a consistent pattern of results, except that risk-of-bias moderated outcomes in several areas, with studies that had a lower risk of bias showing smaller effects. The review found evidence of publication bias in studies involving passive controls or when MBPs were evaluated as universal interventions. The bias was positively skewed, suggesting an overestimation of the effects of MBPs in the published literature. Overall, the role of SMBP in supporting youth mental health and preventing them from developing mental disorders is uncertain, as the effect sizes in reducing anxiety and depressive symptoms are relatively small and very close to insignificant. The scoping review by Tudor et al. (2022) included 31 studies and focused on evaluating SMBP as a universal prevention integrated into the school curriculum. In addition to the outcomes, this review explores moderators, mediators, and implementation factors. The review identified several potential moderators of SMBT on student outcomes, including gender, age, baseline mental health status, and school type, with mixed findings. For the discussion of age and gender effects, please refer to the discussion in Chap. 2. Four studies identified baseline mental health status as a potential moderator, but only one study reported a significant moderating effect.

The Findings of the MYRIAD Project and Its Impact

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Five studies studied the mediating effect on student outcomes. The individual studies reported that improvements in mindfulness skills, cognitive reactivity, or self-criticism were related to better student outcomes at follow-up. However, due to limitations in study design, particularly the simultaneous measurement of mediators and outcomes, these studies were not sufficient to draw firm conclusions. For a robust assessment of mediation, three time points are needed as mediators must temporally precede outcomes rather than be measured at the same time. The review also analyzed implementation factors, which are discussed in Chap. 9.

The Findings of the MYRIAD Project and Its Impact The My Resilience in Adolescence (MYRIAD) project, which evaluated the effectiveness of the .b program, represents one of the largest scales of MBP RCT to date. The study involved 8376 students aged 11–14 years from 85 schools in the United Kingdom. Students were randomly allocated to intervention or control groups. The study revealed no evidence of a difference in any of the measured outcomes between the intervention and control groups at the 1-year follow-up. These outcomes included depression, social–emotional behavioral functioning, psychological well-­ being, executive functioning, anxiety, self-harm and suicidal ideation, and mindfulness skills. Interestingly, students in the intervention arm reported higher levels of hyperactivity/inattention, panic and obsessive–compulsive scores, and lower levels of mindfulness skills, than those in the control group. This result suggests that students who completed the MBP performed marginally worse than those in the control arm (Kuyken et al., 2022). A moderation analysis further revealed that students with a high risk of mental health problems who received MBP reported significant detrimental effects on depression and well-being, compared with those in the control group (Montero-­ Marin et  al., 2022). Based on such evidence, the research team concluded that SMBP is not recommended as a universal intervention. The results indicated that MBP may be contraindicated for students with existing mental health symptoms, although the project was implemented with good fidelity and dosage. The study also included measures of participant responsiveness and satisfaction. Students were asked to rate their level of acceptability of the program, which received a mean score of 4.7. However, the engagement scores, measured on a scale from 0 (never) to 5 (almost every day), were only 1.16 at post-intervention and 0.83 at the 1-year follow-up. These low scores suggest that the students were not highly engaged in mindfulness home practice. The program received a mean score of 4.7 out of 10 (Kuyken et al., 2022). Using a score from 0 (never) to 5 (almost every day) to measure the frequency of mindfulness home practice, students’ engagement was only 1.16 at post-intervention and 0.83 at the 1-year follow-up (Kuyken et al., 2022). These low scores suggest that the students were not highly engaged in mindfulness sessions and home practice.

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The publication of the MYRIAD project results has sparked significant debate in the field. The study’s findings have challenged the view that SMBPs can serve as effective universal prevention programs, particularly for young adolescents. This has led to calls for alternative strategies to address mental health issues in this age group (Cuijpers, 2022; MacPherson & Rockman, 2023). However, instead of viewing the MYRIAD project’s findings as evidence of SMBP’s ineffectiveness, several leading researchers have questioned the assumptions underpinning SMBPs as universal prevention strategies. They have also explored the possibility that students may still benefit from these existing MBP protocols. Several critical directions have been suggested for improving our understanding of SMBPs: Firstly, the design and implementation of SMBPs should be grounded in developmental science. Existing SMBPs often follow the structure and approach of adult MBPs, assuming that children and adolescents can learn and benefit from mindfulness practice in similar ways. However, leading researchers such as Jennings (2023a) and Roeser et al. (2023) argue that the principles of developmental science and milestones should be incorporated into SMBP design and research. Researchers should consider the developmental trajectories of common mental health disorders to identify optimal periods and mechanisms for intervention. This approach would involve tailoring the timing and content of SMBPs to align with these developmental stages (McLaughlin & King, 2015). Second, it is important to develop innovative approaches for teaching mindfulness to children and adolescents in order to enhance their satisfaction and engagement. Mindfulness practices in educational and cultural settings may naturally evolve, with pedagogical and organizational variations (Roeser et al., 2023). Collaborative efforts among educators, mindfulness researchers, and stakeholders can explore creative modalities that appeal to children and adolescents, encouraging them to learn and practice mindfulness through coproduction strategies (MYRIAD, 2022). Third, previous studies have predominantly adopted a clinical research model to examine the outcomes of MBPs. These studies typically focus on the assessment of individual student outcomes and assume that participants can benefit from direct, mechanistic, and linear interventions following a standardized program. However, this clinical model, derived from RCTs conducted in clinical settings to test the effects of pharmacological or psychological interventions, may not be applicable to school contexts. Students in school environments are considerably more complex, interconnected, and constantly changing. The impact of mindfulness extends beyond the practice and learning that occur during MBP sessions. It should be integrated into the broader school system, involving all students, teachers, and the overall school climate (MacPherson & Rockman, 2023; Roeser et  al., 2023; Weare, 2023a). The relationship between mindfulness in school and education will be further discussed in detail in Chap. 8. Lastly, the findings of the MYRIAD project raise questions regarding previous positive outcomes, suggesting that replicating such positive effects in other contexts cannot be guaranteed. Further studies should enhance their methodological rigor, provide detailed reports on program contents, and consider implementation factors in the delivery of MBP (Felver et al., 2023; Roeser et al., 2023).

Implications for Research

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Implications for Research Based on several large-scale studies and the findings of the MYRIAD project (Kuyken et  al., 2022), as well as subsequent reviews and editorials, research on SMBP has entered a new stage. It is important to approach the early studies’ positive findings in SMBP as universal prevention with caution, as these positive outcomes have small effect sizes and may not necessarily translate to large-scale studies or different contexts. Therefore, researchers should now go beyond investigating overall program outcomes and focus on more advanced questions, such as exploring diverse outcomes in different contexts and individual differences in program effects. Furthermore, it is essential to adopt a relational and contextual framework that recognizes the interactions between the school environment and implementation factors, as these have been identified as crucial factors affecting the outcomes of SMBP among students. In addition, there are several important research questions that need to be addressed in the field of SMBP. These include: 1. How can changes in mindfulness and awareness among children and adolescents, particularly those related to their engagement in SMBP, be effectively measured? 2. What strategies can be employed to motivate children of different age groups to learn and practice mindfulness? 3. How can teachers and external instructors collaborate to deliver high-­ quality SMBP? 4. Can SMBP delivered in classroom formats benefit elementary school-aged children and preschoolers? 5. Are there alternative formats of MBP in schools, beyond universal prevention, that may be more beneficial for students? For example, self-voluntary programs, small group programs, selective or indicated prevention programs, or gender-­ segregated programs? 6. How can stakeholders promote implementation factors and facilitate the high-­ quality implementation of SMBP? 7. To what extent can SMBP be effectively implemented across different cultural contexts, not only in North America, Europe, and Australia, but also in other cultural contexts where there are limited studies on SMBP?

Implications for Practice The use of SMBP to promote mindfulness and child mental health may seem appealing, but recent large-scale studies and the findings of the MYRIAD project serve as a reminder that assumptions about its effectiveness should not be taken for granted. In this chapter, it can be concluded that the evidence base supporting SMBP as

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universal prevention program is mixed and not robust. Implementing SMBP in the whole school requires dedicated teachers and supporting staff who have received proper training and have access to necessary resources for program delivery. Successful implementation of SMBP relied on alignment with school contexts and the presence of various implementation factors (a detailed discussion of these factors is covered in Chap. 9). Without these supportive conditions, students may derive limited benefits from SMBP and mindfulness learning. Attention should be given to the outcomes of students who already have preexisting mental health symptoms, as indicated by the MYRIAD project and other studies. These findings suggest that early adolescence may not be an ideal time for learning mindfulness without adequate attention and high-quality guidance from instructors. Delivering SMBP in classrooms may further pose risks, as limited clinical attention can be provided to each adolescent participant in such a format. Mindfulness practitioners should carefully consider the appropriateness of delivering SMBP in classrooms for this age group. Educators who are enthusiastic about implementing SMBP in different cultural contexts and age groups of children should prioritize the use of research to generate more evidence and knowledge, particularly regarding the inclusion of data collection relating to implementation factors. Practitioners with experience working with adolescents can explore creative and innovative approaches to teaching mindfulness skills to children and adolescents, employing coproduction strategies in program development to enhance program satisfaction and engagement. This is particularly important in fostering participants’ interest in regular mindfulness practice. Lastly, it is crucial for education stakeholders to approach the promotion of social–emotional development in children with humility and acknowledge that there is no universal formula. Mindfulness may not provide the answer for every situation and circumstance.

 ppendix: Useful Websites for School-Based A Mindfulness Projects Learning to BREATHE https://learning2breathe.org/ Mindful Schools https://www.mindfulschools.org/ MindUP https://mindup.org/ Mindfulness in Schools Project (.b and Paws b curriculum) https://mindfulnessinschools.org/ Mindful Teens (Mindfulness voor jongeren). https://aandacht.be/mindfulness/teens/ (available in Dutch only). MY Resilience In ADolescent (MYRIAD) Project https://myriadproject.org/

References

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Johnson, C., Burke, C., Brinkman, S., & Wade, T. (2016). Effectiveness of a school-based mindfulness program for transdiagnostic prevention in young adolescents. Behaviour Research and Therapy, 81, 1–11. Kuyken, W., Weare, K., Ukoumunne, O.  C., Vicary, R., Motton, N., Burnett, R., Cullen, C., Hennelly, S., & Huppert, F. (2013). Effectiveness of the mindfulness in schools project: Non-­ randomized controlled feasibility study. British Journal of Psychiatry, 203, 126–131. Kuyken, W., Ball, S., Crane, C., Ganguli, P., Jones, B., Montero-Marin, J., et  al. (2022). Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-­ being in adolescence: The MYRIAD cluster randomised controlled trial. Evidence-Based Mental Health, 25(3), 99–109. https://doi.org/10.1136/ebmental-­2021-­300396 Liehr, P., & Diaz, N. (2010). A pilot study examining the effect of mindfulness on depression and anxiety for minority children. Archives of Psychiatric Nursing, 24(1), 69–71. https://doi. org/10.1016/j.apnu.2009.10.001 MacPherson, S., & Rockman, P. (2023). PreK-12 education. In Mindfulness-based teaching and learning: Preparing mindfulness specialists in education and clinical care (pp.  99–127). Taylor & Francis. Matsuba, M. K., & Williams, L. (2020). Mindfulness and yoga self-care workshop for Northern Ugandan teachers: A pilot study. School Psychology International, 41(4), 351–367. McLaughlin, K. A., & King, K. (2015). Developmental trajectories of anxiety and depression in early adolescence. Journal of Abnormal Child Psychology, 43, 311–323. Metz, S. M., Frank, J. L., Reibel, D., Cantrell, T., Sanders, R., & Broderick, P. C. (2013). The effectiveness of the learning to BREATHE program on adolescent emotion regulation. Research in Human Development, 10(3), 252–272. https://doi.org/10.1080/15427609.2013.818488 Mohoney, J. L., & Weissberg, R. P. (2019). What is systemic social and emotional learning and why does it matter? The Blue Dot, 10, 16–24. Montero-Marin, J., Allwood, M., Ball, S., Crane, C., De Wilde, K., Hinze, V., et  al. (2022). School-based mindfulness training in early adolescence: What works, for whom and how in the MYRIAD trial? Evidence-Based Mental Health, 25(3), 117–124. https://doi.org/10.1136/ ebmental-­2022-­300439 MYRIAD. (2022). Call to action, where next? https://myriadproject.org/what-­we-­did/call-­to-­ action-­where-­to-­next/. Accessed 28 Aug 2023. Phan, M. L., Renshaw, T. L., Caramanico, J., Greeson, J. M., MacKenzie, E., Atkinson-Diaz, Z., et al. (2022). Mindfulness-based school: A systematic review of outcome evidence quality by study design. Mindfulness, 13, 1591–1613. https://doi.org/10.1007/s12671-­022-­01885-­9 Raes, F., Griffith, J. W., van der Gucht, K., & Williams, J. M. G. (2014). School-based prevention and reduction of depression in adolescents: A cluster-randomized controlled trial of a mindfulness group program. Mindfulness, 5, 477–486. Roeser, R. W., Schussler, D., Baelen, R. N., & Galla, B. M. (2023a). Mindfulness for students in pre-K to secondary school settings: Current findings. Future Directions. Mindfulness, 14(2), 233–238. Sanger, K. L., & Dorjee, D. (2016). Mindfulness training with adolescents enhances metacognition and the inhibition of irrelevant stimuli: Evidence from event-related brain potentials. Trends in Neuroscience and Education, 5(1), 1–11. Schonert-Reichl, K. A., & Lawlor, M. S. (2010). The effects of a mindfulness-based education program on pre- and early adolescents’ well-being and social and emotional competence. Mindfulness, 1(3), 137–151. Schonert-Reichl, K. A., Oberle, E., Lawlor, M. S., Abbott, D., Thomson, K., Oberlander, T. F., & Diamond, A. (2015). Enhancing cognitive and social-emotional development through a simple-­ to-­administer mindfulness-based school program for elementary school children: A randomized controlled trial. Developmental Psychology, 51(1), 52.

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Schonert-Reichl, K. A. (2023). Encouraging advances in the science on mindfulness and compassion in schools: Current research, lingering questions, and future directions. Mindfulness, 14(2), 300–306. Sciutto, M. J., Veres, D. A., Marinstein, T. L., Bailey, B. F., & Cehelyk, S. K. (2021). Effects of a school-based mindfulness program for young children. Journal of Child and Family Studies, 30(6), 1516–1527. https://doi.org/10.1007/s10826-­021-­01955-­x Shomaker, L. B., Bruggink, S., Pivarunas, B., Skoranski, A., Foss, J., Chaffin, E., et al. (2017). Pilot randomized controlled trial of a mindfulness-based group intervention in adolescent girls at risk for type 2 diabetes with depressive symptoms. Complementary Therapies in Medicine, 32, 66–74. Shomaker, L. B., Berman, Z., Burke, M., Annameier, S. K., Pivarunas, B., Sanchez, N., et al. (2019). Mindfulness-based group intervention in adolescents at-risk for excess weight gain: A randomized controlled pilot study. Appetite, 140, 213–222. Thierry, K.  L., Vincent, R., Bryant, H., Kider, M.  B., & Wise, C.  L. (2018). A self-oriented mindfulness-­ based curriculum improves prekindergarten students’ executive functions. Mindfulness, 9, 1443–1456. Thomas, G., & Atkinson, C. (2016). Measuring the effectiveness of a mindfulness-based intervention for children’s attentional functioning. Educational and Child Psychology, 33(1), 51–64. Tudor, K., Maloney, S., Raja, A., Baer, R., Blakemore, S. J., Byford, S., et al. (2022). Universal mindfulness training in schools for adolescents: A scoping review and conceptual model of moderators, mediators, and implementation factors. Prevention Science, 1–20, 934. https://doi. org/10.1007/s11121-­022-­01361-­9 Van der Gucht, K. V., Takano, K., Kuppens, P., & Raes, F. (2017). Potential moderators of the effects of a school-based mindfulness program on symptoms of depression in adolescents. Mindfulness, 8, 797–806. https://doi.org/10.1007/s12671-­016-­0658-­x Vickery, C. E., & Dorjee, D. (2016). Mindfulness training in primary schools decreases negative affect and increases meta-cognition in children. Frontiers in Psychology, 6, 2025. Viglas, M., & Lerlman, M. (2018). Effects of a mindfulness-based program on young children’s self-regulation, prosocial behavior and hyperactivity. Journal of Child and Family Studies, 27, 1150–1161. Volanen, S.-M., Lassander, M., Hankonen, N., Santalahti, P., Hintsanen, M., Simonsen, N., Raevuori, A., Mullola, S., Vahlberg, T., But, A., & Suominen, S. (2020). Healthy learning mind  – Effectiveness of a mindfulness program on mental health compared to a relaxation program and teaching as usual in schools: A cluster-randomised controlled trial. Journal of Affective Disorders, 260(1), 660–669. Waldemar, J. O. C., Rigatti, R., Menezes, C. B., Guimaraes, G., Falceto, O., & Heldt, E. (2016). Impact of a combined mindfulness and social-emotional learning program on fifth graders in a Brazilian public school setting. Psychology & Neuroscience, 9(1), 79. https://doi.org/10.1037/ pne0000044 Weare, K. (2023a). Where have we been and where are we going with mindfulness in schools? Mindfulness, 14(2), 293–299.

Chapter 5

Mindfulness-Based Programs for Children with Developmental Challenges

In addition to MBPs implemented in schools, there is a growing interest in applying MBPs for children facing various developmental, mental health, and psychosocial challenges. This chapter specifically focuses on the application of MBPs for children with developmental disabilities, including attention-deficit/hyperactivity (ADHD), autism spectrum disorder (ASD), and intellectual disabilities (ID). These children often face common challenges such as comorbidity and other physical limitations. For instance, a population survey conducted in the United States in 2014 revealed that 56.5% also have learning disabilities, and 61.7% experienced one or more physical impairments, such as visual or hearing difficulties or requiring assistance with personal care (Zablotsky et al., 2015). Such chronic conditions pose challenges for children and their parents, who seek innovative psychosocial support to manage symptoms related to the disorder and enhance overall well-being.

Attention-Deficit/Hyperactivity Disorder (ADHD) Attention-deficit/hyperactivity disorder (ADHD) is among the most prevalent developmental disorders. Based on the review by Polanczyk et al. (2014), which examined 154 studies utilizing diagnostic criteria from the DSM or ICD for individuals aged 18 or under, the global community prevalence of ADHD is approximately 5%. Variation in estimated prevalence can be attributed to methodological differences across studies. However, when similar methodologies were employed, no significant variation was observed among different geographical locations. According to parent reports, the prevalence of ADHD ranges from 8% to 12% worldwide (Danielson et al., 2018). The primary symptoms of ADHD include inattention, hyperactivity, and impulsivity, which can significantly impact social and academic functioning. Children with ADHD often experience impairments in executive functions (EFs) and encounter difficulties in social relationships, such as peer © The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_5

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rejection (Barkley, 2014; Hoza, 2007). The estimated disability-adjusted life years for ADHD peak between the ages of 10 and 14, with higher rates reported among males (Erskine et al., 2010). Furthermore, children with ADHD are often reported to engage in physical aggression more frequently than their counterpart children without ADHD (Mcquade et al., 2017). Pharmacotherapy, specifically psychostimulant medication, is the primary treatment for children with ADHD. Over 70% of the children with ADHD show improvements in behavior compliance and attention maintenance following psychostimulant treatment (Kollins, 2008; Storebø et al., 2016). However, some children may experience side effects such as decreased appetite, sleep problems, and negative mood (Cascade et al., 2010). Although there have been indications of a slight decline in the use of methylphenidate in recent years (Piper et  al., 2018), many children in Western societies continue to be prescribed ADHD medication. For example, 4.3% of Dutch children (Association of Pharmaceutical Statistics, 2016, cited in Bruin et al., 2021) and over 9% of children in certain regions of the United States (Visser et al., 2014) still rely on pharmacotherapy. Parental behavioral interventions, including antecedent-based strategies, contingency management techniques, and self-­ management skills, have been found to be effective in enhancing motivation and reducing disruptive behaviors of children with AD/HD (Hodgson et  al., 2014). However, the application of these techniques in parental behavioral training programs can be complicated by high levels of parental stress and associated symptoms and reactions (Singh et al., 2010). While behavioral training may yield short-term benefits, its long-term effects remain uncertain, as children with ADHD struggle to learn self-regulation without ongoing parental supervision (Zwi et  al., 2011). Therefore, it is crucial to explore innovative psychological interventions that can relieve the challenges faced by these children and their parents. Mindfulness exercises can provide children with ADHD the training they need to enhance focused attention and bring their attention back when they become distracted. Through regular practice, children can develop the ability to sustain their attention, respond mindfully to thoughts and feelings, and avoid impulsive reactions. Some children with ADHD also struggle with emotion regulation, potentially due to a thinner anterior cingulate cortex in the frontal lobe (Bledsoe et al., 2013). Mindfulness training can help control impulsivity and improve emotion regulation by fostering kindness, compassion, and acceptance. By learning to pause and act mindfully, children can reduce ADHD symptoms. Several systematic reviews and meta-analyses have been conducted to examine the effectiveness of MBPs for children with ADHD (Cairncross & Miller, 2016; Lee et  al., 2022; Vekety et  al., 2021; Xue et  al., 2019). Cairncross and Miller (2016) conducted a meta-analysis of 10 studies on child MBPs, six of which reported a moderate average effect size for MBPs in addressing inattention, and five reported the effectiveness of MBPs on hyperactivity/impulsivity, with an average small-to-­ moderate average effect size for addressing hyperactivity/impulsivity. It is worth noting that three of the six studies were unpublished PhD theses, and the earliest published study included in the analysis was from 2012. The authors found larger effect sizes of MBPs in adults compared to children, but the number of adult studies

Attention-Deficit/Hyperactivity Disorder (ADHD)

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was limited. Xue (2019) conducted a review of 11 studies and found that MBPs had significant positive effects on inattention and hyperactivity/impulsivity compared to control conditions. It is important to note that nine of the selected studies focused on adults, with the remaining two studies including either parents of children with ADHD or both children and parents’ programs in the program (Lo et al., 2020). Vekety et al. (2021) conducted a review with a specific focus on children under 12  years old. However, it should be noted that this review included studies that examined attention, hyperactivity, and impulsivity as outcome measures, rather than exclusively focusing on children with ADHD. The review included 21 studies, and findings indicated that MBPs led to a significant decrease in inattention and hyperactivity symptoms, albeit with small effect sizes. These positive outcomes were primarily observed in teachers’ ratings but not in parents’ ratings or children’s self-­ reported ratings. The authors noted that the heterogeneous samples and the fact that behavioral changes in relatively healthy children may not be detected by parents could explain these differences. In a recent review by Lee et al. (2022), 10 RCTs were selected, and the findings showed a moderate effect size for ADHD symptoms and very small effect sizes for internalizing and externalizing behavior problems. This indicates that the evidence supporting the reduction in internalizing and externalizing behavioral problems in children with ADHD through MBPs is still limited. The meta-regression analyses conducted by Lee et al. also reveal that the effect on ADHD symptoms was more pronounced in older children compared with younger children. Although the review suggested that mindfulness has the potential to be a complementary therapy for children with ADHD, it is important to note that six of the selected studies had small sample sizes (n  >  = 30). Therefore, further studies with larger sample sizes are needed to replicate and confirm the effectiveness of MBPs across different cultures and contexts. Earlier studies in this area often had very small sample sizes. For example, Semple et al. (2010) conducted a small RCT with 25 children aged 9–13, where they adapted mindfulness-based cognitive therapy (MBCT) for children. The program aimed to enhance self-management of attention and improve affect regulation and lasted for 12 weeks. Although this study did not specifically target children with ADHD, five of the children met the threshold for clinically elevated attention problems and two met the criteria for ADHD. The results showed that children with ADHD had significantly fewer attention problems, and these improvements were maintained up to 3 months after the training. One commonly applied program for children with ADHD is called MYMind, which was developed for children with ADHD and ASD and their parents in the Netherlands. In an earlier pilot study of MYMind, 22 children aged 8–12 with ADHD and their parents participated. Based on parents’ ratings, the children showed significant reductions in ADHD symptoms, as well as parents’ inattention and hyperactivity symptoms when compared to families in the waitlist control group (van der Oord et  al., 2011). Parental stress and overreactivity also improved, although teacher ratings did not show significant changes.

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In another study of MYMind involving 10 adolescents aged 11–15 with ADHD and both of their parents, improvements in attention and behavioral problems were reported by the adolescents, parents, and tutors (van de Weijer-Bergsma et  al., 2012). Objective computerized tests of attention also showed significant improvement. Fathers reported reduced parenting stress. Mothers reported reduced overreactive parenting, but fathers reported an increase in this outcome. The effects of MBP became stronger at the 8-week follow-up but diminished at the 16-week follow-up. A study evaluated 18 adolescents aged 13–18 with ADHD and their parents found reductions in adolescents’ inattention, conduct problems, and peer relationship problems according to parents’ ratings after participating in MYMind (Haydicky et al., 2015). However, adolescents’ self-ratings did not show significant improvements, except for a reduction in internalizing problems at the 6-week follow-­up. Parents’ ratings of improvements in adolescent symptomatology, mindful parenting, and parenting stress were maintained at the 6-week follow-up. It is important to note that two of these pilot studies did not have a control group for comparison, and none of these studies included young children under the age of 7. In recent years, several large-scale trials have been conducted to evaluate the outcomes of the MYMind program. In an RCT by Siebelink et al. (2022), 103 children and adolescents aged 8–16 with ADHD were randomly assigned to standard care plus MYMind or standard care alone. The mindfulness group showed a small nonsignificant improvement in the self-control deficits posttreatment, and a higher percentage of children in the mindfulness group showed reliable posttreatment improvement compared to the standard care group (32% versus 11%). Parents’ and teachers’ ratings of ADHD symptoms significantly decreased at the posttest, but only parents’ ratings of hyperactivity and impulsivity symptoms remained significant at the 6-month follow-up. Significant effects were found on mindful parenting and self-compassion at follow-ups. However, between-group differences in all outcomes were nonsignificant at the posttest and follow-ups. Bogels et al. (2021) conducted a study on the long-term effects of the MYMind program for children with ADHD. Using a quasi-experimental waitlist design, 167 children aged 7–19 with diagnoses of ADHD and their parents participated in the program. The findings indicated a medium-to-large effect-sized reduction in child ADHD symptoms from pre- and posttest, with further improvement at follow-ups. No significant effects were found during the waitlist period. Parents above the ADHD threshold also showed improvement in their ADHD symptoms. Improvements were observed in children’s and parents’ other psychopathologies, child executive function, and parental overreactivity, while parental stress improved only at the 1-year follow-up. In the mediation analysis, fathers above the ADHD threshold showed greater improvement compared to fathers below the threshold at the posttest and the 8-week follow-up. In addition, a decrease in paternal ADHD symptoms mediated child outcomes. Another RCT compared the effects of the MYMind program with an 8-week methylphenidate treatment (Meppelink et al., 2016) in a sample of 91 children aged 8–18 with ADHD and their parents. The primary outcomes of this trial are ADHD

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symptoms, as rated by parents, children, teachers, and independent observers. Additional outcome measures include child functioning, parent functioning, and underlying mechanisms of change. Due to ethical concerns, between the first and second follow-ups, families were free to choose another treatment, stop treatment, or transfer to the other intervention group. The study has been completed, and the publication on this outcome is in review. Apart from studies in the Netherlands, the MYMind program has been implemented in other countries. An outcome study in Spain included 30 children aged 9–14 years with ADHD and their parents (Valero et al., 2022). Participants were randomly assigned to the MBP group or a waitlist group. The results showed that children did not have significant improvements compared to the waitlist group. However, at the 6-month follow-up, significant improvements in children’s inattention symptoms, executive functions, learning problems, aggression, and peer relations were observed based on parents’ ratings, with small-to-large effect sizes. Parenting stress showed significant improvements in the posttest, but overreactivity was the only variable that showed a decrease at follow-up. In a small nonrandomized study conducted by Zhang et al. in Hong Kong, China (2017), the feasibility, acceptability, and effects of the MYmind program were examined in a Chinese sample of 11 children with ADHD and their parents. The program was found to be highly acceptable and feasible in a different cultural setting. The results showed a significant improvement in some objective attention subtests; however, there were no significant improvements in parent-rated child problems, parent-rated executive functioning of the children, and parents’ own stress, mindfulness, and parenting. Another large-scale RCT (n  =  138) was conducted in Hong Kong, China, by Chan et al. (2018) to compare the MYMind program with group cognitive-behavioral therapy. The results showed that both MYmind and CBT significantly improved children’s selective attention at 6-month follow-up with small effect sizes. There was no significant between-group difference at all time points. In addition, both groups significantly improved in behavioral problems and executive functioning at 6  months. Only MYMind significantly improved well-being in parents at 6-month follow-up, and no significant difference was found in the effects of MYmind and CBT on all secondary child or parent outcomes at all time points (Wong et al., 2023). It demonstrated that MBP has a comparable effect to cognitive-behavioral group therapy, which is an evidence-based approach in child psychotherapy. Some RCTs have explored the effects of a parallel program that combines MBPs for children with ADHD and their parents. Lo et al. (2020) focused on the effect of MBP on young children with ADHD in Hong Kong, China. The study integrated an 8-week Mindfulness Matters child MBP (Snel, 2014) with a brief 6-session MBP for parents (Lo et al., 2017). Each child session lasts for one hour and each parent session lasts for 1.5-hour. A total of 100 children aged 5–7 with ADHD symptoms and their parents participated, and they were randomly assigned to the mindfulness group or a waitlist control group. According to the parents’ ratings, children in the MBP group showed greater improvements compared to the waitlist group, with moderate effect sizes in inattention and hyperactivity. Small effect sizes were

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observed for child internalizing problems and externalizing problems based on parents’ ratings. Improvement in attention was also reflected in a small effect size of improvement in an additional objective behavioral measure, the Attention Network Test, specifically in the conflict monitoring score. The mediation analysis indicated that changes in ADHD symptoms mediated improvements in overall child behavior. Muratori et al. (2021) conducted a study in Italy involving 50 boys aged 8–12 with ADHD and ODD diagnoses. The children and parents were randomly assigned to either the MBP group or a waitlist control group. The MBP program lasted for 8 weeks, with 1.5-h sessions. Each child’s MBP group consisted of only five boys. The results showed moderate effect sizes of improvements in hyperactivity based on parent ratings and attention based on an objective behavioral test. However, there were no significant changes in mindfulness, aggression, or conduct measures. Most studies of MBPs for children with ADHD involved parents, but a few of them were exceptional. Huguet et al. (2019) conducted a study involving 72 children aged 7–12 and randomly assigned to either the MBP group or a control group that received standard treatment without pharmacological treatment. The MBP lasted for 8 weeks, with 75-min sessions. Each group consisted of six children, and parents were not involved in the MBP. The results showed significant improvements in behavioral dysregulation and emotional self-regulation in the children who received MBP compared to the control group. However, these positive changes were not observed in the children with combined inattention and hyperactivity/ impulsivity symptoms. This suggests that while MBP can be beneficial for children with ADHD, those with comorbidities may require more intensive or alternative forms of treatment. A recent small trial conducted in Italy by Zaccari et al. (2021) investigated the effects of MBP on sleep in children with ADHD. Thirty-two children aged 7–11 with ADHD were randomly assigned to either the MBP or an active control group that received an emotional awareness and recognition program. Both programs lasted for 8 weeks, with three sessions per week. The duration of the sessions gradually increased over time to 30 min. The MBP sessions included mindfulness exercises, short debriefing, and homework practice. The results showed that MBP had positive effects on sleep measures based on parent ratings, but no significant effects were found on objective sleep parameters measured by actigraphy. However, the MBP did report significant improvement in behavioral measures related to attention problems, restless-impulsive ratings, and overall behaviors. These improvements were not observed in the active control group. The study by Ramos et  al. (2022) explored the effects of combining MBP (MindUP program) with behavioral treatment (BT) in children with ADHD (Ramos et al., 2022). Children (n = 58) were randomly assigned to receive both MBP, the standard BT, or art classes. Mindfulness sessions occurred three to four times per week for 6 weeks. The results indicated that there were no incremental effects of mindfulness when used in combination with BT on observed child behavior, attention and inhibitory control, or mindful awareness. However, the study was not sufficiently powered to detect the effect of MBT as an adjunct to intensive BT, highlighting the need for further research in this area.

Autism Spectrum Disorder (ASD)

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The study by Singh et al. (2010) took an individual-based approach, delivering mindfulness training to two mother–child dyads with ADHD. Children in this study, in contrast to most of the other studies, were of below-average intellectual ability. The training consisted of 12 sessions of individual training for the mother, followed by 12 sessions of individual training for the child. The results showed improvements in child compliance, parent–child interaction, and happiness in parenting. These effects were maintained up to the six-month follow-up. Overall, ADHD has been extensively studied in the context of MBPs, primarily due to the potential relationship between mindfulness and focused attention. Review studies and meta-analyses have generally found MBPs to be promising in reducing the symptomology of ADHD. Recent studies have employed rigorous designs, including RCTs and active control groups, providing more realistic estimations of the effect size. Further research is still needed to fully understand the potential benefits and optimal implementation of MBIs for children with ADHD.

Autism Spectrum Disorder (ASD) Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects children and adolescents. Earlier studies reported a prevalence of 7.1 per 10,000, but in 2014, the estimated prevalence in the United States was 2.24% due to changes in diagnostic criteria. The main characteristics of ASD include significant impairments in social communication and restricted, repetitive behaviors (American Psychiatric Association, 2013). Comorbidities are common among individuals with ASD and pose serious challenges for children and adolescents. According to the 2014 National Survey in the United States, 62.6% of the children aged 3–17 with ASD also have learning disability, 42.8% have comorbid ADHD, 16.7% have intellectual disability, and 22.9% have other developmental delays. Additionally, these children often experience physical conditions such as epilepsy, gastrointestinal disorders, reflux, constipation, diarrhea, food allergies, colitis, ulcers, and inflammatory bowel disease. Many individuals with ASD, ranging from 20% to 50%, are nonverbal, making it difficult for them to communicate discomfort or report pain (Casanova et al., 2020). They may also have atypical sensory perception. These comorbidities present significant challenges for mental health and social care in this population. Children with ASD also exhibit externalizing and internalizing problems, attention problems, and deficits in executive functions (Bauminger et  al., 2010. They struggle with behavioral regulation, including controlling impulses, shifting attention, and regulating emotion. Metacognition skills such as problem-solving, working memory, planning, organizing, and self-monitoring are also impaired. In the 2014 U.S. survey, 75% of children with ASD were male (Zablotsky et al., 2015). Given the numerous difficulties faced by adolescents with ASD, there is a need for psychological interventions to improve their daily functioning and address comorbid emotional problems. MBPs have recently been identified as a potential

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treatment option. While mindfulness may not be suitable for all children with ASD, MBPs may benefit those with high-functioning autism, particularly when mindfulness training is offered to their parents and caregivers. A study by de Bruin et al. (2015) examined the effects of the MYmind program on 23 adolescents aged 11–23 with ASD. The study used an open trial design in which the participants rated their own quality of life and rumination. The results showed improvements in these areas post-intervention. Although there were no improvements in the core symptoms of ASD, there was an improvement in social responsiveness. It is important to note that this study had limitations, including a small size and the absence of a control group. Another study by Ridderinkhof et al. (2018) involved 45 adolescents with ASD aged 8–19 and their parents who participated in the MYMind program. The children self-rated their social communication problems and emotional and behavioral functioning, but no improvement was found in mindfulness. However, the positive outcomes remained significant at the 2-month follow-up and partly remained at the 1-year follow-up, as reported by the parents. These outcomes included improvements in internalizing and externalizing problems, attention, and social communication, which remained significant at the 2-month and 1-year follow-ups. Two other studies were conducted to evaluate the outcome of the MYMind program outside the Netherlands. Salem-Guirgis et  al. (2019) conducted a study in Canada involving 23 youth aged 12–23 with ASD and their parents. Parents reported a significant decrease in children’s behavioral symptoms after the MBP. However, the effect was not maintained at the 10-week follow-up. Significant increases in the children’s adaptive skills and parent mindfulness were observed at the posttest and the 10-week follow-up. Ho et al. (2021) conducted a feasibility study of the MYMind program in Hong Kong, China, involving 37 adolescents with ASD and their parents using a waitlist control design (Ho et  al., 2021). Both parents’ ratings of social competence and behavior problems showed significant improvements after the program. However, similar changes were observed in the waitlist control group, possibly due to the effects of standard care. The program had high satisfaction and attendance, but no between-group difference was found at posttreatment. Instead of using the traditional group-based approach in delivering an MBP, Hwang et al. (2015) conducted an outcome study of an MBP in Australia involving six dyads of children aged 8–15 with ASD and their mothers. The mothers participated in a program similar to MBSR consisting of a weekly 2.5-h session for 8 weeks, but there was a 4-week break between the last two sessions, allowing the mothers to practice independently as a transition from the end of the intervention to home practice. After the end of 8 weeks, the mothers delivered mindfulness training to their children with the support of the trainer through home visits and online meetings. Improvements were observed in the children’s overall behaviors and anxiety following MBP. Most MBPs for children with ASD offer parallel intervention to parents, but the following two studies are two exceptions. Shah et al. (2022) delivered the Soles of the Feet program to three 9- to 10-year-old children with ASD and challenging behaviors. After an 8-h training, the school mental health counselor implemented

Intellectual Disability (ID) and Specific Learning Difficulties (SLDs)

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SoF in five 20- to 30-min sessions on an individual basis. After the intervention, all three students showed a stable and decreasing trend of observed challenging behaviors. However, there was an increase in teachers’ perceptions of challenging behavior for two of the three students. Juliano et al. (2020) implemented the 16-session Mindful Schools curriculum in small groups of 9–12 children with ASD. A total of 29 students aged 11–16 with ASD were involved using a quasi-experimental, pretest–posttest comparison design. Significant improvements were found in medium effect sizes of prepotent response inhibition and interference control and a large effect size of selective attention. However, this study did not include other ASD symptomology, and there was no control group in this study. Further studies should include a more rigorous design, and more information should be included for replication, such as the number and training background of instructors involved in program delivery. The systematic review conducted by Hartley et al. (2019) included 10 independent studies involving a pooled sample of 233 children and adults and their caregivers in their meta-analysis. Based on their findings, children with ASD demonstrate fewer short-term benefits from MBPs compared to adult cohorts. However, the number of child participants in the three included studies was 74 only. Overall, the available research on MBIs for children with ASD shows mixed results, with some studies reporting positive outcomes in terms of behavioral improvements and adaptive skills. However, the effects may not always be sustained over time, and the lack of control groups and small sample sizes in some studies limits the generalizability of the findings. Further research with larger sample sizes and more rigorous study designs, including control groups, is needed to provide more robust evidence for the efficacy of MBIs in children and adolescents with ASD.

I ntellectual Disability (ID) and Specific Learning Difficulties (SLDs) Intellectual disability (ID) is a condition characterized by arrested or incomplete development of the mind, leading to impaired cognitive, language, motor, and social abilities. It is defined as a limitation in both intellectual functioning and adaptive behavior, which include conceptual skills, social skills, and practical skills (American Association on Intellectual and Developmental Disabilities, 2023). Learning disabilities, however, are neurological conditions that hinder an individual’s ability to store, process, or produce information (Learning Disabilities Association of America, 2023). Children with specific learning disabilities (SLDs) experience significant delays in reading, writing, and mathematics, which greatly affect their academic performance. They may also exhibit in memory, attention, psychomotor coordination, and emotional maturity, often leading to psychological distress, demoralization, and difficulties in social skill deficits. Approximately 4.8% of American students have been diagnosed with a learning disability.

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Globally, the prevalence of ID varies between 1% and 3% globally, as reported by Harris (2006). According to the National Center for Education Statistics in the United States, the prevalence of ID is 0.9, while SLDs have a prevalence of 4.8 (National Center for Education Statistics, 2023). Among individuals with ID, approximately 85% have mild ID, 10% have moderate ID, 4% have severe ID, and 2% have profound ID (King et al., 2009). Unfortunately, research on the application of mindfulness for individuals with ID is very limited, and most studies have focused on adult samples. Singh et al. (2013) conducted a small waitlist RCT, involving 34 individuals aged 17–31  years with mild ID. The participants were randomly assigned to either the Soles of the Feet (SoF) group or a waitlist control group (Singh et al., 2013). The SoF training lasted for 12 weeks. The results showed that verbal and physical aggression significantly decreased only in the SoF group. When the waitlist group received the SoF training, they also showed similar reductions in aggression. The frequency of physical aggression continued to decrease during the follow-up period. These findings suggest that MBP, specifically the SoF program, is effective for late adolescents and young adulthood with mild ID. However, more research is needed to determine the effectiveness in younger children. One study conducted by Beauchemin et  al. (2008) recruited 34 students with LDs from four school classes in a private residential school in the United States. The study aimed to evaluate the outcomes of a 5-week MBP for these students. The results, based on self and teacher ratings, indicated a significant reduction in trait anxiety, improved social skills, and enhanced academic performance. Unfortunately, the study did not provide specific details about the program structure or adaptations made for the students with LDs, making it impossible to replicate the study accurately. Another study by Malboeuf-Hurtubise et al. (2017, 2018) examined the effectiveness of an MBP in a sample of 14 school students aged 9–12 years with SLDs and borderline IQ. The program consisted of eight 1-h sessions and was adapted to the developmental level of the students. The results, analyzed using repeated measures analyses of variance, showed significant improvements in anxiety, depression, inattention, aggression, and conduct problems (Malboeuf-Hurtubise et al., 2017). However, the students reported significant reductions in competence, autonomy, and relatedness after the program (Malboeuf-Hurtubise et al., 2018). These findings suggest potential issues in the implementation and study of MBPs among children with ID and SLDs, including possible adverse effects, insufficient language adaptation for children with special needs, and the selection of appropriate outcome measures for this population. In summary, research on the efficacy of MBPs in children with ID and SLDs is scarce in the literature. It may be more practical and effective to provide training to parents or caregivers instead of solely focusing on the children with ID and SLDs alone. Practitioners and researchers should be mindful of the limitations and potential risks associated with delivering MBPs to this specific population. Chapters 9 and 10 discuss implementation and ethical issues in MBPs in more detail.

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Implications for Research The first published study of the effect of MBP on ADHD in a peer-reviewed journal was in 2013. Research on the application of MBPs in developmental challenges is relatively recent but has been accumulating evidence over the past decade. The growing attention to this area of interest is evident in the increasing number of systematic reviews and meta-analyses. Given the theoretical and empirical support for using MBPs in ADHD, it is considered a promising approach for treating ADHD. To strengthen the evidence in this area, further studies should focus on the following areas: 1. Conducted more RCTs on the outcomes of MBP with active control groups, including comparison with pharmacological treatment, CBT, and standard care. Currently, large-scale studies with sample sizes over 100 are only available in the Netherlands and Hong Kong, and it remains uncertain whether the positive outcomes can be replicated in other parts of the world. 2. Explore the effectiveness of MBPs involving children and adolescents with ADHD, without parallel MBPs for parents. Most studies with large sample sizes are parallel programs with MBPs for children and parents, except for one study that reported positive outcomes specifically for the inattention Further studies are needed to test the efficacy of directly targeting children and adolescents with ADHD. 3. Investigating the efficacy of MBPs for children with ADHD and comorbidity in hyperactivity or conduct disorder. In addition to traditional group-based formats, alternative delivery modes, such as parent–child dyads or online MBPs should be explored to ensure safety and ethical considerations. 4. Develop a booster version of MBPs considering the chronic nature of ADHD symptoms. Children who have responded positively to MBPs should have access to booster sessions to sustain the effects of the program. The effectiveness of low-intensity MBPs as boosters should be investigated and tested on how they can maintain the program’s impact over time. However, the evidence regarding the effectiveness of MBPs in ASD, ID, and SLDs is very limited. Previous studies have also highlighted limitations and challenges in delivering MBPs to these special needs populations. Cognitive ­ impairments and social responsiveness issues may restrict the benefits of mindfulness for children with these developmental challenges. Further research may explore innovative approaches to apply mindfulness within a family context and provide support to parents. Alternatively, the application of MBPs to parents and caregivers may be a more feasible approach in these populations, considering the potential limitations of delivering MBPs directly to children with ASD, ID, or SLDs alone.

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Implications for Practice Previous studies have demonstrated the promising effects of MBPs in reducing symptoms of inattention and hyperactivity in children with ADHD, as well as improving certain aspects of functioning in those with ASD, ID, and SLDs. However, it is important to note that MBPs should not replace standard treatments based on current knowledge and evidence. Additionally, it is worth mentioning that most MBPs designed for children with developmental disabilities also include parallel programs for parents and caregivers. Efforts should be made to improve the implementation of these programs, allowing more families to benefit from them. For instance, the current implementation mode may not be suitable for all families, particularly those with parents who work long or irregular hours, making it difficult for them to participate in face-to-face MBPs. Although implementing an online version of MBP may present challenges, preliminary results indicated its potential effectiveness. To enhance the accessibility of MBPs, it is crucial to provide innovative programs and alternative implementation options for children with developmental disabilities and their families. Another important consideration is the sustainability of the program’s effect on children with developmental disabilities. Unlike adults who can easily access support through single-session workshops, retreats, or many self-help materials, children often require specific resources to support their ongoing mindfulness practice. It is essential to provide after-program care for child clinical populations and evaluate their outcomes through research studies. Mental health professionals should also focus on developing support systems for parents, teachers, and caregivers, ensuring that children with ADHD receive the necessary assistance to maintain the benefits gained from an MBP. In exploring the implementation and sustainability of MBPs for children with developmental disabilities or special needs, it is important to acknowledge the differences among these children. For example, children with ADHD may require different guidance and practice to sustain their interest in mindfulness exercises, while children with ASD may find repetitive exercises more comfortable. Mindfulness training should be adaptable to meet the individual interests and preferences of each child, allowing for flexibility in program implementation (Hwang & Kearney, 2015). Additionally, innovative programs that involve collaboration with adolescents with special needs and their parents can be explored to maximize the benefits of these clinical populations (Boxs 5.1 and 5.2). Box 5.1 MYMind Founder: Prof. Susan M. Bogels (University of Amsterdam). The intervention includes eight weekly 90-min group sessions for children with ADHD and their respective parents. The intervention is delivered mainly in separate groups for parents and children concurrently, with joint exercises in Session 1 and Session 8, following the training manual. (continued)

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Themes and exercises for children 1 From Mars: Raisin exercise with parents Child session: Sensory awareness exercises; raisin exercise with chips; breathing meditation 2 My body: Breathing meditation, body awareness exercises, body scan, yoga exercises 3 My breath: Breathing meditation, body awareness exercises, body scan, yoga exercises 4 Distraction: Breathing meditation, body awareness exercises, body scan, yoga exercises

5

6

7

8

Themes and exercises for parents From Mars: Raisin exercise with parents Psychoeducation on ADHD, mindfulness, breathing meditation, doing homework for yourself, and helping a child with homework My body: Breathing meditation, body scan

My breath: Body scan, breathing space, breath and body awareness meditation Automatic responding: Breath and body awareness meditation, psychoeducation stress and automatic responding, exercise awareness of positive interaction with child, breathing space Automatic responding: Habits and automatic responding: Breathing space, awareness of automatic Breath and hearing meditation, responding exercises, body scan, yoga psychoeducation responding to stressful exercises situations with child and using breathing space in stressful situations Up to now: Communication with your child: Breathing meditation, repetition learned Breathing meditation, exercise breathing skills, breathing space in difficult situations, space in stressful situation with your body scan by one of the children, hearing child, body scan meditation with bell, yoga exercises Practice: Accepting your child: Breathing meditation, meditations and yoga Breathing meditation, exercise breathing with children as instructors, looking space in stressful situation with your meditation, body scan child On my own: On your own/letting go: With parents: Breathing meditation, body With children: Breathing meditation, scan, yoga and meditation with children as body scan, yoga and meditation with instructors, meditation schedule for next children as instructors, meditation 3 months, evaluation training schedule for next 3 months, evaluation training

For more detailed information about the content and training of the MYMind program, please contact Prof. Susan M. Bogels (email: s.m.bogels@ uva.nl).

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Box 5.2 Soles of the Feet Mindfulness of my Soles of the Feet is the method developed by Prof. Nirbhay N. Singh. It has been widely applied to children, adolescents, and adults for promoting self-control and self-control that would be applicable in managing aggression and impulsivity, ranging from clinical populations such as individuals with autism spectrum disorders, intellectual disability, conduct disorder, and others. Children and adults can practice applying the same procedure in remembering a past event, from a pleasant event to an unpleasant event that would evoke angry reactions, and to identify a trigger. The core Soles of the Feet procedure includes the following: 1. To begin, sitting up straight, placing your feet flat on the floor, allowing your eyes to close if this feels comfortable…. 2. Placing one hand on your belly and beginning to pay attention to your breath coming into and out of your belly… Noticing your breathing… Noticing your belly moving with your breath… Breathing low and slow into your belly…. 3. Now, quickly shift the focus of your attention to your feet…. 4. All of your attention is on your feet…. 5. Wiggling and noticing your toes…. 6. Putting attention on the ball of your feet…. 7. Focusing on the arches of your feet…. 8. Going to the heel of your feet…. 9. Putting your attention on the soles of your feet…. 10. Feeling the entire foot…. 11. Continuing to stay in your feet just by wiggling your toes and noticing your feet…. 12. Now, slowly opening your eyes and returning to your life…. For more detailed information about the content and training of the Soles of the Feet program, please contact Prof. Nirbhay N. Singh (email: nirbz52@ gmail.com).

References American Association on Intellectual and Developmental Disabilities. (2023). Defining criteria for intellectual disability. Available online http://www.aamr.org/content_100.cfm%3FnavID=21 American Psychiatric Association (Ed.). (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association. Barkley, R.  A. (2014). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. Guilford Press. Bauminger, N., Solomon, M., & Rogers, S. J. (2010). Externalizing and internalizing behaviours in ASD. Autism Research, 3(3), 101–112. https://doi.org/10.1002/aur.131

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Juliano, A. C., Alexander, A. O., DeLuca, J., & Genova, H. (2020). Feasibility of a school-based mindfulness program for improving inhibitory skills in children with autism spectrum disorder. Research in Developmental Disabilities, 101, 103641. https://doi.org/10.1016/j. ridd.2020.103641 King, B.H., Toth, K.E., Hodapp, R, Dykens, E.M. (2009). Intellectual disability. In Sadock, B.J., Sadock, V.A., Ruiz, P. (eds.), Comprehensive textbook of Psychiatry, 9th ed. (pp. 3444–3474). Lippincott Williams & Wilkins. Kollins, S. H. (2008). ADHD, substance use disorders, and psychostimulant treatment: Current literature and treatment guidelines. Journal of Attention isorders, 12, 115–125. Learning Disabilities Association of America. (2023). Defining learning disabilities. Available on http://ldaamerica.org/support/new-­to-­ld/. Retrieved on 24 July 2023. Lee, Y.  C., Chen, C.  R., & Lin, K.  C. (2022). Effects of mindfulness-based interventions in children and adolescents with ADHD: A systematic review and meta-analysis of randomized controlled trials. International Journal of Environmental Research and Public Health, 19(22), 15198. Lo, H. H. M., Chan, S. K. C., Szeto, M. P., Chan, C. Y. H., & Choi, C. W. (2017). A feasibility study of a brief mindfulness-based program for parents of children with developmental disabilities. Mindfulness, 8(6), 1665–1673. Lo, H. H. M., Wong, S. W. L., Wong, J. Y. H., Yeung, J. W. K., Snel, E., & Wong, S. Y. S. (2020). The effects of family-based mindfulness intervention on ADHD symptomology in young children and their parents: A randomized control trial. Journal of Attention Disorders., 24, 667–680. https://doi.org/10.1177/1087054717743330 Malboeuf-Hurtubise, C., Lacourse, E., Taylor, G., Joussemet, M., & Taylor, G. (2017). A mindfulness-­based intervention pilot feasibility study for elementary school students with severe learning difficulties: Effects on internalized and externalized symptoms from an emotional regulation perspective. Journal of Evidence-Based Complementary & Alternative Medicine, 22(3), 473–481. Malboeuf-Hurtubise, C., Joussemet, M., Taylor, G., & Lacourse, E. (2018). Effects of a mindfulness-­based intervention on the perception of basic psychological need satisfaction among special education students. International Journal of Disability, Development and Education, 65(1), 33–44. Mcquade, J. D., Breaux, R. P., Miller, R., & Mathias, L. (2017). Executive functioning and engagement in physical and relational aggression among children with ADHD. Journal of Abnormal Child Psychology, 45(5), 899–910. Meppelink, R., de Bruin, E. I., & Bögels, S. M. (2016). Meditation or medication? Mindfulness training versus medication in the treatment of childhood ADHD: A randomized controlled trial. BMC Psychiatry, 16, 267. Muratori, P., Conversano, C., Levantini, V., Masi, G., Milone, A., Villani, S., Bögels, S., & Gemignani, A. (2021). Exploring the efficacy of a mindfulness program for boys with attention-­ deficit hyperactivity disorder and oppositional defiant disorder. Journal of Attention Disorders, 25(11), 1544–1553. https://doi.org/10.1177/1087054720915256 National Center for Education Statistics. (2023). Digest of education statistics. Retrieved July 24, 2023, https://nces.ed.gov/programs/digest/d22/tables/dt22_204.30.asp Piper, B.  J., Ogden, C.  L., Simoyan, O.  M., Chung, D.  Y., Caggiano, J.  F., Nichols, S.  D., & McCall, K. (2018). Trends in use of prescription stimulants in the United States and territories, 2006 to 2016. PLoS One, 13, e0206100. Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C., & Rohde, L. A. (2014). ADHD prevalence estimates across three decades: An updated systematic review and meta-regression analysis. International Journal of Epidemiology, 43, 434–442. Ridderinkhof, A., de Bruin, E. I., Blom, R., & Bögels, S. M. (2018). Mindfulness-based program for children with autism spectrum disorder and their parents: Direct and long-term improvements. Mindfulness, 9(3), 773–791. Salem-Guirgis, S., Albaum, C., Tablon, P., Riosa, P. B., Nicholas, D. B., Drmic, I. E., & Weiss, J.  A. (2019). MYmind: A concurrent group-based mindfulness intervention for youth with autism and their parents. Mindfulness, 10, 1730–1743.

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Shah, M., Moskowitz, L. J., & Felver, J. C. (2022). Soles of the feet mindfulness-based program for students with autism spectrum disorder and challenging behavior. Mindfulness, 13, 1342–1353. https://doi.org/10.1007/s12671-­022-­01887-­7 Siebelink, N. M., Bögels, S. M., Speckens, A. E. M., Dammers, J. T., Wolfers, T., Buitelaar, J. K., & Greven, C. U. (2022). A randomised controlled trial (MindChamp) of a mindfulness-based intervention for children with ADHD and their parents. Journal of Child Psychology and Psychiatry, 63(2), 165–177. https://doi.org/10.1111/jcpp.13430 Singh, N.  N., Singh, A.  N., Lancioni, G.  E., Singh, J., Winton, A.  S., & Adkins, A.  D. (2010). Mindfulness training for parents and their children with ADHD increases the children’s compliance. Journal of Child and Family Studies, 19(2), 157–166. Singh, N. N., Lancioni, G. E., Karazsia, B. T., Winton, A. S. W., Myers, R. E., Singh, A. N. A., & Singh, J. (2013). Mindfulness-based treatment of aggression in individuals with intellectual disabilities: A waiting list control study. Mindfulness, 4, 158–167. Snel, E. (2014). Mindfulness matters: Mindfulness for children. Trainer’s handbook. The Academy for Mindful Teaching. Storebø, O. J., Simonsen, E., & Gluud, C. (2016). Methylphenidate for attention deficit hyperactivity disorder in children and adolescents. JAMA, 315, 2009–2010. Valero, M., Cebolla, A., & Colomer, C. (2022). Mindfulness training for children with ADHD and their parents: A randomized control trial. Journal of Attention Disorders, 26(5), 755–766. van de Weijer-Bergsma, E., Formsma, A. R., de Bruin, E. I., & Bogels, S. M. (2012). The effectiveness of mindfulness training on behavioral problems and attentional functioning in adolescents with ADHD. Journal of Child and Family Studies, 21, 775–787. https://doi.org/10.1007/ s10826-­011-­9531-­7 van der Oord, S., Bögels, S. M., & Peijnenburg, D. (2011). The effectiveness of mindfulness training for children with ADHD and mindful parenting for their parents. Journal of Child and Family Studies, 21, 139. https://doi.org/10.1007/s10826-­011-­9457-­0 Vekety, B., Logemann, H. N. A., & Takacs, Z. K. (2021). The effect of mindfulness-based interventions on inattentive and hyperactive–impulsive behavior in childhood: A meta-analysis. International Journal of Behavioral Development, 45(2), 133–145. Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, R. M., & Blumberg, S. J. (2014). Trends in the parent-report of health care provider diagnosed and medicated attention deficit hyperactivity disorder: United States, 2003–2011. Journal of the American Academy of Child & Adolescent Psychiatry, 53, 34–46. Wong, S.Y.S., Chan, S.K.C., Yip, B. H.K., Wang, W., Lo, H.H.M., Zhang, D., & Bogels, S. (2023). The effects of mindfulness for youth (MYMind) versus group cognitive behavioral therapy (CBT) in improving attention and reducing behavioral problems among children with Attention Deficit Hyperactivity Disorder (ADHD) and their parents: A randomized controlled trial. World Health Organization (1992). The International Classification of Diseases –Tenth revision (ICD10). World Health Organization. Xue, J., Zhang, Y., & Huang, Y. (2019). A meta-analytic investigation of the impact of mindfulness-­ based interventions on ADHD symptoms. Medicine, 98(23), e15957. Zablotsky, B., Black, L.  I., Maenner, M.  J., et  al. (2015). Estimated prevalence of autism and other developmental disabilities following questionnaire changes in the 2014 National Health Interview Survey. National health statistics reports; no 87. National Center for Health Statistics. 2015. Zaccari, V., Santonastaso, O., Mandolesi, L., De Crescenzo, F., Foti, F., Crescentini, C., Fabbro, F., Vicari, S., Curcio, G., & Menghini, D. (2021). Clinical application of mindfulness-oriented meditation in children with ADHD: A preliminary study on sleep and behavioral problems. Psychology & Health, 1. https://doi.org/10.1080/08870446.2021.1892110 Zwi, M., Jones, H., Thorgaard, C., York, A., & Dennis, J. A. (2011). Parent training interventions for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years. Cochrane Database of Systematic Reviews, 12, CD003018.

Chapter 6

Mindfulness-Based Program for Children Facing Mental Health and Sociocultural Challenges

Anxiety Anxiety disorders are among the most prevalent mental disorders in childhood, often manifesting at an early age. Research suggests that approximately 12% of children and up to 32% of adolescents in the community have been diagnosed with some form of anxiety disorder (Essau et al., 2018). The following clinical features are commonly observed in anxiety-related disorders affecting children and adolescents (Riordan & Singhal, 2018): 1. Separation Anxiety Disorder: Children with this disorder experience excessive and developmentally inappropriate worry regarding separation from a primary attachment figure. Symptoms may include refusal to sleep alone, avoidance of school, agitation during separation, and somatic complaints. Separation anxiety disorder is particularly prevalent among individuals under the age of 12. 2. Selective Mutism: Children with selective mutism fail to speak in specific social situations where verbal communication is expected. These children are capable of fluent speech in other settings, often indicating comorbid social anxiety disorder. 3. Generalized Anxiety Disorder: Children with generalized anxiety disorder exhibit excessive worry without a discernible cause. This condition is typically accompanied by multiple somatic complaints, difficulty concentrating, irritability, and a tendency toward perfectionism. They may also seek excessive reassurance from others. Generalized anxiety disorder can emerge as early as 4 years of age. 4. Social Anxiety Disorder: Children with social anxiety disorder experience significant discomfort in social interactions, driven by fears of evaluation and embarrassment. While they desire social relationships, anxiety hinders their ability to engage, resulting in social isolation and avoidance in daily life.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_6

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5. Specific Phobias: Children with specific phobias display excessive anxiety toward a particular object or situation, such as dental procedures or animals. This fear often leads to avoidance behaviors. If unexpectedly confronted with a dear object, a child may exhibit impulsive reactions that could potentially put them at risk. 6. Obsessive–Compulsive Disorder: Children with obsessive–compulsive disorder (OCD) exhibit obsessions and intrusive thoughts, often relating to contamination fears or concerns about causing harm to others. These obsessions drive them to engage in repetitive behaviors such as checking, counting, and tapping. In addition, children with OCD often resist interventions from others trying to disrupt their rituals. The onset of OCD typically occurs around 8 years of age or later. The effects of MBSR and MBCT on anxiety disorders have been well studied in adult populations (de Abreu Costa et al., 2019). However, there is growing interest in applying MBPs to support children, particularly due to their potential benefits in emotion regulation for those experiencing anxiety symptoms or anxiety disorders. Mindfulness offers a novel perspective on managing anxiety by disrupting the habit loop that contributes to anxiety-related behaviors and emotions. For example, individuals may become caught in a cycle triggered by factors such as an unfinished to-do list, leading to persistent worry and increased anxiety (Brewer, 2022). Mindfulness allows individuals to recognize these patterns and develop new, positive habits by dismantling the process of perseverative thinking associated with anxiety (Berwer, 2021). While early attempts have been made to develop MBCT for children (Semple et al., 2010), research on the outcomes of MBPs in clinical samples is accumulating. Two systematic reviews and meta-analyses have examined the effects of MBPs on anxiety in children (Borquist-Conlon et al., 2019; Odgers et al., 2020). Borquist-Conlon et al. (2019) reviewed five studies involving a total of 188 youths aged 5–18, most of them had diagnoses such as posttraumatic stress disorder, generalized anxiety disorder, social anxiety disorder, and unspecified anxiety disorder. The study revealed a moderate size and significant effect of mindfulness on anxiety disorders in children. However, the mean effect size was smaller compared to meta-analyses for MBPs in adults with anxiety disorders, and the limited number of studies and sample size were identified as major limitations. Taking a more inclusive approach, Odgers et al. (2020) reviewed 20 studies on MBPs for anxiety in children and adolescents, encompassing diverse backgrounds, such as the general school population, adolescents with chronic pain or cardiac diagnoses, and psychiatric outpatients. The findings indicated a small positive effect following MBPs, but RCTs conducted in Western countries did not show significant effects compared to control interventions. The posttreatment effect on adolescents (d = 0.21) was smaller than that on children (d = 0.41). Notably, the effect size in clinical samples was weak. It is worth highlighting the contrasting conclusions drawn by these two meta-­ analyses regarding the effects of MBPs on child anxiety. Overall, the number of robust RCTs in this clinical population remains limited, with many studies focusing on general child and adolescent populations rather than specifically those with

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diagnoses of anxiety disorders. There is a need for more rigorous RCTs with well-­ defined control groups, particularly studies that target clinical populations within this age range. As mentioned, several studies have examined the application of MBPs in child anxiety, focusing on children with anxiety or internalizing symptoms, instead of those meeting clinical diagnoses. Lam (2016) conducted an MBP for 20 students aged 9–13, who were selected based on screening results indicating high internalizing problems and low externalizing programs. The participants were randomly assigned to either the treatment or the waitlist control group. The mindfulness group reported larger reductions in worry, symptoms of panic disorder, obsessive–compulsive disorder, generalized anxiety, and overall internalizing problems, although these reductions were not statistically significant. In another study, Wright et  al. (2019) implemented an MBCT program for children aged 8–13 (n = 89) to prevent internalizing difficulties. They included an active control group receiving cognitive-­ behavior therapy (CBT). The participants were nominated by parents and teachers, with a focus on excluding those with severe symptoms requiring more clinical attention. Both MBCT and CBT programs had small effects on anxiety and depression symptoms, quality of life, attention control, and parent- and teacher-rated behavioral difficulties. They also showed moderate-to-large effects on shifting attention. However, there were no significant changes in mindfulness or attention in either group. Shanok et al. (2019) examined the neurological effects of a 10-week MBP on 66 preadolescents aged 7–10 years with anxiety and depressive symptoms. The participants demonstrated increases in interhemispheric alpha coherence, as well as increased theta, alpha, and beta power, particularly in the frontal and central areas. These findings suggested a lower neurological risk of anxiety development. However, two common measures linked to anxiety, including frontal and posterior alpha asymmetry, remained largely unchanged following the MBP. Further research is needed to explore the potentially positive effects of mindfulness training on adolescents and their neurophysiological functioning. There have been limited studies conducted on clinical or hospital samples. Blum et al. (2021) investigated the effect of state anxiety in adolescent inpatients, as anxiety is known to be a predictor of suicide attempts. Adolescent inpatients aged 13–19 (n  =  53) attended a 30-min optional MBP session while hospitalized for mental health care. The study found that state anxiety significantly decreased after the first exposure to the MBP, regardless of adolescent age, sex, and prior experience with mindfulness, including those experiencing symptoms of psychosis. This suggests that mindfulness could be an effective and immediate transdiagnostic intervention to lower state anxiety in adolescent inpatient units. In Iran, two studies have examined MBPs in adolescents with clinical diagnoses of anxiety disorders, both focusing on social anxiety disorders. Ebrahiminejad et al. (2016) conducted a study on 30 female students with clinical diagnoses of social anxiety. They were randomly assigned to receive MBCT (consisting of eight sessions, each lasting 2 h) or no treatment. The mindfulness group showed significant improvements in the social phobia inventory and self-esteem. Similarly,

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Mohammadpour et al. (2020) investigated the outcomes of MBP on 24 university students diagnosed with social anxiety disorders by clinical psychologists. The program followed the same protocol as MBCT for adults. The participants showed moderate effect sizes of improvements in social anxiety and interpersonal sensitivity. Cotton et al. (2016) conducted a unique study focusing on adolescents with anxiety disorders who had parents with bipolar disorders. The aim was to explore the effects of MBPs as a non-pharmacological treatment, considering that antidepressant medications commonly used for anxiety symptoms may accelerate the onset of mania in at-risk youth. Ten participants reported improvements in clinician-rated anxiety, youth-rated trait anxiety, parent-rated emotion regulation, and high levels of feasibility, acceptability, and usefulness, providing preliminary evidence in this specific population. Most studies on MBPs for child and adolescent anxiety have focused on participants with anxiety symptoms or clinical samples with mixed backgrounds, making it uncertain whether MBPs are beneficial for those with diagnosed anxiety disorders. In addition, the two studies on social anxiety disorders mentioned earlier were conducted in a single country, limiting generalizability to other populations worldwide. It remains unclear whether similar findings can apply to other types of anxiety disorders. Notably, a recent review of MBPs for adult anxiety found that the effects of MBPs are influenced by gender, with females more likely to perceive MBPs as effective compared to control interventions (de Abreu Costa et al., 2019). Another study in adults by Vollestad et  al. (2012) revealed that individuals with multiple anxiety disorders were more likely to benefit from MBPs. Therefore, further research on MBPs for children and adolescents should investigate the differential effects on individuals with different symptoms, aiming to identify who benefits the most from these interventions.

Depression Depression is a significant global mental health concern, particularly among adolescents. It is the fourth leading cause of illness and disability in the age group of 15–19  years (Twenge et  al., 2019). The prevalence of major depressive disorder (MDD) varies across regions, with high-income areas such as Western Europe and North America reporting rates over 40% (Erskine et al., 2017). The prevalence of MDD increased significantly across adolescence, and female adolescents have a higher risk compared to males, with a two-to-threefold increased risk (Erskine et al., 2017). Comorbidity is also common, with 63.7% of individuals with MDD reporting psychiatric comorbidity (Avenevoli et al., 2015). Certain comorbid conditions, such as anxiety and behavioral disorders, ADD, and substance use disorders, are associated with an increased risk of MDD (Avenevoli et al., 2015).

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Several studies have explored the mechanism of change in individuals with depressive disorders who undergo MBPs (van der Velden et  al., 2015). In adults with MDD, MBCT has been found to reduce ruminations, cognitive reactivity, and overgeneral autobiographical memory and increase specificity in life goals and goal attainment, self-compassion, meta-awareness, and decentering (van der Velden et al., 2015). However, it is uncertain whether the mechanisms of change in children would be identical, as all reviews have been based on adult samples. Although MBPs have been recognized as effective in supporting adults with major depressive disorder, they are primarily focused on relapse prevention rather than initial treatment for individuals with recurrent depressive symptoms (Segal et al., 2013). Since many adolescents experience their first onset of MDD and may not meet the criteria for benefiting most from MBCT, the applicability of MBPs in this population requires further investigation (Piet & Hougaard, 2011). In recent years, there has been an accumulation of studies on MBPs for adolescent depression, and two meta-analyses have examined their effects (Chi et  al., 2018; Reangsing et al., 2021). Chi et al. (2018) reviewed 18 studies and found a moderate effect of MBPs in reducing depressive symptoms in adolescents and young adults, with mild-to-moderate effects at posttreatment but no significant effects at follow-up. It is important to note that 10 of the selected studies focused on college or university students. Another meta-analysis by Reangsing et  al. (2021) included 29 studies with a sample size of 3688 adolescents. MBPs showed a small effect size in reducing depression compared to control groups, with only 10 of the 19 studies showing a significant effect size. Studies combining MBP with individual counseling showed greater improvement compared to those with MBPs alone. However, there is a need for more studies based on adolescents with clinical diagnoses of MDD to further understand the effectiveness of MBPs in this specific population. Gómez-Odriozola and Calvete (2021) conducted an RCT study on high school and undergraduate students aged 13–21 (n = 300), implementing a six-session version of the Learning to Breathe (L2B) curriculum. The results showed that the MBP prevented increases in depression and somatic symptoms, reduced interpersonal difficulties, and increased social self-concept in older adolescents. However, there was a moderating effect of age, as younger adolescents experienced an increase in depression and somatic symptoms post-intervention. This finding suggests that MBPs may be more precisely adapted for younger adolescents. There have been limited studies specifically targeting adolescents with MDD, which deviates from the typical criteria for individuals suitable for MBCT. Ames et al. (2014) conducted a small pilot study with adolescents aged 12–18 receiving psychological treatment for mood disorders and excluding those with a high level of risk, i.e., those who experienced an acute episode of depression, active substance use, and incompletion of psychological therapy. The program was adapted from the MBCT for adults. Eleven adolescents were included in this study. Three dropped out of the study, and one attended 50% of the sessions only. For program completers, improvements were found in mood, quality of life, and worry. McIndoo et al. (2016) recruited 50 college students after screening and diagnostic interviews

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and randomly assigned them to either a brief 4-session MBP, a behavioral activation program, or a waitlist control condition. This MBP showed similar effects to the behavioral activation program and was superior to the control group. It led to significant improvements in depression, rumination, stress, and mindfulness, with moderate effect sizes, and most gains were maintained at the 1-month follow-up. Huang et al. (2015) conducted a study on Chinese adolescents (n = 120) aged 13–18 with diagnoses of MDD. The participants were randomly assigned to standard care plus MBP, with meetings organized twice weekly, each session lasting 1 h, or to treatment as usual. The group receiving MBP reported significant reductions in depressive symptoms compared to the control group. Racey et al. (2018) conducted a small open trial of MBCT involving adolescents aged 14–18 (n = 25) utilizing mental health services, and 18 of them were diagnosed as having MDD. In this study, MBCT was offered in parallel for adolescents and their parents. Significant improvements were observed in young people’s depressive symptoms, rumination, self-compassion, and mindful attention, as well as improvements in rumination and self-compassion for parents. These studies provide preliminary evidence for the effectiveness of MBPs in reducing depressive symptoms and improving various outcomes in adolescents, including those with MDD. However, given the limited number of studies targeting adolescents with MDD, more research is needed to establish the efficacy of MBPs specifically for this population. Further studies should focus on larger sample sizes, utilize RCTs, and compare MBPs to active control conditions to better understand their effects on adolescent depression. Aligning with the practice guidelines for adults with MDD, MBP may not be a primary treatment for adolescents with MDD and severe recurrent mood symptoms.

Aggression and Disruptive Behaviors Aggression refers to behaviors that are intended to harm oneself or others, and it is one of the most common behavioral problems in childhood and adolescence (Siever, 2008). In the DSM-5, aggression and anger are considered core symptoms of oppositional defiant disorder (ODD), while aggressive behavior is strongly associated with conduct disorder (CD) (American Psychiatric Association, 2013). In the United States, aggression is highly prevalent among children and adolescents. Studies show that 14% of third graders frequently report being frequently shoved, slapped, hit, or kicked by other students, and 8% of high school students admit to being involved in physical fights on school grounds within the past 12 months (Musu-Gillette et al., 2017). Another study focused on youth in grades 6 through 10, revealing that over 50% of them experienced verbal aggression in the previous 2 months (Wang et al., 2012). Notably, children with other mental health disorders are at an increased risk of displaying aggression. The prevalence of disruptive behavior disorders in children with ADHD ranges from 14% to 35%, from 14% to 62% in anxiety disorders, and from 9% to 45% in mood disorders (Nock

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et al., 2007). Given these statistics, it is evident that there is a pressing need to support children and adolescents in managing their aggression and disruptive behaviors. To address this issue, various approaches have been identified for treating and preventing child aggression, including parent management training and cognitive-­ behavioral therapy (Farrington et al., 2017; Sukhodolsky et al., 2016). There is also a growing interest in exploring the potential of MBPs in managing aggression in children and adolescents. Several studies have provided preliminary evidence on the effects of MBPs on reducing aggression among this population. Franco et al. (2016) conducted an RCT in a public school, involving 27 students randomly assigned to a 10-week MBP or a control group. A significant decrease in impulsivity and aggressiveness was observed after MBP compared to the control group. Similarly, in another RCT by Parker et  al. (2014), 111 students aged 9–11 from two public schools were randomly assigned to participate in a brief MBP, meeting once a day for 15 min for 20 lessons, or a control group. The results showed that students who underwent the MBP demonstrated significant improvements in self-rated executive functioning skills and teacher-rated aggression and social problems compared to those in the control group. Studies targeting clinical populations with conduct or aggressive disorders are few. Muratori et al. (2021) conducted a waitlist control study with 50 children diagnosed with ADHD and ODD in an outpatient service. The parallel MBP for children and parents, similar to MYMind, lasted for 9 weeks with 1.5-h sessions. The mindfulness group showed a moderate effect size of reduction in hyperactive behaviors in the school context with a moderate effect size and a moderate-to-large effect size improvement in visual sustained attention compared to the waitlist control group. However, there was no significant effect on aggressive behaviors. Roux and Philippot (2020) conducted a study with 44 boys aged 12–19 in residential service, diagnosed with ADHD, CD, or ODD. They were assigned to the MBP or waitlist control group. The program included six sessions of group dynamics and emotional skills followed by 10 sessions of mindfulness training. Using a nonrandomized controlled study design, the boys in the MBP showed significant decreases in impulsivity and externalizing problems compared to those receiving treatment as usual. Some studies have focused on delivering mindfulness skills on an individual approach. The Soles of the Feet (SoF) program adopts this one-to-one approach to training children with ASD or mild ID and their parents. By directing attention from an emotionally aroused state to the Soles of the Feet, children develop mindfulness and calmness in situations that may trigger aggressive behavior (Singh et al., 2011a, b). In a multiple-baseline design study with a train-the-trainer approach, mothers trained their three adolescents with ASD to practice the SoF approach to self-­ manage their physical aggression at home (Singh et al., 2011a). After training, the adolescents showed no aggressive behaviors for three consecutive weeks during weeks 17, 22, and 24 and maintained this improvement during a 4-year follow-up. In a similar study, three adolescents with ASD were taught by their mothers to use the SoF procedure to self-manage aggression (Singh et al., 2011b). These adolescents took longer to achieve the training outcome of no aggression for four

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consecutive weeks and displayed occasional aggressive behaviors during the 3-year follow-up. In another study, both parents were taught the SoF practice and then instructed to teach it to their adolescent children with Prader–Willi syndrome who exhibited verbal and physical aggression (Singh et al., 2017). The results showed that the parents successfully reduced their adolescents’ verbal aggression to very low levels and eliminated physical aggression. During the 12-month follow-up, the adolescents maintained low levels of verbal aggression and did not engage in physical aggression. Ahemaitijiang et al. (2020) taught the mothers of three Chinese adolescents with ASD a basic meditation on the breath before introducing the SoF practice. Once they developed mindfulness skills and competence in using SoF, the mothers taught their adolescents to use SoF for precursors of aggressive and destructive behaviors, which was maintained during the 12-month follow-up. This study demonstrated the applicability of the SoF practice across cultures in Chinese children with ASD. The SOBER Breathing Space technique, which stands for Stop, Observe, Breathe, Expand, and Respond, has been applied in adolescents and adults with ASD (Singh et al., 2019). It is a mindfulness-based technique used for regulating emotions, thoughts, feelings, and desires in daily life. The technique has been used in the Mindfulness-Based Relapse Prevention program for individuals with addictions. In a study involving four children with ASD aged 10–12 who exhibited high-­ frequency verbal and physical aggression, the effects of SOBER Breathing Space were examined using a multiple-baseline across participants’ design (Singh et al., 2019). The children were taught the practice at home until they could use it fluently when needed. The frequency of aggression was measured at home by their parents and at school by their teachers. The results showed a significant reduction in the frequency of verbal and physical aggression to near zero in both home and school settings. A 12-month follow-up demonstrated the maintenance of behavioral gains in both settings. This study indicated that children with ASD could effectively use SOBER Breathing Space to manage their aggression, generalize its use across different settings, and sustain behavioral improvements for at least 12 months. Tao et al. (2021) conducted a meta-analysis based on 18 studies involving a total sample of 1223 adolescents. The analysis revealed a moderate effect size of MBPs on aggression. However, the quality of studies in this area varied, with only three studies employing a RCT design and two focusing on student populations without clinical diagnoses. Additionally, some studies utilized a single-subject design with small sample sizes. Moreover, the delivery procedures of the interventions varied across studies, making it challenging to directly compare their effects.

Transdiagnostic Psychiatric Conditions The concept of transdiagnostic psychiatric conditions suggests that different emotional disorders, such as anxiety, mood, and eating disorders, share common symptom presentations and underlying temperament traits. As a result, there has been a

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call for a unified approach to treating adults with emotional disorders using a ­common set of principles of change (Barlow 2004; Brown & Barlow, 2018). The Unified Protocol for Emotional Disorders and mindfulness-based programs (MBPs) share similar intervention strategies, such as promoting emotional awareness, reducing avoidance behaviors, and cultivating cognitive reappraisal (Kennedy & Barlow, 2018). Several studies have explored the effectiveness of transdiagnostic approaches and MBPs in treating emotional disorders in children and adolescents. For example, Biegel et al. (2009) conducted an RCT of MBSR in adolescent psychiatric outpatients aged 14–18, with mood or anxiety disorders. This study program followed the MBSR format, consisting of eight 2-h sessions and home practice for 20–35 min. The study found that participants who received MBSR reported reduced symptoms of anxiety, depression, somatic distress, improved self-esteem, and better sleep quality compared to those in the control group. However, the developmental appropriateness of the adult-based MBSR-based intervention for adolescents was not extensively addressed, apart from adjusting the intensity of practice. In another study, Bögels et al. (2008) developed an MBCT-based MBP for adolescents (n = 14) with externalizing disorders such as ADHD, ASD, ODD, and conduct disorder, and their parents. The program consisted of eight sessions and each lasted for 1.5 h. The pilot study showed self-reported improvements in internalizing and externalizing problems, attention problems, self-control, and attunement to others in the MBP group compared to the waitlist group (Bögels et al., 2008). This led to the development of the MYMind program for children with ADHD and ASD and their parents. Díaz-González et  al. (2018) found that adolescents aged 13–16 (n  =  80) with various mental health diagnoses. The participants were randomly assigned to receive either an MBP in addition to standard therapy or treatment as usual. They reported a small effect size reduction of state anxiety following MBP when compared with the active control group. However, no significant differences were observed for other outcomes, such as depression, stress, or somatization. Hutchison et al. (2023) conducted an online MBP during the COVID-19 pandemic, involving 56 adolescents aged 12–17 who were engaged in mental health treatment. The MBP consisted of eight 1-h sessions, with a group size of 4–8 participants. Significant reductions in mental health symptoms and increases in adaptive coping strategies were observed at the posttest. The effectiveness of MBP varied based on the severity of symptoms, with moderate-risk participants (those engaged in outpatient therapy only) benefiting more than high-risk participants (those with treatment histories of intensive service such as in-home services, intensive family therapy, and hospitalization). While these studies employed rigorous research designs, one major limitation is the heterogeneity of the samples, which makes it challenging to study the mediators and change mechanisms of treatment outcomes. Different individuals may experience changes after MBPs due to various factors, and the specific needs of children with different diagnoses may not be fully addressed. It is also important to note that adolescents with moderate symptom severity may benefit most from an MBP.

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Suicide Suicide and suicidal ideation are serious concerns, particularly among adolescents. Suicidal ideation refers to self-reported thoughts about engaging in suicide-related behavior, which can range from passive thoughts to active planning (O’Leary et al., 2006; Wagner, 2009). It is alarming that suicide was the third leading cause of death among children aged 10 to 14 in the United States in 2013 (Heron, 2016). Research has shown that childhood suicidal ideation is highly predictive of suicidal ideation in adulthood and a lifetime history of attempted suicide, emphasizing the need for resources and intervention strategies to support children with suicidal ideation (Herba et al., 2007). While individuals who have made previous suicide attempts are at high risk of repetition, it has been observed that both hopelessness and problem-solving abilities can improve rapidly in the days following a suicidal crisis, even without formal treatment (Schotte et al., 1990). However, cognitive vulnerability, which predicts depression and suicidality, may be inaccessible outside of an episode. However, a suicidal mode of mind can be reactivated by even mild deteriorations in mood, leading to a reactive mind dominated by suicidal cognitions, characterized by thoughts of being a burden to family and others, perceiving the distress as unbearable, and believing suicide is the only option to solve the problems (Williams et al., 2006). Mindfulness practices can play a role in addressing suicidal ideation by promoting awareness of internal experiences, facilitating a shift from automatic to conscious processing, and creating space for making choices. MBCT has been modified to support adults with suicidal ideation (Williams et al., 2015), and specific MBPs have been developed for adolescents facing similar challenges. Le and Gobert (2015) developed an MBP for Native American youth, with a 2.5 times higher suicide rate than the national average (Centers for Disease Control and Prevention, 2012). The program consisted of four sessions per week, each lasting 55 min, over 10 weeks, implemented in a Native American school setting. The pilot study involved eight youths aged 15–20, and the evaluation reported that participants had better self-regulation, less mind wandering, and decreased suicidal thoughts. Yen et al. (2019) developed a program called “Skills to Enhance Positivity” targeting adolescents hospitalized due to suicidal risk. The program consisted of an in-person phase (four sessions) and a remote delivery phase (text messaging and phone class), integrating mindfulness exercises with psychoeducation, gratitude, and savoring. Participants aged 12–18 years (n = 20) were involved. The outcomes showed a lower rate of suicidal attempts, with only one participant having an attempt, and five were readmitted for suicidality in the following 6 months, compared to naturalistic studies. While these studies provide preliminary evidence for the effectiveness of MBPs in addressing adolescent suicidality, further research is needed. Large-scale RCTs should be conducted to determine the efficacy of the program in reducing suicidal behaviors. Additionally, it is important to explore the optimal dosage of MBP for

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this particular population, considering individuals with the previous traumatic experiences and high levels of vulnerability may not be suitable for intensive mindfulness practice (Koerbel & Meleo-Meyer, 2019; Treleaven, 2018).

Substance Use Substance use is a significant issue among adolescents, with a 12-month prevalence rate of 4.3% for drug abuse/dependence in the United States (Substance Abuse and Mental Health Services Administration, 2019). Studies consistently show that males have nearly double the rates of alcohol and drug use disorders compared to females, and the peak period for these disorders occurs in late adolescence (Merikangas & McClair, 2012). The onset of substance abuse in adolescence is strongly linked to persistent symptoms into adulthood (Rohde et al., 2009). Substance use disorder, as defined by the DSM-5, refers to a problematic pattern of substance use that leads to significant impairment or distress (American Psychiatric Association, 2013). This can involve various substances such as alcohol, tobacco, stimulants, opioids, inhalants, and cannabis. Substance use disorder can result in substance intoxication, withdrawal, and various substance-induced mental disorders. It is worth noting that approximately half of individuals with mental illness will also experience a substance use disorder and vice versa. Moreover, individuals with substance use disorders often had a higher prevalence of other health problems, such as chronic pain, chronic obstructive pulmonary disease, congestive heart failure, and hepatitis C (Sarlin, 2017). MBPs have been developed for various types of addictions, including the well-­ known Mindfulness-Based Relapse Prevention program (Bowen et al., 2010), which has shown positive effects in adult populations. However, there is a surprising lack of published studies on the application of MBPs in adolescents with addictions. A recent meta-analysis on MBPs for substance and behavioral addictions (Sancho et al., 2018) found only four studies focused on adolescent samples, two of which were yoga interventions. Mindfulness can be beneficial in addressing cravings and addictive behaviors by increasing awareness of triggers and promoting conscious choices to engage in alternative activities that reduce or prevent cravings (Witkiewitz et  al., 2005). Craving in the context of addiction and substance use disorder is a cognitive response triggered by environmental cues, consisting of rigid cognitive patterns and positive outcome expectancies associated with the substance. Craving provides both positive and negative reinforcement for substance use. Mindfulness training can interrupt this cycle by fostering heightened awareness and acceptance of the initial craving response without judgment or reactive behavior. It serves as an alternative to addiction, not only as a coping strategy for managing urges and temptations but also as a behavior that brings gratification (Witkiewitz et al., 2005). Harris et al. (2017) developed a brief MBP called urge surfing, which focuses on attending to cravings and urges in high-risk situations rather than avoiding them.

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This program has shown effectiveness in coping with alcohol, tobacco, and drug use in adults, but only one study has been conducted with an adolescent sample. This study involved 67 participants aged 14–18 who were attending an aftercare program following a school-based intervention. The participants were randomly assigned to a 4-week MBP or a waitlist control. The results demonstrated marginal reductions in alcohol frequency and quantity after MBP compared to the control group. In another study by Himelstein et al. (2015), mindfulness training was integrated into individual and group psychotherapy programs for incarcerated youth. Thirty-­ five adolescents aged 14–18 in the juvenile detention camp were randomly assigned to either the intervention group or the treatment-as-usual group. The program included meditation time ranging from 5 to 25  min, combined with motivational interviewing, goal planning, and discussions on reintegration into the community. Between-group analyses indicated significant increases in self-esteem and staff ratings of good behavior. However, changes in  locus of control and attitude toward drugs did not reach significance. It is important to note that in both studies, mindfulness training was just one component of the overall intervention for adolescents with addictions. This highlights the complex treatment needs of this population, and practitioners should carefully design the dosage, timing, and type of intervention in conjunction with other treatment modules. Additionally, it is worth mentioning that the sample size in these studies was relatively small. In the study by Harris et al. (2017), 77% of the participants were male, and in the study by Himelstein et  al. (2015), the entire sample consisted of males. Further research is needed to explore the effects of MBPs on various types of addictions, different target populations (studies for studies involving girls), and a range of outcomes related to recovery and symptom management.

Other Health Challenges Chronic Pain Chronic pain is defined as pain lasting longer than 3 months or past the normal time for tissue healing. It is a significant issue affecting a considerable percentage of children and adolescents, with estimates ranging from 20% to 35% (King et  al., 2011). The most common chronic pain disorders in this population include primary headaches, centrally mediated abdominal pain syndromes, and chronic or recurrent musculoskeletal and joint pain (Friedrichsdorf et al., 2016). Chronic pain in children and adolescents has a profound impact on various aspects of their development and overall functioning, leading to a decline in their quality of life. Psychological interventions are considered vital in the interdisciplinary management of chronic pain, particularly as comorbid mental health disorders such as depression and medication overuse are often present (McCracken et  al., 2006). Given the need for advanced treatment, MBPs have been explored as a potential approach for children and adolescents with chronic pain.

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Mindfulness training aims to redirect attention to the present moment and increase awareness of external surroundings and internal experiences, allowing individuals to reframe their perceptions of pain and health conditions. As MBPs have been applied to adults with chronic pain and shown benefits (Hilton et  al., 2017), their effectiveness in children with similar issues has been investigated through limited studies. One pilot study examined the effects of an MBP on 20 adolescents aged 13–17 with chronic pain (Waelde et al., 2017). The program lasted for 6 weeks, with one-­ hour sessions. The results indicated no significant changes in pain intensity or depression, but there were improvements in functional disability and the frequency of pain-related functioning complaints, albeit with small effect sizes. However, this study had a small sample size and lacked a control group for comparison. Another pilot RCT conducted by Chadi et  al. (2016) included 19 girls aged 13–18 with a history of chronic pain, randomly assigned to either the MBP or a waitlist control group. The MBP lasted for 8 weeks, with 90-min sessions. Participants reported a positive change in coping with pain, but no significant changes were found in quality of life, depression, anxiety, pain perception, or psychological distress. Due to the limitations of existing studies, it remains uncertain whether the observed benefits can be generalized to the wider population. The duration of MBPs for children with chronic pain has been relatively short, possibly due to concerns about acceptability and avoidance of pain intensity awareness in adolescents. Both studies lacked follow-up assessments, making it unclear whether the benefits are sustainable over time. Further research with a more robust design and intensive approach is needed, including the use of an active control group, longer MBP durations, follow-up assessments, and potentially incorporating a parallel program for parents.

HIV Studies have shown that adolescents and young adults have a higher likelihood of being diagnosed with HIV, are less than other age groups, and are less likely to receive effective medical care and treatment (Centers for Disease Control and Prevention, 2022). Improving medical adherence among individuals living with HIV is a key strategy for ending the HIV epidemic, as it promotes viral suppression and reduces transmissibility (Department of Health and Human Services, 2020). One study investigated the effects of MBSR on 72 HIV-infected youth aged 14–22 using an RCT design (Webb et al., 2018). The MBSR group reported higher levels of mindfulness, problem-solving coping, life satisfaction, and lower aggression compared to the control group at the 3-month follow-up. Furthermore, participants in the mindfulness group were more likely to have reductions in HIV viral load, indicating better HIV disease control, possibly due to higher levels of medication adherence. In a more recent study, 74 adolescents and young adults were randomly assigned to MBSR or general health education. The MBSR program consisted of eight 2-h

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weekly sessions and a 3-h retreat. At the 3-month follow-up, MBSR participants showed greater increases in medication adherence and marginally larger decreases in HIV viral load compared to the health education group. However, these differences were not sustained at the 6-month and 12-month follow-ups (Sibinga et al., 2022). These studies provided initial evidence that MBPs can promote medical adherence and stress coping among adolescents affected by HIV, suggesting a potential role in health promotion in this clinical population.

Cancer A systematic review focused on MBPs for symptom management in children and adolescents with cancer included six studies with a total sample of 178 participants (Tomlinson et al., 2020). The review found beneficial effects of MBPs on symptoms such as procedural pain, distress, and quality of life. However, it is important to note that the number of studies and sample sizes was small. One of the selected studies used a regular breathing technique called (Hey-Hu), which trained children in slow and deep breathing for pain management (Pourmovahed et  al., 2013). This technique differs from most procedures of MBPs, and its inclusion in the review might be considered controversial. In a recent study by Abedini et al. (2021), 40 children aged 11–13 with cancer were randomly assigned to either MBCT or a treatment-as-usual control group. Modifications were made to the program to accommodate the medical conditions, resulting in twenty 45-min sessions. Mindful movements and mindful eating were excluded. The mindfulness group showed significant reductions in internalizing and externalizing symptoms, which were maintained at the 2-month follow-up. While mindfulness training has been widely applied to support adults with cancer, its application in children with similar conditions is limited. It is important to note that psychological interventions for individuals with medical conditions often incorporate various coping skills, and some programs may include meditations and breathing exercises that represent different approaches to pain and suffering. For example, the study by Pourmovahed et al. (2013) specifically mentioned that their use of diversion as pain management should not be conflated with the orientation of MBPs. Further research is needed to explore the application of mindfulness in children and adolescents with cancer, considering the specific needs and characteristics of this population.

Cardiac Diagnoses Congenital heart disease is a common birth defect, occurring in 9 of 1000 live births (Hoffman & Kaplan, 2002). While the majority of individuals with congenital heart disease survive to adulthood, about half of them experience significant anxiety and

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meet diagnostic criteria for mood or anxiety disorder (Kovcas et al., 2009). These mental health disorders often begin in adolescence, with a prevalence three to four times higher than that of the general population (Kovcas et al., 2009). Children and adolescents with these chronic, potentially life-threatening conditions are at risk of psychological maladjustment and impaired quality of life. In a study by Freedenberg et al. (2017), an MBP program was compared to an online support group for adolescents with cardiac diagnoses. This study involved 46 adolescents with congenital heart disease, cardiac device, or postural orthostatic tachycardia syndrome. The MBP program lasted for 6 weeks, with each session lasting 90 min. Higher baseline anxiety and depression symptom scores predicted improvement in these symptoms in both the MBP and online support groups. The MBP group also reported benefits from learning specific skills that they could apply in daily life to relieve distress.

Diabetes Type 2 diabetes is a chronic disease that poses significant health problems, affecting 40–50% of adults in the United States, with a higher prevalence among disadvantaged ethnic groups (Gregg et  al., 2014). Youth-onset type 2 diabetes is twice as common in adolescent girls and has been associated with a more aggressive disease course. These individuals are more likely to experience overweight (Morrison et al., 2010) and depressive symptoms (Rohde et  al., 2009). Depressive symptoms can increase stress-related behaviors and alter stress physiology, leading to insulin resistance and a vicious cycle (Holt et  al., 2014). MBPs may be helpful in reducing depressive symptoms and improving insulin resistance, as studies in adults have shown that mindfulness can enhance self-regulation, stress response, and positive lifestyle behaviors for managing illness. In a study by Shomaker et al. (2017), 33 girls aged 12–17 at risk of type 2 diabetes due to family history, overweight, and elevated depressive symptoms were randomized to a six-week MBP or cognitive-behavioral program. This study utilized the Learning to Breathe (L2B) program, which was introduced in Chap. 4. At posttreatment and six-month follow-up, adolescents in the mindfulness group showed greater decreases in depressive symptoms, insulin resistance, and fasting insulin compared to those in the cognitive-behavioral group, indicating the benefits of MBPs in managing illness.

Obesity Neurobiological models of obesity suggest that individuals with heightened sensitivity to food as a reward and inadequate self-control are more prone to excess weight gain (Volkow et  al., 2013). During adolescence, executive functioning,

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which governs goal-directed behaviors and self-regulation, undergoes maturation (Diamond, 2013). Executive dysfunction has been associated with overeating and weight gain in adolescents (Reinert et  al., 2013). Adolescents gain autonomy in food choices and may experience increased stress levels, which can lead to reliance on food as a reward and reactive eating behaviors associated with excess weight gain (Alberga et al., 2012; Feltonetal., 2017; Stice & Yokum, 2016). Interventions targeting reward sensitivity and executive functions in at-risk adolescents may provide effective strategies for preventing excess weight gain. MBPs have shown physical and psychological benefits for overweight or obese adults in previous reviews (Carrière et al., 2018; Rogers et al., 2017). To explore the potential of MBPs for adolescents at risk for excess weight gain, a pilot RCT was conducted with 54 adolescents aged 12–17 (Shomaker et  al., 2017). Participants were at risk of excess weight gain based on above-average weight (body mass index) or parental history of obesity. They were randomized to either an MBP based on the Learning to Breathe (L2B) program (Broderick, 2013) or a health education control group. The MBP consisted of six weekly one-hour sessions. The results of the study showed that compared to the health education group, adolescents who participated in the MBP exhibited lower food reward sensitivity at six-month follow-­up with moderate effect size. However, there were no between-group differences in terms of changes in BMI or adiposity. These findings provide promising preliminary evidence that MBPs may be beneficial as preventive programs for adolescents at risk for obesity. However, larger studies with long-term follow-up are needed to further examine the efficacy of MBP in this specific population.

Psychosocial Challenges The following section discusses the application of MBPs in the context of social care for disadvantaged groups. It focuses on various issues such as children from low-income families, children dealing with divorce or migration, and the experiences of sexual minority individuals. Due to the limited access to mental health care, selective prevention programs have been implemented to assist children facing disadvantaged conditions (Mrazek & Haggerty, 1994; Stockings et al., 2016).

 acial Minorities, Low-Income Children R from Disadvantaged Families Racial minorities and children from low-income families who come from disadvantaged backgrounds face numerous challenges across different aspects of their development. They are more likely to experience delayed cognitive and language development, as well as poor mental health (Dickerson & Popli, 2016; Huston & Bentley, 2010). These disadvantages impact children on three levels: the individual

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level, which includes issue factors such as the quality of their food intake; the relational level, which involves the quality of their peer relationships; and the institutional or contextual level, which encompasses their schooling and neighborhood environments (Yoshikawa et al., 2012). Furthermore, disadvantaged children often experience chronic physiological stress, which can affect their blood pressure and lead to dysregulated cortisol levels (Obradovic et al., 2010). A systematic review identified eight studies that focused on MBPs specifically designed to support children studying in schools located in low-income neighborhoods (Segal et  al., 2021). The findings varied across these studies, but overall, some improvements were reported in terms of externalizing and internalizing symptoms, emotional regulation, and perceived stress. The promising result from the study conducted by Black & Fernando (2014) is discussed in Chap. 4. Another study examined the outcomes of 300 fifth- to eighth-grade students who were randomly assigned to either an adapted MBSR program or a health education program (Sibinga et al., 2016). The participants in this were predominantly African American (99.7%) and faced stressors such as community violence, multigenerational poverty, substance use, health risks, and trauma. After completing the MBP, the students reported significant improvements in various areas, including somatization, depression, negative affect, negative coping, rumination, self-hostility, and posttraumatic symptom severity, when compared to the students in the control group. Four studies were conducted to examine the impact of the Learning to BREATHE (L2B) program on promotion. The first study took place at an alternative high school where students in grades 9–12 were at high risk and had low academic achievement (Bluth et al., 2016). Twenty-seven students were randomly assigned to either the L2B program or a substance abuse preventive class, which served as the control group. Adaptations were made to enhance the acceptability of the MBP, including increased engagement of instructors in school activities. The results indicated a reduction in depressive symptoms among students who participated in the MBP compared to the control group. The second pilot study was conducted at an alternative high school based and focused on 23 marginalized boys aged 17–20 (Eva & Thayer, 2017). These students either dropped out or were unable to graduate due to low grades and lost credits. Within this sample, 75% of the students were from diverse ethnic backgrounds, including immigrants and refugees. Pre- and posttest comparisons showed significant differences in self-esteem and perceived stress, with small-to-moderate effect sizes. Focus group discussions after the program revealed that students valued mindfulness practice, particularly the body scan technique, and reported benefits in self-regulation, attention-awareness, and positive thinking. The third study of L2B involved two classrooms in an ethnically diverse at-risk high school (Felver et  al., 2019). Twenty-nine students in grades 9–12, who had consented to attend a health education class, were recruited to participate in the L2B program. They were randomly assigned to either the L2B program or a typical health education class as the control condition. The results showed a significant increase in self-reported resilience among students in the MBP, while students in the control condition reported a significant reduction. However, MBP did not

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demonstrate effects on self-reported problem behavior, school attendance, or academic grades. The final study included a larger sample of ethnic minority students (Asian and Latino) in the ninth grade, recruited from three high schools that offered a school-­ based mental health service (Fung et al., 2019). The study aimed to address the limitations of the previous studies, which had small sample sizes and were conducted at a single study site. A total of 145 students were randomly assigned to either the L2B program or a waitlist control that would receive the program in the following semester. The intent-to-treat analyses indicated significant effects of the MBP, with a moderate effect size on internalizing symptoms and a large effect size on perceived stress after MBP. Mediation analyses indicated that the program’s effects on internalizing symptoms and perceived stress were mediated by reductions in expressive suppression and rumination, which are common maladaptive coping styles among ethnic minority groups. Moderation analyses revealed that program effects were more significant among adolescents with more severe problems at baseline, suggesting that the program delivery may be particularly beneficial for high-risk adolescents. In a trial conducted by Lo et al. (2019), the outcomes of school-aged children from economically disadvantaged families in Hong Kong, China, were examined using a waitlist randomized controlled trial. The study involved 102 parents and their children aged 5–7 years. The children in the mindfulness group showed more significant improvements in attention and self-regulation compared to those in the control group. Parents also exhibited significant between-group differences in the reduction in parenting stress. Saliva samples were collected from some randomly selected dyads to measure cortisol levels and investigate whether the improvements were related to the mindfulness program. The children from the mindfulness group showed increased morning cortisol levels and decreased diurnal cortisol slopes, suggesting that the brief family-based MBP had positive effects on the neuroendocrine functioning of parents and children (Ho et al., 2020). The acceptability of mindfulness programs among children and adolescents has been a major concern. Limited feasibility data are available, with only two studies measuring student-rated satisfaction. While MBPs have reported high enrollment and retention rates, low homework compliance has been observed, similar to other MBP studies for youth (Segal et al., 2021). Therefore, it remains uncertain whether the positive outcomes are solely due to mindfulness components or if common factors, such as the social–emotional learning components and supportive instructors contribute to the results.

Children of Divorced Parents and from Migrant Families Divorce is a common transition for many marriages and families in contemporary societies, and a significant proportion of children experience emotional and behavioral challenges (Raley & Sweeney, 2020). Esmaeilian et al. (2018) conducted an

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RCT of a modified version of the MBCT-C with 83 participants aged 10–13 years whose parents had divorced. The research team obtained approval from the education department and approached parents with legal custody of the children. The program lasted for 12 weeks, with each session lasting 90 min. At the end of the intervention, children in the mindfulness group showed significant improvements in symptoms of depression, trait anxiety, state anxiety, trait anger, and state anger compared to the control group. In mainland China, many families moved from rural to urban areas, and children from these families reported significantly greater emotional and behavioral problems than their counterparts. The study conducted by Lu et al. (2018) examined the effectiveness of an after-school MBP for children aged 9–13 from migrant families in Mainland China. The MBP lasted for 4 weeks with two sessions per week, each lasting 45 min. Using a non-experimental pretest–posttest design, the researchers found that children with low mindfulness at baseline showed improvements in internalizing and externalizing problems after participating in the MBP. However, no significant improvements were observed in other children. These findings suggest that MBPs may be beneficial for children from divorced and migrant families who experience emotional and behavioral difficulties. By cultivating mindfulness skills, children may develop better emotional regulation and coping strategies, leading to improvements in their overall well-being. Additionally, the study highlights the importance of considering unique psychosocial challenges faced by children, such as divorce or family transitions. In societies where division or separation is associated with stigma, it can be challenging to develop interventions that address the specific needs of children in such situations. MBPs may offer support for children experiencing divorce or other family transitions by promoting emotional resilience, self-regulation, and coping skills.

Sexual and Gender Minorities Studies consistently demonstrate that LGBT youth experience higher rates of depressive and anxiety disorders, self-harm, suicidal ideation, and suicidal behavior compared to their heterosexual peers (Russell & Fish, 2016). A large population-­ based, longitudinal cohort study found that sexual minority individuals were at heightened vulnerability for depression and suicidality throughout adolescence to young adulthood, with sexual minorities being 4.53 times more likely to report lifetime self-harm with suicide intent than their heterosexual peers at age 21 (Irish et al., 2019). Transgender youth are at 5.9 times greater odds of suicide attempts compared to their peers (Di Giacomo et al., 2018). The minority stress theory (Meyer, 2003) provides a framework for understanding these mental health disparities, suggesting that sexual minorities face chronic stressors related to their stigmatized identities. These stressors include experiences of victimization, prejudice, discrimination, and the internalization of negative social

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attitudes (often named internalized homophobia). These stress processes can compromise the mental well-being of LGBT individuals (Hatzenbuehler, 2009). While there is a growing body of research on MBPs for adults in the LGBT community, studies focusing on MBPs for LGBT adolescents are limited. One study conducted by Cochrane (2017) involved six LGBTQ+ youth aged 15–18 participating in a six-week MBP, with 45-min weekly sessions. Self-reported ratings indicated positive changes in stress levels, life satisfaction, and coping skills among the participants. Additionally, recent studies have explored the use of mindfulness training and affirmative practice approaches in LGBT youth (Iacono et al., 2022) and transgender youth (Bigelow, 2023). Preliminary results from these studies suggest that mindfulness and self-compassion practices can be helpful for LGBTQ+ youth, but further research is needed to specify the benefits of MBPs in this distinct population.

Implications for Research The chapter highlights several implications for further research on MBPs for children and adolescents facing mental health and psychosocial challenges. Studies on program outcomes are growing, but there are mixed findings on the benefits of these MBPs. Systematic reviews focusing on anxiety and depression in children and adolescents have included studies with varying sample populations, which may not provide a clear understanding of MBP efficacy. Current evidence suggests that MBPs may be beneficial as prevention programs and in reducing anxiety and mood symptoms. However, the efficacy of MBPs for adolescents with clinical diagnoses of anxiety and depressive disorders remains uncertain, as some researchers exclude those at high risk from MBPs from intensive mindfulness practices. It should be highlighted that during the development of MBCT, the founders intended to design a program for relapse prevention with residual symptoms for adults. It is important for researchers to note that in the development of MBCT, the founders intended to design a program for relapse prevention with residual symptoms. Researchers should be mindful of putting MBPs into context and exploring the potential roles in treating adolescents with clinical diagnoses with standard care. For other adolescent mental health issues, there is limited evidence on the effectiveness of MBPs for addressing suicide, substance use, aggression, and disruptive behaviors. Most studies in these areas have small sample sizes, and larger clinical trials are needed to test the effects of MBPs. Additionally, the involvement of parents in the same intervention should be considered. For health challenges, MBPs have shown promise in supporting children and adolescents facing chronic conditions, such as cancer, chronic pain, diabetes, and HIV.  However, studies in these areas often have small sample sizes, and further research with rigorous designs and adequate sample sizes is needed to explore the potential benefits of MBPs in reducing comorbid anxiety and mood disorders and promoting illness management.

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Finally, for social care and children and families in disadvantaged conditions, the use of MBPs in ethnic minority backgrounds, sexual minorities, and those experiencing transitions such as migration and divorce is explored. Researchers should provide detailed explanations of how and why adaptations are necessary to make MBPs culturally appropriate and effective in different contexts. This information can help inform others to make necessary adjustments when implementing MBPs in diverse populations. Implications for Practice. The research on applying MBPs with clinical samples of children with mental health diagnoses, except for ADHD, is still limited. Therefore, further investigation is needed to determine the suitability and effectiveness of MBPs for children with mental health disorders. Practitioners should exercise caution when using MBPs in these cases and take into account the specific needs and challenges of children with mental health diagnoses. It is important for practitioners to consider appropriate dosage and acceptability of MBPs. This includes adapting the program to be developmentally appropriate and engaging for young participants. The use of MBPs in social care and selective prevention programs may improve the accessibility of care and support to children from disadvantaged groups. Practitioners should prioritize the safe and ethical implementation of MBPs with children and adolescents. This involves creating a supportive and trauma-sensitive environment, as vulnerable populations may open up emotionally during the practice. It is essential to provide individual attention and additional professional support when delivering MBPs in group settings.

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van der Velden, A.  M., Kuyken, W., Wattar, U., Crane, C., Pallesen, K.  J., Dahlgaard, J., et  al. (2015). A systematic review of mechanisms of change in mindfulness-based cognitive therapy in the treatment of recurrent major depressive disorder. Clinical Psychology Review, 37, 26–39. Volkow, N. D., Wang, G. J., Tomasi, D., & Baler, R. D. (2013). The addictive dimensionality of obesity. Biological Psychiatry, 73, 811–818. Vollestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness- and acceptance-based interventions for anxiety disorders: A systematic review and meta-analysis. British Journal of Clinical Psychology, 51(3), 239–260. https://doi.org/10.1111/j.2044-­8260.2011.02024.x Waelde, L. C., Feinstein, A. B., Bhandari, R., Griffin, A., Yoon, I. A., & Golianu, B. (2017). A pilot study of mindfulness meditation for pediatric chronic pain. Children, 4(5), 32. https://doi. org/10.3390/children4050032 Wagner, B. M. (2009). Suicidal behavior in children and adolescents. Yale University Press. Wang, P., Baker, L. A., Gao, Y., Raine, A., & Lozano, D. I. (2012). Psychopathic traits and physiological responses to aversive stimuli in children aged 9–11 years. Journal of Abnormal Child Psychology, 40(5), 759–769. https://doi.org/10.1007/s10802-­011-­9606-­3 Webb, L., Perry-Parrish, C., Ellen, J., & Sibinga, E. (2018). Mindfulness instruction for HIV-­ infected youth: A randomized controlled trial. AIDS Care, 30(6), 688–695. Williams, J. M. G., Duggan, D. S., Crane, C., & Fennell, M. J. (2006). Mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. Journal of Clinical Psychology, 62(2), 201–210. Williams, J. M. G., Fennell, M., Crane, R., & Silverton, S. (2015). Mindfulness and the transformation of despair: Working with people at risk of suicide. Guilford Publications. Witkiewitz, K., Marlatt, G.  A., & Walker, D. (2005). Mindfulness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy, 19(3), 211–228. Wright, K. M., Roberts, R., & Proeve, M. J. (2019). Mindfulness-based cognitive therapy for children (MBCT-C) for prevention of internalizing difficulties: A small randomized controlled trial with Australian primary school children. Mindfulness, 10, 2277–2293. Yen, S., Ranney, M. L., Tezanos, K. M., Chuong, A., Kahler, C. W., Solomon, J. B., & Spirito, A. (2019). Skills to enhance positivity in suicidal adolescents: Results from an open development trial. Behavior Modification, 43(2), 202–221. Yoshikawa, H., Aber, J.  L., & Beardslee, W.  R. (2012). The effects of poverty on the mental, emotional, and behavioral health of children and youth: Implications for prevention. American Psychologist, 67, 272–284.

Chapter 7

Mindful Parenting and Mindfulness-Based Programs on Parents

Evolution of the Construct of Mindful Parenting Many models of parenting have been rooted in social learning theory (Bornstein, 2002; Sanders & Morawska, 2018). Many parent support and education programs have focused on enhancing parents’ knowledge and skills, utilizing universal principles of behavioral approaches to improve child behavior management and address related problems. In contrast, mindful parenting places emphasis on cultivating a mindful and conscious relationship between parents and children, characterized by mutual love and discovery (Kabat-Zinn & Kabat-Zinn, 2021) The primary intention of mindful parenting is not to strive for a better child or parent, but rather to foster awareness and non-instrumental mindfulness practices within parenting interactions. This distinctive approach highlights the value of providing quality attention and unconditional care to promote children’s growth and development. The concept of mindful parenting was first introduced by Myla Kabat-Zinn and Jon Kabat-Zinn (1997/2014). It encompasses the intentional and nonjudgmental ability to be fully present in the parent–child relationship, paying attention to children and parenting. Mindful parenting is an ongoing process that involves developing a heightened awareness of children’s unique qualities, emotions, and needs, as well as an enhanced capacity to be fully present. Through mindfulness practice, parents learn to accept things as they are, without judgment, whether the experiences are pleasant or unpleasant. This practice also helps parents recognize their own reactive impulses and respond to their children with clarity and kindness (Kabat-Zinn & Kabat-Zinn, 2021). The three fundamental components of mindful parenting can be summarized as follows: 1. Sovereignty: This involves recognizing and honoring children’s intrinsic nature, allowing them to be who they truly are, and supporting their growth and development without imposing the parents’ will.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_7

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2. Empathy: Mindful parenting emphasizes the intention to understand children’s perspectives, their emotions, experiences, and struggles. 3. Acceptance: Mindful parenting encourages parents to have a relationship with the present moment and to be mindful of when they may be struggling against the way things are, particularly regarding children’s behaviors that may be upsetting or threatening (Kabat-Zinn & Kabat-Zinn, 1997/2014). Drawing inspiration from the teachings of Kabat-Zinn and Kabat-Zinn, mindful parenting views raising a child as a practice of mindfulness in daily life. Parenting becomes an opportunity for parents to observe themselves, engaging in both an interpersonal process of relating to their child and an intrapersonal process of self-­ reflection. It involves consciously seeking lessons in every situation and making choices based on awareness to nurture the inner growth of both children and parents (Kabat-Zinn & Kabat-Zinn, 1997/2014). As a prominent researcher in the field, Bögels and Restifo (2014) has integrated the key concepts from MBCT, including stress, coping, and automatic pilot, with parenting (Bögels & Restifo, 2014). From an evolutionary perspective, parenting has become increasingly stressful in contemporary societies. The duration of parental roles and responsibilities has extended to 18 years or longer, especially when adult children continue to live with their parents in certain societies. Additionally, many parents no longer have extensive support from extended family and kinship networks. Consequently, parents often find themselves multitasking and experiencing exhaustion while solving problems for their children and families. This leads to more frequent activation of fight-flight-freeze responses and automatic parenting, resulting in decreased sensitivity to their children’s needs. Mindfulness training provides an opportunity for parents to become more aware of moments when they are parenting on automatic pilots. By paying attention to their bodily sensations, feelings, and thoughts under stress, parents can experience differences in the quality of their interactions when they parent more mindfully. Bögels and Emerson (2019) highlight that most MBPs primarily target individuals themselves. However, there is growing evidence supporting the notion that individual mindfulness can improve relational functioning. This sheds light on how mindfulness in parents can positively impact child outcomes, potentially through enhancing self-regulation within family relationships. Thus, an MBP designed for parents can benefit not only the parent’s physical and psychological well-being but also the entire family system, including other family members and their relationships. Mindful parenting has been associated with reduced parenting stress, improved mental health, higher levels of positive parenting practices, and enhanced collaborative parenting for parents (Bögels & Restifo, 2014); Gouveia et al., 2016). For children, mindful parenting is linked to greater well-being encompassing physical, emotional, mental, social, and behavioral aspects, as well as lower levels of psychopathology, including internalizing and externalizing problems (Geurtzen et al., 2015; Parent et al., 2016; Turpyn & Chaplin, 2016). The benefits of mindful parenting have been studied in relation to infants’ hypothalamic–pituitary–adrenal (HPA) axis activity in a study conducted by Laurent et al. (2017). The study involved 73 mother–infant dyads, and hierarchical linear

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modeling was used to analyze the infants’ cortisol trajectories. The results showed that mindful parenting had a significant effect on both maternal and infant cortisol levels. Higher scores in mindful parenting were associated with steeper cortisol recovery slopes in mothers. Maternal mindful parenting also moderated the impact of life stress on mother and infant cortisol levels. Among parents experiencing high life stress, higher levels of maternal mindful parenting predicted lower infant cortisol levels but extended maternal cortisol elevations.

Assessment of Mindful Parenting There has been a growing number of measures designed specifically for mindful parenting in the last two decades (Parent & MiMarzio, 2021), including parent rating, child rating, and behavioral coding, which are reviewed.

Interpersonal Mindfulness in Parenting (IM-P) The Interpersonal Mindfulness in Parenting (IM-P) scale, developed by Duncan (2007), was one of the first self-report measures of mindful parenting. It consists of 31 items and encompasses five dimensions: (1) listening with full attention to the child, (2) nonjudgmental acceptance of the self and the child, (3) emotional awareness of the self and the child, (4) self-regulation in the parenting relationship, and (5) compassion for the self and the child. The psychometric properties of the IM-P have been examined in various studies across different cultures. For example, a validation study of the IM-P scale conducted in the Netherlands by de Bruin et  al. (2014) involved 1177 mothers and resulted in a 29-item version of the scale with a six-factor structure. Emotional awareness of the child and emotional awareness of oneself as a parent were identified as separate factors. Lo et al. (2018) proposed a four-dimensional assessment of mindful parenting based on a sample of Hong Kong Chinese individuals. They developed a 23-item Chinese version of the IM-P scale, which included dimensions, including compassion for the child, nonjudgmental acceptance of parenting, emotional awareness in parenting, and listening with full attention. The scale demonstrated negative correlations with parental depression, stress, and child behavioral problems. Furthermore, Lippold et  al. (2015) modified the IM-P scale by incorporating adolescents’ evaluations of their mothers’ mindful parenting behaviors. This study aimed to explore the relationship between mindful parenting and mother–adolescent communication. The scale used in this study contained 19 items and assessed adolescents’ perceptions of their parents’ mindful parenting behaviors, including dimensions of listening with full attention, exhibiting emotional awareness in parenting, showing self-regulation, and displaying nonjudgmental acceptance and compassion. The scale demonstrated good internal consistency (0.89). It is worth

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noting that including measures of child-reported mindful parenting or using both parent-rated and child-rated versions of IM-P in future studies can provide a more comprehensive understanding of mindful parenting behaviors. The IM-P has also been translated and validated into other languages and cultures, including Portuguese (Moreira & Canavarro, 2017), Korean (Kim et  al., 2019), and Spanish (Orue et al., 2023).

Mindfulness in Parenting Questionnaire (MIPQ) The Mindfulness in Parenting Questionnaire (MIPQ) was developed by McCaffrey et al. (2017) and is designed for parents of children aged 2–16. It consists of 28 items that assess two dimensions of mindful parenting: mindful discipline and being in the moment with the child. The mindful discipline encompasses nonreactivity in parenting, parenting awareness, and goal-focused parenting, while being in the moment with the child including present-centered attention, empathic understanding of the child, and acceptance. The MIPQ has been translated and validated in various languages, including Turkish (Gördesli et  al., 2018), Chinese (Wu et  al., 2019), Spanish (Orue et al., 2020), and Indonesian (Febriani et al., 2021). However, a limitation of the MIPQ is its simple two-dimensional structure, which may limit the interpretation of empirical data in studies on mindful parenting.

Bangor Mindful Parenting Scale (BMPS) The Bangor Mindful Parenting Scale (BMPS), developed by Jones et al. (2018), is based on the Five Facets Theory of Mindfulness (Bear et al., 2008). It consists of 15 items, with three items representing each of the five underlying constructs: observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience. The BMPS has shown good internal consistency and strong correlations with the Five-Facet Mindfulness Questionnaire (FFMQ) and other acceptance measures. A Chinese version of the BMPS has also been developed (Cheung et al., 2019). Further studies are needed to validate the scale in different populations.

 indful Parenting Inventories for Parents (MPIP) M and Children (MPIC) A recent initiative in measuring mindful parenting is the Mindful Parenting Inventories for Parents (MPIP) and Children (MPIC) developed by Acet and Oliver (2023). The inventories consist of 18 items that assess four dimensions of mindful

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parenting: self-regulation in parenting, acceptance, and compassion toward child, being in the moment with child, and awareness of child. What makes the MPIP and MPIC unique is that they include parallel parent- and child-reported inventories, allowing for the measurement of parent and child perspectives of mindful parenting. The inventories have demonstrated good convergent validity and concurrent validity in relation to measures of dispositional mindfulness, traditional parenting constructs, children’s behaviors, and mothers’ psychological distress. However, the scale validation study was conducted with a small sample size and has not been applied to different cultural groups. Further research is needed to validate the inventories in diverse cultural contexts and assess their suitability for intervention outcomes.

 ehavioral Observation: Mindful Parenting Observation B Scale (MPOS) The Mindful Parenting Observation Scale (MPOS) is an observational method developed by Geier (2012) to assess mindful parenting behaviors during interpersonal interactions between parents and children. The MPOS aims to capture how the intrapersonal components of mindful parenting manifest in actual parenting behavior. The MPOS aims to capture how the intrapersonal components of mindful parenting manifest in actual parenting behavior. Youth and parents are required to participate in 15-min structured dyadic recorded interaction tasks, covering a series of 13 questions about the nature of their relationship. Such questions are intended to elicit strong emotional responses and potential disagreements when participants perform the task. The scale consists of 17 behavioral rating scales, such as reactivity, affection, emotion speech, and articulation of present emotion, which assess various facets of mindful parenting as proposed by Duncan (2007). During the assessment, participants engage in structured dyadic recorded interaction tasks, and independent observers rate the behavior of both parents and children based on the rating scales. Each interaction session is divided into five 3-min segments, and ratings are provided at five consecutive time points using a Likert scale ranging from 1 (“Low”/“None”) to 5 (“High”). While the MPOS offers the advantage of providing objective judgments of mindful parenting behaviors by trained observers, its use in research has been limited due to the lengthy procedures involved, which may not be feasible for large-scale studies (Benton et al., 2019).

Adapting MBPs for Parents When adapting MBPs for parents, Bögels and Restifo (2014) developed the Mindful Parenting program, which retains the content and structure of the MBCT program. The program includes mindfulness practices including body scan, mindful eating,

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3-min breathing space, and mindful sitting, and yoga exercises from MBSR/MBCT, but adapts them to the parenting context. Additional practices and exercises are included to promote mindful parenting, such as observing one’s child with a beginner’s mind or using nonjudgmental awareness in interactions. Parents are encouraged to become aware of automatic patterns in their interactions with their child and to use breathing space to delay automatic reactions to their children. The program addresses conflict in the parent–child relationship and mindful limit-setting in parenting. Like MBSR/MBCT, parents are invited to maintain regular formal and informal practices at home, six times per week for approximately 1 h each time. The Mindful Parenting Program is also integrated with a parallel child MBP to form the MYMind program, specifically developed for children with ADHD and ASD and their parents. An interesting mindfulness practice in this program is the “distraction exercise,” where children take turns being the meditators and distractors. The meditators engage in a meditation practice, while the distractors walk around and create distracting noises. The exercise helps parents monitor their children’s improvements in sustained attention and develop nonjudgmental acceptance. Studies of MYMind and other programs that integrated child MBPs have been reviewed in Chap. 5.

 rograms for Parents of Children P with Developmental Challenges Several studies have examined the effects of mindful parenting programs on parents of children with developmental challenges, making adaptations to the standard 8-week MBSR/MBCT program. Neece (2014) conducted a study with 46 parents of preschool children with developmental disabilities. They were randomly assigned to either the MBSR program or a waitlist control group. After the program, parents reported improvements in stress and depression, life satisfaction, child behavior, and attention problems. Benn et al. (2012) conducted an RCT with 32 parents and 38 educators who were part of the special education services office. The MBP in this study was based on the SMART program, originally designed for teacher stress management (which is discussed in Chap. 8 in detail). It consisted of nine sessions, each lasting 2.5  h, and two full-day sessions over a 5-week period. The results showed significant reductions in parenting stress and distress, with increased mindfulness mediating the impact of mindfulness training on reducing negative outcomes. Bazzano et al. (2015) explored the benefits of a modified MBSR program with 76 parents and caregivers of children with developmental disabilities. In this study, the silent retreat was shortened to 4 h, and the daily home practice was reduced to 30 min. There was no comparison group in the study design. The intervention group demonstrated improvements in perceived stress, mindfulness, self-compassion, and psychological well-being, which were maintained at the two-month follow-up. Jones et al. (2018) investigated the outcome of an MBP for 21 parents of children with ID or ASD. The program, similar to MBCT, consisted of eight weekly

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sessions, each lasting 2  h, without a retreat. The practice CD was shortened to 5–20 min. Statistical analysis revealed significant increases in mindfulness and self-­ compassion, as well as reduced general stress. Another study focusing on the Mindful Parenting program designed by Bögels and Restifo (2014) was conducted by Liu et al. (2021) for Chinese parents of children with ADHD. Participants (n  =  113) were randomly assigned to either the mindfulness group or the waitlist control group. After 8 weeks, parents in the mindfulness group showed a significantly greater reduction in parental stress, with a small effect size, compared to the waitlist control group. They also exhibited greater improvements in mindfulness and self-compassion, with moderate effect sizes, but not in mindful parenting, compared to parents in the control group. The study provided preliminary evidence of the mediating effects of mindfulness and self-compassion on their children’s ADHD symptoms and behavioral symptoms issues, as well as their own parenting stress, indicating potential mechanisms of change in MBP programs for parents. In addition to the standard 8-week MBPs, some practitioners and researchers have explored alternative program structures to accommodate parents who work full-time or have demanding household responsibilities. Brief MBPs have been developed for this purpose, aligning with the low-intensity public health intervention approach, which is more cost-effective for the health and social care system. Dykens et al. (2014) conducted an RCT of 243 mothers of children with developmental disabilities, comparing the effects of a 6-week MBP with a positive psychology program. The modified MBP, lasting for 6 weeks with 1.5-h sessions, showed significant improvements in anxiety, depression, sleep, and well-being. The effect sizes for improvements in depression and anxiety were large. However, the study lacked detailed information about the intervention’s content, time allocated for mindfulness practice during class and at home, and the rationale for using qigong instead of yoga, creating challenges in replicating the study. Similarly, Lo et al. (2017) developed a brief MBP consisting of one 1.5-h session per week for 6 weeks. Audio practice files, ranging from 10 to 15 min, were provided to the participants. In a feasibility study, 180 eligible parents of children with developmental disability were recruited and assigned to either the MBP or a treatment-­as-usual group. After completing the program, parents experienced significant improvements in parental stress, depression, and stress relating to dysfunctional parent–child interaction. However, no significant improvements were observed in children’s behavioral problems. At baseline, parents with severe stress and depression showed more substantial positive changes, with moderate effect sizes for improvements in parenting stress and depression. Gershy et al. (2017) conducted an RCT to evaluate the effects of a single 90-min session of an MBP for parents of children with ADHD and behavioral challenges. A total of 79 families were randomly assigned to either the regular parent program or a mindfulness-enhanced program. However, only 43 families completed the training. The study found that fathers in the mindfulness-enhanced program showed significantly better effects in emotion regulation compared to the regular program. No significant differences were found in child outcomes, such as reduced externalizing symptoms, between the two groups at the end of the intervention.

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In a pilot study by Myers et al. (2018), a health promotion program was implemented for overweight or obese adolescents (n = 32) with ID. The program consisted of 10-week training for the parents through an online platform. The training integrated mindfulness exercises with health education, including physical exercise, healthy eating and nutrition, mindful eating, mindful responses to thoughts of hunger, and mindfulness training to control the urge to eat. Parents then delivered the training to their children. Only two participants dropped out, and those who completed the MBP lost an average of 38.27 lbs. (17.36 kg) by the end of the intervention, maintaining their target weight for four consecutive years. A similar study conducted by Myers et al. (2023) investigated the effects of the Mindfulness-Based Health Wellness (MBHW) program using telehealth. In this study, 80 adolescents with intellectual and developmental disabilities (IDDs) were randomized into experimental and control groups. The experimental group engaged in the program as taught by their families, while the control group received treatment as usual. The adolescents in the experimental group self-determined the parameters of each component of the MBHW program and engaged in self-paced weight reduction. All 42 adolescents in the experimental group reached their target weights by an average of weight 38 lbs., indicating a significant reduction in weight and body mass index (BMI). In contrast, the control group only reduced their weight by an average of 3.47 lbs. at the posttest. This study demonstrated that parents and caregivers can effectively support adolescents with IDDs in using the MBP to manage their weight and overall health. Mah et al. (2020) examined the efficacy of a mindfulness-enhanced behavioral parent training program compared to a standard parent program for families of children with ADHD. The families were randomly assigned to either a mindfulness-­ enhanced program or a standard parent program and participated in 12 weekly 2-h sessions. Parents in the mindfulness-enhanced program reported a reduction in harsh discipline practices and improved self-regulation compared to the control group. Parents in the standard program reported a decline in behavioral regulation. Both groups showed improvements in parenting sense of competence and child ADHD symptoms, but there were no significant differences in mindful parenting or parenting stress between the two groups. The mixed results in the control group indicated that parents may face challenges in applying behavioral strategies to manage their children’s behaviors, while the MBP can help improve parents’ flexibility, patience, and nonreactivity in handling their children’s ADHD symptoms. Several studies have focused on the 8-week Mindfulness-Based Positive Behavior Support (MBPBS) program for parents of children with developmental challenges. Unlike many other MBPs, the MBPBS can be delivered in a one-on-one format by the trainer, catering to each individual parent. The training incorporated Buddhist teachings, such as the four immeasurables (loving-kindness, compassion, joy, and equanimity), the three poisons (attachment, anger, and ignorance), Shenpa and compassionate abiding, and meditation on the Soles of the Feet, along with behavior analysis techniques for interactions with children. Singh et al. (2014) conducted a study to examine the effect of MBPBS on three parents of adolescents with ASD,

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aged 15–19 years. The results reported improvements in challenging behaviors and compliance behaviors of the adolescents following their mothers’ MBPBS training. Building on this research, Singh et al. (2019) conducted an outcome study with a larger sample size (n = 92) by evaluating the differential effects of MBPBS on the stress levels of mothers of adolescents with ASD or ID. The study also examined the effects of the program on children’s aggressive, disruptive, and compliance behaviors. Participants completed a 40-week study, including 10  weeks of control and 30 weeks of the MBPBS program. They rated their own stress levels and collected observational data on the adolescents’ behavior. Significant reductions in parenting stress were observed in both groups of mothers, regardless of whether children had ASD or ID. Additionally, improvements were noted in child aggression, disruptive behavior, and compliance behaviors, indicating that the program was equally beneficial for mothers of adolescents with ASD or ID. In a recent three-arm RCT, Singh et al. (2021) conducted a component analysis of the MBPBS program for mothers of children with ASD. The study consisted of a 10 weeks pretreatment control condition, followed by 30 weeks of intervention, and a 3 years post-intervention follow-up. Mothers were randomly assigned to the three arms: mindfulness, behavioral analysis program, or MBPBS, which included both programs. Participants in all three arms underwent 3 days of training. A total of 195 mothers were randomly assigned to three arms, and the effects of the programs on the mothers and the spillover effects on their children with ASD were assessed. The results revealed that the MBPBS arm reported greater reductions in perceived psychological stress, followed by the mindfulness arm, while participants in the behavioral analysis arm did not show significant changes. Similar patterns were observed for improvements in child aggression, disruptive behavior, and compliance, with MBPBS showing the largest positive changes and the behavioral analysis condition reporting the least changes. The improvements in both mothers and their children were maintained for 3 years post-intervention. When controlling for time and type of intervention, the time spent in meditation emerged as a significant predictor of improvements in child behavior.

 rograms for Parents of Children with Mental P Health Challenges In a previous study, Bögels et al. (2013) examined the effectiveness and acceptability of the 8-week Mindful Parenting program in mental health care. The study used a waitlist-controlled design and included 86 parents who were referred to the program due to their children and/or their own psychopathological symptoms. The results showed that the program led to improvements in the children’s internalizing and externalizing problems, and these improvements were generally maintained during the follow-up period. Another study compared the effects of the Mindful Parenting program as a preventive intervention for 98 parents experiencing parental stress or problems (nonclinical sample) with those of a curative intervention for 87

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parents in mental health care for their own or their children’s psychiatric problems (clinical sample). At the baseline, the parents from the nonclinical sample displayed greater well-being and fewer behavior problems, but similar levels of parental stress, parental overreactivity, mindful parenting, and partner relationship when compared to the parents in the clinical sample. The results revealed that improvements in child well-being and behavior problems, although small in effect size, were associated with improved mindful parenting. This suggests that the benefits of the program can extend to parenting behaviors and positively impact their children’s functioning. In a replication study conducted by Meppelink et al. (2016), 70 parents of school-­ age children with psychopathology participated in the same Mindful Parenting Program. The study found a significant decrease in both children’s psychopathology and parents’ psychopathology, as well as a significant increase in mindful parenting and general mindful awareness. The improvement in general mindful awareness predicted a reduction in parental psychopathology, while the improvement in mindful parenting predicted a reduction in child psychopathology. A study in Australia focused on a sample of 21 parents of young children aged 3–7 diagnosed with anxiety disorders, using an open trial design (Farley et  al., 2023). The parents reported significant improvements in mindful parenting and dysfunctional parent–child interaction, although no significant changes were observed in mental health symptoms. The study also found significant reductions in parent-­ rated child anxiety symptoms, the severity of child anxiety diagnoses, and the number of comorbid diagnoses. However, it is important to note that the study had limitations, including the absence of a control group, a small sample size, and a high dropout rate of over 40%. To reduce caregiver burden and promote the recovery of young adults with psychosis in Hong Kong Chinese individuals, Lo et  al. (2019) developed a Brief Mindfulness-Based Family Psychoeducation (MBFPE) program. An RCT was conducted to compare this intervention with an ordinary Family Psychoeducation (FPE) program. Both MBFPE and FPE programs consisted of six sessions, each lasting for 2 h. The study involved 65 caregivers of young adults who experienced the onset of the first episode of psychosis within the last 3 years (Zhang et al., 2023). Among them, 18 young adults in recovery participated in the evaluation of recovery outcomes. The results showed that while there were no significant differences between MBFPE and ordinary FPE programs in terms of caregivers’ outcomes, the young adults with psychosis reported higher levels of recovery after the MBFPE program. They also reported a greater reduction in the overinvolvement of caregivers (Zhang et al., 2023). Interestingly, the caregivers following the MBPFE reported a significant and large effect size on positive caregiving experiences at the nine-­ month follow-up compared to the control group (Zhang et al., in review). Young adults with psychosis reported that their caregivers following MBFPE showed significantly greater reductions in criticism and hostility during the follow-up period, suggesting that the MBFPE program may be more effective in promoting recovery and reducing expressed emotions, which could significantly decrease the risk of relapse.

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In addition to the quantitative findings, Lo et al. (2022b) conducted a study to explore the experiences of caregivers using a technique called photovoice. This technique involved caregivers sharing and discussing photographs related to their caregiving experience. The researchers transcribed the caregivers’ inquiries with the MBFPE instructors and conducted qualitative analysis on the photo images, participants’ reflections, and inquiries. The analysis identified six themes that shed light on the lived experience of caregivers: (1) I pay attention to the present moment, (2) I care about my family; (3) I trust my children; (4) I appreciate the connection with and support from nature and the universe; (5) I observe my worries and guilt and learn not to be reactive; and (6) I find space in offering care and exercising self-care. The application of photovoice offers an innovative approach to enhance the awareness and insights of parents in an MBP, but it can also be utilized in any MBP participant, including children and adolescents.

Programs for Parents Encountering Social Challenges The social unrest that emerged in Hong Kong in 2019 had a significant impact on public mental health and intergenerational family relationships. In response, a study conducted by Lo et  al. (2022a) explored the outcomes of a four-session mindful parenting workshop called “Restoration and Reconnection” on parent mental health and family functioning. Using an RCT, 54 parents of adolescents and young adults were assigned to either the intervention group or the waitlist control group. The study found a significant increase in family functioning in the intervention group compared to the control group. Additionally, when controlling for child-initiated physical conflict as a covariate, the intervention group exhibited a significant reduction in self-rated depressive symptoms compared to the control group. In another study, Wiliams (2020) evaluated the effects of an MBP on 67 low-­ income, ethnically diverse parents of preschool children using a waitlist control group design. The results demonstrated large effect sizes in improvements in mindful parenting and parenting following the MBP. This highlights the effectiveness of MBP in providing support to parents facing disadvantaged conditions.

Parents of Children in Nonclinical Samples Coatsworth et  al. (2010) conducted a pilot RCT with 65 families to evaluate the outcomes of an MBP. The study compared an evidence-based parenting program with an enhanced program that included mindfulness exercises for parents and youth aged 10–14. The results indicated that the MBP produced similar effects to the original program on child management practices and showed stronger effects on mindful parenting and parent–youth relationship qualities.

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The same research team conducted a large-scale replication study involving 432 families to compare the Strengthening Families Program, with the Mindfulness-­ Enhanced Strengthening Families program and a control group (Coatsworth et al., 2015). The enhanced program included a brief mindful breathing exercise. Mothers in the MBP reported improved affective/interaction quality with their youth, as well as better inductive reasoning, monitoring, and communication about alcohol rules. Fathers in the MBP reported better inductive reasoning, monitoring, and communication about alcohol rules with their youth. However, there were no significant differences between groups in terms of parent well-being. Furthermore, Corthorn (2018) conducted a study on MBSR for mothers of preschool children in Chile. The study included 21 participants in the MBP and 22 participants in the comparison group. The MBP group demonstrated a significant reduction in general and parental stress and an increase in mindful parenting and general mindfulness compared to the comparison group. Effect sizes ranged from small to medium, with the highest effect observed in stress reduction (general and parental) and mindful parenting. These effects were maintained at the 2-month follow-­up assessment.

Online MBPs for Parents Online MBPs have gained popularity, especially during the COVID-19 pandemic, as practitioners and researchers have adapted to the use of technology. Several studies have explored the effectiveness of online MBPs for parents. Guenther et  al. (2021) conducted a study with 22 parents and their healthy school-aged children, implementing a 6-week online program that included regular meetings with instructors, as well as additional resources such as books, worksheets, audio recordings, and daily practices. Participating families reported satisfaction, indicating the feasibility of adapting the program for further use in clinical populations. Potharst et al. (2019) conducted an RCT with 76 mothers, randomly assigning them to an 8-week online MBP or a waitlist control group. The sessions lasted for 35–50 min, and the home practice was 1–20 min. The online MBP showed significant improvements compared to the waitlist period in terms of overreactive parenting discipline, symptoms of depression, and anxiety, with small-to-medium effect sizes. Boekhorst et  al. (2021) conducted an RCT with 157 mothers of preschool children using an online MBP. Significant improvements were found in personal goals, self-compassion, parental overreactivity, anxiety, and depressive symptoms posttest and at follow-up, with small-to-medium effect sizes. However, attrition was a major issue, with only 23% of participants completing the training. Portnoy et al. (2022) compared the effects of online MBP with face-to-face MBP in a study of 37 parents. Both groups showed significant benefits in terms of parent well-being and self-compassion, and the delivery options (online vs. face-to-face) were equally effective.

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However, it should be considered that studies on online programs for clinical populations are limited. Incorporating professional contact and clarifying expectations for strengthening the rapport were recommended for online interventions (Hall & Bertuccio, 2021). In a study by Lo et al. (in review), an online MBP for parents of children with ADHD, involved 43 parents and randomly assigned them to the intervention group and waitlist control group. The MBP lasted for 28 days and consisted of psychoeducation videos, audio for homework guidance, and online instructor-led meetings. The online MBP showed promising effects, including a medium-to-large effect on reducing child ADHD symptoms. Participants reported positive experiences and personal changes in emotion regulation and paying quality attention to their children in qualitative interviews. These findings suggest that online MBPs for parents can be effective in improving various aspects of parenting and parental well-being. However, attrition rates and the need for professional contact remain important considerations for successful implementation. Further large-­ scale RCTs are recommended to investigate the effects of online MBPs, especially in clinical populations.

 vidence of MBPs for Parents in Systematic Reviews E and Meta-Analyses Systematic reviews and meta-analyses have been conducted to evaluate the effects of MBPs on parents. Burgdorf et al. (2019) conducted a meta-analysis based on 25 selected studies, including open trials and RCT studies. They found a small effect size in post-intervention reduction in parenting stress and a moderate effect size at 2-month follow-up. Changes in parenting stress predicted changes in youth externalizing problems and cognitive outcomes but not in internalizing problems. In RCTs, the improvement in parenting stress was significantly larger than that in control groups. Anand et al. (2021) conducted a systematic review including 20 studies with a total of 1003 parents. They found moderate effects on general stress, internalizing psychological symptoms, and well-being, and small effects on mindfulness, parenting stress, and parenting behavior. However, MBPs did not show positive effects on parent–child interactions, marital outcomes, self-compassion, emotion regulation, general mindfulness, or mindful parenting. Subgroup analyses suggested that participants with clinical conditions benefited more than those with subclinical conditions. Additionally, parallel MBPs involving both parents and children showed slightly greater improvement in parent well-being compared to MBPs for parents alone. Shorey and Ng (2021) conducted a meta-analysis specifically focusing on RCT studies. They included 11 studies with a total of 1340 participants. The overall intervention effects for mindful parenting and parenting stress were found to be insignificant. However, subgroup analysis indicated a moderate effect size when MBPs were specifically targeted at parents of children from nonclinical samples. The

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outcomes related to parenting behaviors, psychological well-being, relationships, and child behavior were inconclusive due to the limited number of studies. These reviews highlight some inconsistencies in the findings of MBPs for parents, which may be attributed to differences in selection criteria, data analysis procedure, and the heterogeneity of participants, program content, and structure. The limited number of studies available and the variety of factors involved in MBPs pose challenges and limitations in comparing and synthesizing the outcomes of these interventions. Further research, including larger-scale studies with standardized methodologies, is needed to provide more conclusive evidence on the effectiveness of MBPs for parents.

Implications for Research We summarize the implications of research in the field of MBPs for parents including: 1. Conceptualization and Measurement: There is a need for further clarity in the conceptualization of mindful parenting, as well as the development and validation of standardized measures. Researchers should work toward reaching a consensus on the definition of mindful parenting and its cultural relevance. Additionally, exploring the dynamics between intrapersonal and interpersonal dimensions of mindful parenting would enhance the design of MBPs. 2. Diverse Populations and Program Structures: Parents in clinical populations and nonclinical populations have different needs, and MBPs should be tailored to suit these diverse populations. Researchers and practitioners should consider developing flexible program structures, such as brief intervention, single sessions, online formats, or self-help options, to accommodate the accessibility and preferences of parents. Service mapping and practice guidance can support the planning and provision of MBPs that meet the needs of families. 3. Setting Outcomes and Change Mechanisms: Researchers should strategically select individual and relational outcomes to assess the benefits of MBPs for parents. Identifying specific outcomes or change mechanisms that are most effective in supporting parents would enhance the design and implementation of MBPs. The relationship between reductions in parenting stress and improvements in youth outcomes should be further explored, considering the complexity of family dynamics. 4. Parent-Only vs. Parent–Child Parallel MBP: The differential effects of parent-­ only MBPs and parent–child parallel MBPs require further investigation. Studies have shown mixed results in terms of outcomes and benefits. Comparisons should be made to determine whether a parent-only MBP can produce comparable effects to parallel programs involving both parents and children.

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Implications for Practice The implications for practice in the field of MBPs for parents include: 1. Emphasizing the Core Principles and Components of MBP for Parents: MBPs for parents should prioritize the use of present-moment awareness, acceptance, and compassion in parenting throughout the program. While integrating other psychological approaches may be beneficial, the core principles of mindfulness should remain central to the MBPs for parents. 2. Tailoring Practices for Different Ages: As mindfulness practice is mostly individual-­ focused, further development of MBPs for parents and families should consider creating different practice exercises for parents and family members of different ages. This alternative program structure can promote interpersonal and intergenerational mindfulness, benefiting a wider range of children, parents, and families.

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Wu, L., Buchanan, H., Zhao, Y., Wang, P., Zhan, Z., Zhao, B., & Fan, B. (2019). Translation and validation of a Chinese version of the mindfulness in parenting scale questionnaire (MIPQ). Frontiers in Psychology, 10, 1847. https://doi.org/10.3389/fpsyg.2019.01847 Zhang, Z. J., Lo, H. H. M., Ng, S. M., Mak, W. W. S., Wong, S. Y. S., Hung, K. S. Y., Lo, C. S. M., Wong, J. O. Y., Lui, S. S. Y., Lin, E., Siu, C. M. W., Yan, E. W. C., Chan, S. H. W., Yip, A., Poon, M. F., Wong, G. O. C., Mak, J. W. H., Tam, H. S. W., Tse, I. H. H., & Leung, B. F. H. (2023). The effects of a mindfulness-based family psychoeducation intervention for the caregivers of young adults with first episode psychosis: A randomized controlled trial. International Journal of Environmental Research and Public Health, 20, 1018. https://doi.org/10.3390/ijerph20021018 Zhang, Z. J., Lo, H. H. M, Ho, W. C., Lau, E. N. S., Ng, S. M., Mak, W. W. S., Wong, S. Y. S., Hung, K. S. Y., Lai, I. Y. S., Lo, C. S. M., Wong, J. O. Y., Lui, S. S. Y., Siu, C. M. W., Yan, E.  W. C., Chan, S.  H. W., Lin, E., Wong, G.  O. C., Mak, J.  W. H., Tam, H.  S. W., & Tse, I. H. H. (in review). Mindfulness-based family psychoeducation intervention for caregivers of young adults with first-episode psychosis: Results at 9-month follow-up.

Chapter 8

Mindfulness in Teaching and Education

 he Role of Mindfulness in Teaching and the Role of Teachers T in Mindfulness Teaching Teachers hold significant roles and responsibilities in supporting the growth and development of children, and their impact should never be underestimated. Mindful teachers have the potential to inspire and empower students in their learning and developmental journeys. They can also serve as a reliable support system for students facing transitions and challenges in their lives. However, the involvement of teachers in mindfulness teaching can vary, ranging from inviting external mindfulness instructor or leading occasional mindfulness practices outside the regular curriculum to taking on a comprehensive MBP after receiving extensive training. The existing literature provides limited models and evidence regarding teachers’ involvement in this process. Hawkins (2017) suggests three dimensions of mindfulness in teaching: 1. Being Mindful: Teaching can be stressful and emotionally draining, putting teachers at risk of burnout, similar to social workers or psychologists. Being mindful helps teachers maintain personal emotional balance amidst the stress of teaching profession and school environment. 2. Teaching Mindfully: This dimension emphasizes the presence of the teacher in the learning process. Mindful awareness increases sensitivity to students’ needs and the teachers themselves. It also highlights the importance of relational competence in teaching and learning and the quality of relationships with students. 3. Teaching Mindfulness: Students can learn mindfulness techniques to enhance attention and focus, emotion regulation, and stress management through teacher-­ led MBPs. However, not every teacher is obligated to possess the knowledge and skills to teach an MBP.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_8

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Educators have also identified additional themes regarding the impact of mindful teachers on school culture, particularly in fostering a democratic learning environment. Firstly, being mindful ensures that every student’s voice is heard and that different perspectives and cultural realities are shared and respected. Mindful teachers can create a community characterized by respect, competence, personal regard, and integrity, which safeguards students’ interests and well-being (Seigle et  al., 2019). Secondly, mindfulness serves as a valuable resource for school leaders to effectively support individual and organizational growth and transformation across various domains, including their personal lives (Drago-Severson & Blum-Destefano, 2019). Thirdly, mindfulness promotes teachers’ embodiment in the classroom, including emotional calmness, mental clarity, and interpersonal kindness (Taylor et al., 2019). Finally, teachers can establish partnerships with parents to promote positive social–emotional learning development and academic performance (Coatsworth et al., 2019). Recently, Lavy & Berkovich-Ohana (2020) proposed a Mindful Self in School Relationships Model to explain the positive effects of mindfulness in schools for both teachers and students. In this model, mindful teachers decrease self-­ centeredness, leading to enhanced emotion regulation, empathy, and compassion. Ultimately, this fosters improved relationships within schools, increases teacher well-being and effectiveness, and promotes student well-being and social and academic development. Further research is needed to validate this model with empirical data. However, the model does not explicitly address the connection between teachers, teacher–student relationships, and the broader world. Hawkins (2017) adds an important note about the role of a mindful teacher beyond the classroom, which involves prioritizing the heart of learning and the needs of children in education, considering local and global development. Promoting self-awareness in education serves as a foundation for understanding oneself, others, and the overall flourishing of human beings. In other words, teachers play a prominent role in aligning children, schools, and education with the community and the wider world, with the intention and vision of creating a healthy, balanced, and sustainable society.

Assessing Mindfulness in Teaching Frank et  al. (2016) developed and validated the Mindfulness in Teaching Scale (MTS) specifically for assessing teacher mindfulness in an educational context. The MTS consisted of two dimensions, intrapersonal mindfulness and interpersonal mindfulness. It is a self-reported scale designed for teachers from kindergarten to grade 12. The scale comprises 14 items, with nine items assessing intrapersonal mindfulness and five items assessing interpersonal mindfulness. The MTS has been translated and validated in cross-cultural samples, including Chinese (Li et  al., 2019), Korean (Kim & Singh, 2018), Spanish (Moyano et al., 2023), and Turkish samples (Gördesli et al., 2019). These validation studies

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provide preliminary evidence that the concept of mindfulness in teaching has relevance across cultural contexts. As of the time of writing, no similar selfreported measure specific to teacher mindfulness has been identified in this area of interest.

Mindfulness-Informed Programs for Teachers While studies have consistently shown that MBSR/MBCT can improve teachers’ well-being and mental health, few mindfulness programs have been specifically adapted for teachers, educators, and staff in educational settings.

CARE for Teachers One such program is the Cultivating Awareness and Resilience in Education (CARE) program. CARE is a professional development program that supports teachers in handling stress, reducing burnout, and enhancing teacher effectiveness. It aims to improve the quality of teaching of teachers by promoting teacher awareness, presence, compassion, and reflection. The CARE program does not have a fixed format and can be tailored to the specific needs of individual schools or districts. There is also a version of CARE designed for principals and administrators, addressing their unique needs. The CARE program is the most extensively studied mindfulness program for teachers. In an earlier RCT with 50 teachers, participants who underwent the CARE program reported significant improvements in teacher well-being, efficacy, burnout/ time-related stress, and mindfulness compared to the control group (Jennings et al., 2013). A subsequent cluster RCT involving 36 elementary schools and 224 teachers further investigated the efficacy of the CARE program (Jennings et al., 2017). At both pre-intervention and post-intervention, both teachers’ self-ratings and students’ assessments were collected. The results showed that after the program, teachers exhibited significant positive effects on adaptive emotion regulation, mindfulness, psychological distress, and time urgency. The program also had a significant positive effect on emotional support based on direct observations. These findings indicated that the CARE program can enhance teachers’ social and emotional competence and improve the quality of their classroom interactions. More recently, the effectiveness of the CARE program was examined in Croatia using self-report assessments and physiological data collection (Mihić et al., 2020). The participants reported significant positive effects on self-compassion after the program, but no significant effects were found on mindfulness, burnout, or compassion. At the 6-month follow-up, participants showed higher levels of observing, self-compassion, and compassion, as well as lower levels of overidentification and

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disengagement (subscales of compassion and self-compassion) compared to the control group. However, there were no significant effects on burnout measures at follow-up. Participants also exhibited lower average heart rates than the control group, immediately after the program, although this effect was not maintained at follow-up. No significant effects on blood pressure measures were found at posttest or follow-up. These studies collectively demonstrate the potential benefits of the CARE program, for teachers’ well-being, classroom interactions, and social–emotional competence.

SMART Program The SMART program is an evidence-based course designed to help kindergarten to grade 12 teachers better manage work-related and personal stress while cultivating emotional balance. It integrates MBSR, the Mindful Self-Compassion program, and concepts from emotional literacy and positive psychology to address the specific needs and challenges faced by teachers. The program consisted of eight 2-h sessions and a 4-h silent retreat. To make it more manageable for teachers, the home practice has been reduced to 15–20  min per day. Additionally, variations of the SMART program have been developed for educators in tertiary institutions, nursing, caring professions, and organizational leaders. To investigate the effects of the SMART program on teachers, a study was conducted using a waitlist control design (Roeser et al., 2013). The study involved 113 elementary and secondary school students from Canada and the United States. The results showed that teachers who completed the SMART program experienced significant increases in focused attention, working memory, and self-compassion. They also reported reduced work stress, burnout, anxiety, and depressive symptoms compared to the control group. However, no significant differences were found in physiological measures of stress between the groups.

.begin Another program called .begin was introduced by the Mindfulness in Schools Project. It serves as an introductory program for teachers to understand mindfulness and improve well-being. The .begin program spans 90  min and lasts for 8 weeks, resembling an adapted version of MBSR/MBCT for teachers. Unfortunately, no studies have investigated the effects of the .begin program specifically on teachers.

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 ore Evidence About Students’ Benefits from MBPs M for Teachers While many meta-analyses have examined the effects of MBPs on teachers’ well-­ being, psychological stress, burnout, and teaching practices, few studies have explored the impact on students (Emerson et al., 2017; Hwang et al., 2017; Zarate et  al., 2019). For example, in the most recent meta-analysis, Zarate et  al. (2019) included 18 studies and 1001 educators and reported positive outcomes including increased mindfulness and reductions in stress, anxiety, depression, and burnout, with small-to-large effect sizes. However, most of the earlier studies of MBPs for teachers focused on assessments on teacher outcomes, and few have included measures on students. One small study by Singh et al. (2013) evaluated the benefits of an 8-week MBP for three teachers and its effects on 18 preschool children with mild ID. The results showed significant reductions in socially unacceptable behaviors, improved compliance with teacher requests, and enhanced social interactions with peers after the teachers completed the mindfulness training. In a large cluster RCT involving 185 teachers from 20 Australian schools, Hwang et al. (2019a, b) examined the effects of an 8-week MBP on teachers’ well-being and teaching quality. The MBP for teachers called Reconnected was delivered by an external organization independent of the research team. It aimed to provide educators with support for stress management, mindfulness, self-awareness, and emotional regulation. The outcomes of the study included teachers’ ratings of their relationships with students, students’ ratings of their sense of relatedness to teachers, and independent observers’ assessments of teachers’ verbal interactions with students. The study found no significant change in teachers’ ratings of teacher–student relationships. However, there was a significant increase in students’ ratings of their sense of connectedness to teachers. Classroom observations of a subset of 60 teachers showed positive changes in person-centered teaching practices, such as reduced teacher talk, increased indirectivity in teaching, and increased student talk immediately after the program and at the 6-week follow-up. Similarly, a RCT conducted in Portugal by de Carvalho et al. (2021) examined the effects of an MBP on teachers. An MBP program called Atentamente was specifically designed for teachers, consisting of 30 h through 10 weekly 2.5-h sessions and a 5-h booster session 3 months after the tenth session. It aims to foster the well-­ being of teachers by cultivating mindfulness, social–emotional competence, and compassion. They followed up with a subsample of 41 teachers from the intervention group and 18 teachers from the waitlist control group. The study also involved 1503 students and 1494 parents from the intervention group and 947 students and 913 parents from the waitlist group. The results indicated significant improvements in independent observers’ ratings of the teacher’s competence in engaging students in the classroom after MBP. There were also improvements in students’ ratings of the teachers’ involvement in classroom relationships, students’ self-reported affect, and parents’ perceptions of their children’s social competencies compared to the control group.

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In the United Kingdom, a study was conducted prior to the implementation of the MYRIAD project (Kuyken et al., 2022). A total of 679 teachers from 85 schools were randomly assigned to either continue with an ordinary social–emotional learning curriculum (control group) or participate in an MBP. All schools nominated up to 15 teachers for personal mindfulness training, and no more than five of them would continue SMBP teacher training. The mindfulness group, after an 8-week MBCT for life intervention, reported small effect sizes of reductions in exhaustion and increases in personal accomplishment, school leadership, and a respectful climate. However, these effects were not maintained except for the improvement in a respectful climate at the one-year follow-up. There were no significant between-­ group differences in other outcomes, including student engagement, teacher mental health, mindfulness, and staff attitude. In summary, the findings suggest that MBPs for teachers can have positive effects on their well-being, reducing stress and burnout, and potentially improving classroom dynamics and teaching quality.

 Whole-School Approach: An Answer for Effective A Promotion of Mindfulness in Schools? A whole-school approach has emerged as a promising strategy for effectively promoting mindfulness in schools. Unlike approaches that focus solely on the impact of a SMBP on individual students, the whole-school model emphasized collaboration and integration across the entire educational environment (Jennings 2023; Roeser et al., 2023; Weare, 2023). This approach, which has been developed over several decades, encourages educational and health organizations to work together to enhance student well-being and academic outcomes (Hunt et al., 2015). For educators interested in implementing and promoting social–emotional learning within a whole-school model, the ASPIRE principles and pedagogy provide valuable guidance (Roffey, 2017). ASPIRE represents six core values, each represented by the first letter of its component: Agency, Safety, Positivity, Inclusion, Respect, and Equity. The agency emphasizes empowering students to make their own decisions, reflect on issues, engage in discussions with peers, and take actions in the classroom to put learning into real life. Safety encompasses physical, emotional, and psychological well-being and protects students from risks such as overt and covert bullying. Positivity, grounded in positive psychology, focuses on fostering growth and flourishing rather than emphasizing deficits and faults. Inclusion promotes a sense of connectedness, belonging, and shared humanity, while also recognizing and celebrating diversity. Respect involves honoring and valuing individuals, acknowledging their presence, effort, feelings, competences, and cultural contexts. Equity emphasizes fairness, cooperation, and recognizing both the unique qualities and commonalities among people. The whole-school approach goes beyond implementing an additional curriculum and instead encompasses comprehensive policies and practices. These may include health and mental health education, teacher well-being, creating a social and

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emotional school climate, optimizing the physical environment and health, providing health and counseling services, engaging the community, and involving families in the educational process. Various pedagogies and learning activities are employed to promote students’ overall well-being within this approach (Roffey, 2017). Importantly, the whole-school approach aligns with the values and principles of mindfulness and MBPs, particularly in fostering social–emotional development, empathy, creativity, relationships, and compassion, which empower students to thrive. Implementing a whole-school model for promoting mindfulness requires wisdom, collaboration, and careful consideration of various factors. Several studies have provided insights into the practical aspects of implementing mindfulness in a whole-school approach. Sheinman et al. (2018) evaluated the long-term impact of a mindfulness whole-school approach on three public schools in Israel. One school had been implementing the whole-school approach for 13 years, a second school had been implementing it for 1 year, and a third had no mindfulness implementation and thus served as a comparison. The study involved 646 students aged 9–12 and found significant differences in the use of mindfulness-based coping strategies among schools with respect to students’ use of mindfulness-based coping strategies. However, the study did not include teacher factors and variables, highlighting the need for a more comprehensive approach. Ventura et al. (2023) investigated the implementation of the MindUP program, which follows a whole-school approach, in an elementary school. The study emphasized parallel programs for staff and students, including specific programs for students with emotional–behavioral disorders (EBD). The quantitative data showed improvements in aggression, attention, and social–emotional competence for students in regular education and improvement in aggression for students with EBD. The qualitative data highlighted the role of teacher feedback in program adaptation and improvements in school climate and coping skills. Hudson et al. (2020) aimed to identify the determinants of successful implementation of a mindfulness whole-school approach in five secondary schools in the United Kingdom. The study explored school staff attitudes, beliefs, and experiences regarding implementation. The interview data were coded according to the Consolidated Framework for Implementation Research (Damschroder et al., 2009). The findings revealed that school leadership played a crucial role in differentiating high- and low-implementation schools, along with other factors such as relative priority, networks and communications, formally appointed implementation leaders, and knowledge and beliefs about the intervention. Each study mentioned above has its own research questions and designs, highlighting the unique contexts encountered by individual schools, communities, and cultures. Ergas and Hadar (2019) identified two major patterns in studies of mindfulness and education: mindfulness in education vs mindfulness as education. Most studies on MBPs fall into the former category, where mindfulness is implemented as an additional curriculum to address student stress and specific challenges such as special needs of students with developmental disabilities. However, a smaller proportion of studies aim to integrate mindfulness as part of the educational process,

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involving teachers and school staff who practice and embody mindfulness in daily working environments. The study by Hudson et al. (2020) is particularly noteworthy as it integrates an implementation framework and links it to program outcomes. The identification of school leadership as a crucial factor aligns with the critique by Ergas and Hadar (2019) that successful whole-school approaches depend on highly committed educators. Scaling up mindfulness as education to other school contexts may be challenging without the necessary conditions and support. Implementing mindfulness as a key mechanism within a whole-school approach for promoting student well-being and mental health is appealing. However, it is important to consider the challenges and barriers that may arise during implementation. Chapter 9 discusses recent concepts and ideas in implementation sciences and their relevance in MBPs for children within the school context, providing further insights into practice.

Implications for Research The studies on MBPs specifically designed for teachers and their impact on students and schools are accumulating. Further research may focus on the following areas: 1. Conduct Longitudinal Studies: More longitudinal studies are needed to assess the long-term effects of MBPs for teachers. These studies should evaluate programs and strategies that can sustain their mental health and well-being in a stressed working environment. 2. Investigate the Impact of MBPs for Teachers on Classrooms and Students: Further studies should explore the impact of teacher mindfulness programs on classroom dynamics and student outcomes. Large-scale studies on teachers have shown positive effects on teacher–student relationships and school climate, but more rigorous research is needed to understand the overall impact on the entire school population. 3. Explore the Roles and Impact of Teachers: Research should focus on understanding the influence of teachers who have learned and practiced mindfulness. The impact of teachers on students extends beyond MBPs, and studies should investigate the broader factors relating to implementation in school contexts to advance the knowledge of mindfulness as education.

Implications for Practice Similar to many types of SMBP for children, MBP has been offered to teachers by integrating social–emotional learning theories with intentions to improve their competence in this aspect. In this chapter, several areas have been highlighted for the awareness and reflection of practitioners:

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1. Consider Context Factors of Mindfulness Training in Education: Mindfulness programs for teachers in educational settings are often influenced by theories and concepts in positive psychology that focus on positive and effective coping of emotions and behaviors. It is important to recognize the subtle difference between these programs and those MBPs originally developed in health care and clinical practice emphasizing the values of nonstriving and acceptance. Furthermore, contextual factors such as individual instructor style and cultural values of the participants and school environments can influence program design and implementation. 2. Reflect on Expectations of Mindfulness Training in Students and Education: Mindfulness should not be seen as a cure-all solution for all problems in schools. Putting mindfulness into all dimensions of school life requires much reflection, wisdom, effort, and realistic expectation. The application of mindfulness may be distorted by unrealistic expectations, and claims about the benefits of mindfulness can undermine its true potential. 3. Address Implementation Challenges: Implementation of mindfulness in schools requires careful consideration. Attention should be given to address the stress (or suffering) of teachers and students. The mission and real actions of promoting mental health and well-being to the whole school through mindfulness should be explored, and practitioners should share and disseminate strategies for improving the implementation of mindfulness in schools.

Appendix: Information About Teacher Mindfulness Programs The SMART program: a 20-h. evidence-based MBP for teachers, nurses, and other helping professionals. https://www.mindfulnesseveryday.org/smart.html The Cultivating Awareness and Resilience in Education (CARE) program. https://www.garrisoninstitute.org/initiatives/programs/cultivating-­awarenessand-­resilience-­in-­education/ .begin: offered by the Mindfulness in Schools Project (which developed .b, Paws b, and other SMBP). https://mindfulnessinschools.org/begin-­eight-­week-­mindfulness-­course/

References Coatsworth, J. D., George, M. W., & Walker, A. K. (2019). Creating mindful and compassionate schools including parents as partners. In P. A. Jennings, A. A. DeMauro, & P. P. Mischenko (Eds.), The mindful school: Transforming school culture through mindfulness and compassion (pp. 189–210). Guilford. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation science, 4(1), 1–15.

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de Carvalho, J. S., Oliveira, S., Roberto, M. S., Gonçalves, C., Bárbara, J. M., de Castro, A. F., et al. (2021). Effects of a mindfulness-based intervention for teachers: A study on teacher and student outcomes. Mindfulness, 12(7), 1719–1732. Drago-Severson, E., & Blum-Destefano, J. (2019). Modeling mindfulness: Principal leadership and development for personal and organizational growth. In P. A. Jennings, A. A. DeMauro, & P. P. Mischenko (Eds.), The mindful school: Transforming school culture through mindfulness and compassion (pp. 78–98). Guilford. Emerson, L.  M., Leyland, A., Hudson, K., Rowse, G., Hanley, P., & Hugh-Jones, S. (2017). Teaching mindfulness to teachers: A systematic review and narrative synthesis. Mindfulness, 8, 1136–1149. Ergas, O., & Hadar, L. L. (2019). Mindfulness in and as education: A map of a developing academic discourse from 2002 to 2017. Review of Education, 7(3), 757–797. Frank, J. L., Jennings, P. A., & Greenberg, M. T. (2016). Validation of the mindfulness in teaching scale. Mindfulness, 7, 155–163. Gördesli, M.  A., Arslan, R., Çekici, F., Sünbül, Z.  A., & Malkoç, A. (2019). The psychometric properties of the mindfulness in teaching scale in a Turkish sample. Universal Journal of Educational Research, 7(2), 381–386. Hawkins, K. (2017). Mindful teacher, mindful school: Improving wellbeing in teaching and learning. . Hudson, K. G., Lawton, R., & Hugh-Jones, S. (2020). Factors affecting the implementation of a whole school mindfulness program: A qualitative study using the consolidated framework for implementation research. BMC Health Services Research, 20(1), 1–13. Hunt, P., Barrios, L., Telljohann, S.  K., & Mazyck, D. (2015). A whole school approach: Collaborative development of school health policies, processes, and practices. Journal of School Health, 85(11), 802–809. Hwang, Y. S., Bartlett, B., Greben, M., & Hand, K. (2017). A systematic review of mindfulness interventions for in-service teachers: A tool to enhance teacher wellbeing and performance. Teaching and Teacher Education, 64, 26–42. Hwang, Y.  S., Goldstein, H., Medvedev, O.  N., Singh, N.  N., Noh, J.  E., & Hand, K. (2019a). Mindfulness-based intervention for educators: Effects of a school-based cluster randomized controlled study. Mindfulness, 10, 1417–1436. Hwang, Y. S., Noh, J. E., Medvedev, O. N., & Singh, N. N. (2019b). Effects of a mindfulness-­ based program for teachers on teacher wellbeing and person-centered teaching practices. Mindfulness, 10, 2385–2402. Jennings, P. A. (2023). Minding the gap: Attending to implementation science and practice in school-based mindfulness program research. Mindfulness, 14(2), 314–321. Jennings, P. A., Frank, J. L., Snowberg, K. E., Coccia, M. A., & Greenberg, M. T. (2013). Improving classroom learning environments by cultivating awareness and resilience in education (CARE): Results of a randomized controlled trial. School Psychology Quarterly, 28, 374–390. Jennings, P. A., Brown, J. L., Frank, J. L., Doyle, S., Oh, Y., Davis, R., et al. (2017). Impacts of the CARE for teachers program on teachers’ social and emotional competence and classroom interactions. Journal of Educational Psychology, 109(7), 1010–1028. Kim, E., & Singh, N. N. (2018). Psychometric properties of the Korean version of the mindfulness in teaching scale. Mindfulness, 9, 344–351. Kuyken, W., Ball, S., Crane, C., Ganguli, P., Jones, B., Montero-Marin, J., et  al. (2022). Effectiveness of universal school-based mindfulness training compared with normal school provision on teacher mental health and school climate: Results of the Myriad cluster randomised controlled trial. Evidence-Based Mental Health, 25(3), 125–134. Lavy, S., & Berkovich-Ohana, A. (2020). From teachers’ mindfulness to students’ thriving: The mindful self in school relationships (MSSR) model. Mindfulness, 11, 2258–2273. Li, C., Kee, Y. H., & Wu, Y. (2019). Psychometric properties of the Chinese version of the mindfulness in teaching scale. International Journal of Environmental Research and Public Health, 16(13), 2405.

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Mihić, J., Oh, Y., Greenberg, M., & Kranzelic, V. (2020). Effectiveness of mindfulness-based social-emotional learning program CARE for teachers within Croatian context. Mindfulness, 11, 2206–2218. Moyano, N., Navarro-Gil, M., Pérez-Yus, M.  C., Herrera-Mercadal, P., & Valle, S. (2023). Psychometric properties of the mindfulness in teaching scale among Spanish teachers. Current Psychology, 42, 3195–3203. Roeser, R.  W., Schonert-Reichl, K.  A., Jha, A., Cullen, M., Wallace, L., Wilensky, R., Oberle, E., Thomson, K., Taylor, C., & Harrison, J. (2013). Mindfulness training and reductions in teacher stress and burnout: Results from two randomized, waitlist-control field trials. Journal of Educational Psychology, 105(3), 787–804. Roeser, R. W., Schussler, D., Baelen, R. N., & Galla, B. M. (2023). Mindfulness for Students in Pre-K to Secondary School Settings: Current Findings, Future Directions. Mindfulness, 14(2), 233–238. Roffey, S. (2017). The ASPIRE principles and pedagogy for the implementation of social and emotional learning and the development of whole school well-being. International Journal of Emotional Education, 9(2), 59–71. Seigle, P., Wood, C., & Sankowski, L. (2019). Turn and listen: Strengthening compassion and leadership in the adult Community in Schools. In P. A. Jennings, A. A. DeMauro, & P. P. Mischenko (Eds.), The mindful school: Transforming school culture through mindfulness and compassion (pp. 59–77). Guilford. Sheinman, N., Hadar, L. L., Gafni, D., & Milman, M. (2018). Preliminary investigation of wholeschool mindfulness in education programs and children’s mindfulness-based coping strategies. Journal of Child and Family Studies, 27, 3316–3328. Singh, N. N., Lancioni, G. E., Winton, A. S. W., Karazsia, B. T., & Singh, J. (2013). Mindfulness training for teachers changes the behavior of their preschool students. Research in Human Development, 10(3), 211–233. Taylor, C., Jennings, P.  A., Harris, A., Schussler, D.  L., & Roeser, R.  W. (2019). Embodied teacher mindfulness in the classroom: The calm, clear, kind framework. In P.  A. Jennings, A. A. DeMauro, & P. P. Mischenko (Eds.), The mindful school: Transforming school culture through mindfulness and compassion (pp. 107–134). Guilford. Ventura, A., Kissam, B., Chrestensen, K., Tfirn, I., Brailsford, J., & Dale, L.  P. (2023). Implementation of a whole-school mindfulness curriculum in an urban elementary school: Tier 1 through tier 3. OBM Integrative and Complementary Medicine, 8(2), 1–25. Weare, K. (2023). Where have we been and where are we going with mindfulness in schools?. Mindfulness, 14(2), 293–299. Zarate, K., Maggin, D.  M., & Passmore, A. (2019). Meta-analysis of mindfulness training on teacher Well-being. Psychology in the Schools, 56(10), 1700–1715.

Chapter 9

Implementing Mindfulness-Based Programs for Children

A Growing Attention in Implementation Science There is an increasing interest in implementation sciences, particularly in the field of public health. Implementation sciences focus on the capacity to select, adapt, and implement evidence-based interventions (Leeman et  al., 2017; Singh, 2020). In order to effectively implement a MBP in a particular setting, it is necessary for mindfulness instructors to have the necessary skills to deliver the essential ingredients of MBPs. Additionally, they should possess fundamental knowledge about the etiology of the target health outcomes, existing interventions that have been shown effective for the health outcome, population, and context, the appropriate delivery systems and settings, as well as a deep understanding of the culture, values, and communication patterns of the target population (Loucks et al., 2022). A recent review of MBPs implemented in schools pointed out shortcomings in intervention integrity and teacher training. It found that only 45% of the selected studies included core mindfulness practices, and only 26% met the standards for teacher training (Emerson et al., 2020). While assessment of teacher competence has been developed for MBPs targeting adults, there is a need for adaptation when implementing MBPs for children in school contexts. The review also emphasized the importance of support systems and contextual factors in implementation, such as design training, technical assistance, and capacity-building strategies tailored to specific intervention approaches and practice contexts (Baelen et al., 2023; Leeman et al., 2017). In addition to instructors and child participants, other stakeholders involved in organizing an MBP for children include parents, school personnel, mental health service providers, pediatric or psychiatric service providers, and policymakers. The successful translation of evidence-based practice into daily implementation of MBPs requires coordination and collaboration, including dissemination,

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_9

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integration, capacity-building, and scale-up strategies. The perceptions, efforts, and actions of these stakeholders in implementing an MBP have a significant impact on the quality and sustainability of the MBP for children.

Factors Contributing to Effective Implementation of an MBP Consolidated Framework for Implementation Research (CFIR) The chapter introduced two frameworks for effective implementation. The first framework is called the Consolidated Framework for Implementation Research (CFIR), which was initially developed in 2009 and updated in 2022 by Damschroder et al. (2022). This framework allows researchers to use mixed or qualitative methods to explore the barriers and facilitators to implementation effectiveness. The CFIR helps inform the selection of implementation strategies that address contextual factors, generate hypotheses for predicting implementation outcomes, and retrospectively analyze outcomes by assessing differences in conditions across implementation settings. The CFIR can be applied to various practice or intervention approaches, such as blood pressure control (Robins et al., 2013), weight management programs (Damschroder & Lowery, 2013), and digital depression prevention programs (Freund et al., 2023), in healthcare, educational, agricultural, or other community settings (Damschroder et al., 2022). Recent studies have shown that the CFIR framework is applicable across different cultures, including low- or middle-income countries (Damschroder et al., 2022; Means et al., 2020). The CFIR collects data from individuals who have power and influence over implementation outcomes. It consists of five key domains, each with several constructs for investigation: 1. The innovation domain focuses on the project being implemented, including its source (the degree to which the group that developed or sponsored the innovation is reputable or credible), evidence base, relative advantage, adaptability (the degree to which it can be modified, tailored, or refined to fit local context or needs), trialability (which can be tested on a small scale), complexity (level of complication in terms of its scope or nature), design, and cost. 2. The outer setting domain refers to the community, system, or state where the innovation is located and includes critical incidents (large-scale and unanticipated events disrupt implementation of delivery), local attitudes (sociocultural values and beliefs that support the implementation or delivery), local conditions (economic, political, and technological conditions enable the outer setting to support implementation), partnerships and connections, policies and laws (legislation, regulations, professional group guidelines, and recommendation support implementation), financing (funding from external bodies to support implementation), and external pressure (including pressure from societal level, market level, or performance measurement).

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3. The inner setting domain pertains to the specific setting where the innovation is implemented, covering structural characteristics (including physical infrastructure, information technology, and work organization of tasks and responsibilities between individuals and teams, staffing levels, and support for functional performance of the inner setting), relational connections, communications, and culture (shared values, beliefs, and norms particularly in relating to caring, supporting, and the needs and welfare of recipients, and those of the delivers; and those relating to psychological safety, continual improvement, and use of data to inform practice), tension for change (whether the current condition is intolerable and needs to change), compatibility (fits with workflows, systems, and processes), relative priority (the importance of the innovation compared to other initiatives), incentive systems (tangible or intangible incentives or disincentives or punishments support implementation), mission alignment (innovation is in line with the overarching commitment, purpose, or goals in the inner setting), and available resources (funding and physical space). 4. The individual domain explores the roles and characteristics of individuals involved in innovation, such as leaders, implementation facilitators (individuals with expertise who assist coaches and support implementation), implementation leaders and team members, other implementation supporters, innovation deliverers, and recipients. It focuses on their needs (individuals with deficits in relation to survival, well-being, or personal fulfillment, which is addressed by implementation), capabilities (individuals with interpersonal competence, knowledge, and skills to fulfill role), opportunities (individuals with availability, scope, and power to fulfill roles), and motivations (individuals with commitment to fulfill roles). 5. The implementation process domain addresses the activities and strategies used to implement the innovation, including teaming (the degree to which individuals join together, coordinate, and collaborate on interdependent tasks), needs assessment (about the priorities, preferences, and needs of deliverers and recipients), context assessment (about the barriers and facilitators to implement), planning, tailoring strategies, engagement (attracting and encouraging participation of deliverers and recipients in implementation and innovation), execution (the actual small steps, tests, cycles of change to trial and optimize delivery of the innovation), reflection and evaluation (data collection about the success of implementation and innovation), and adapting (modification of the innovation and inner setting for fitting into work processes).

 he School-Based Mindfulness Program Implementation T Framework (SBMP-IF) The School-Based Mindfulness Program Implementation Framework (SBMP-IF) was developed by Baelen et al. (2023) specifically for studying the implementation of SMBP. Compared to the CFIR, which can be applied to any innovative project, the SBMP-IF consisted of 14 core components based on implementation literature:

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1. The program domain includes two subdomains: the core program components and the implementation support system. The core program components refer to the essential aspects of the program, including specific practices (e.g., focused attention vs loving-kindness practices), processes or principles that contribute to the program outcomes, such as the use of embodied presence, and inquiry between instructor and children (Domitrovich et al., 2008). Implementation science emphasizes the flexibility to adapt the program to fit specific contexts while preserving the core intervention strategies and activities (Dymnicki et al., 2020). The implementation support system involves practices and policies that promote high-quality implementation, including training and other support provided to instructors delivering the MBP. Strategies such as program selection and marketing, technical support, assessment and feedback, networking of teachers and administrators, incentives, and responsiveness to the target ­audience’s needs are crucial in the implementation process (Leeman et  al., 2017). The support required by school teachers and the whole school is beyond the delivery of a time-limited MBP. For example, Hwang et al. (2021) formed a learning circle of making connections with the self and colleagues in supportive mindfulness practice, following an MBP for teachers. In a community of practice, teachers could be aware of their stress and challenges in themselves, which form the intention to learn and practice mindfulness. After learning in an MBP, teachers can find a common ground, and mindfulness can be a tool to connect with the self and the ground of a community to support the self-care and care of children in schools. 2. The participants domain focuses on the people involved in the program, including those who deliver and receive it. It is important to report the characteristics of the instructors or support staff, such as their demographics and previous experience with mindfulness practices (Dymnicki et al., 2020). For the participants receiving the program, their distinct characteristics, including disabilities or other mental health challenges, are relevant to understanding for whom the MBP may be effective (Dymnicki et al., 2020). This domain helps assess the representativeness of participants and the program’s external validity. 3. The context domain is divided into the school level and broader level. The school level involves the specific setting, geographic location, time, and other characteristics of the school or site-delivering organization. It also considers the expertise and background of the delivery organization and the specific training given to the program providers (Dymnicki et al., 2020). The broader level encompasses the wider environment, including the country, region, state, or locale (urban or rural) and any special events occurring during the program. Factors such as socioeconomic conditions, residential or clinical setting, financial sponsorship, organizational climate and culture, and support for the program influence its implementation (Dymnicki et al., 2020). 4. The implementation domain is the most critical domain in the SBMP-IF and consists of three subdomains with eight constructs. The implementation domain includes three subdomains: quality of implementation, amount, and goodness of fit. The subdomain of quality of implementation includes three constructs:

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integrity, competence, and adaptations. Integrity refers to the extent to which the program’s core components, objectives, and principles are implemented and received as planned. It emphasizes alignment with validated or hypothesized core components and objectives rather than strict adherence to a prescribed curriculum or protocol (Greenhalgh & Papoutsi, 2019). Competence pertains to the skill level of the MBP instructor in effectively delivering the program (Crane et  al., 2013). It involves how instructors convey and embody the themes and mindfulness exercises, embrace vulnerability and authenticity in teaching, and engage in the process of inquiry. Teaching assessment criteria have been adopted as a reference for instructors of MBPs, and further adaptations have been developed for instructors who are working in the school context (Burnett et al., 2019). The Mindfulness-Based Intervention: Teaching Assessment Criteria (MBI: TAC) provide standards for evaluating the competence of instructors and consists of six domains:

(a) Coverage, Pacing, and Organization of the Session Curriculum: Instructors should demonstrate clarity in delivering the curriculum within the constraints of contextual factors such as time allocated for each lesson and the size and layout of the classroom. (b) Relational Skills: Instructors should be able to adjust their boundaries for sharing information based on the specific context and the population they are working with. In a classroom setting, they should observe issues of confidentiality and handle sensitive topics with discretion. Instructors need to skillfully manage children with special needs or behavioral issues, finding a balance between meeting their individual needs and maintaining the engagement of the whole class. (c) Embodiment: Instructors should embody mindfulness themselves and demonstrate presence and trust in mindfulness practices, even when encountering resistant behaviors from students. They need to stay in control of the class and show students how mindfulness can be a resource in facing stress and resistance in their daily lives. (d) Guiding Mindfulness Practices: Instructors of MBPs for children should use language that is developmentally appropriate and easily understood by children. They should be attentive and responsive to students who may not be engaged or are misbehaving, offering support and guidance as needed. (e) Using Interactive Inquiry and Didactic Teaching: Instructors face challenges of effectively conveying program themes and intentions. They can use aids such as PowerPoint presentations or videos, present ideas directly, or preferably involve children in interactive inquiry and didactic dialogs whenever possible. (f) Holding the Group Learning Environment: Instructors must skillfully address the diverse needs of a group of children. This may involve adapting the pacing or teaching style to maintain engagement, using approaches ranging from gentleness and patience to entertaining and fast-paced, or even adopting a strict and authoritative mode when necessary. Instructors should also consider any specific safeguarding procedures required in the particular setting, such as in a clinic or school.

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While the MBI: TAC is developed specifically for training and certification of MBP instructors, Broderick et al. (2019) devised a scoring system for Learning to BREATHE (L2B) instructors. In response to the challenges when operationalizing embodiment in behavioral terms, they integrate it with relational skills and develop the teaching criteria with four domains. The last construct within the quality of implementation subdomain is adaptations. This refers to making additions or modifications to the MBP in order to better align it with specific context or the needs of participants during implementation (Berkel et al., 2011). While adaptations are generally viewed favorably, most studies failed to provide detailed information about the specific adaptations made, highlighting the challenge of defining and differentiating integrity and adaptations clearly (Kuyken, 2022; Tudor et al., 2022). It is crucial to consider the modification of an MBP to cater to the specific needs of marginalized or disadvantaged populations. Through such adaptations, MBPs can become more culturally sensitive, promoting mental health equity and children’s overall well-being (Renshaw & Phan, 2023). The implementation domain encompasses the second subdomain, the amount, which is further divided into two closely related constructs, dosage and uptake. Dosage refers to the extent of program delivery and is measured by factors such as session frequency (number of sessions), session intensity, and session duration (Durlak & Dupre, 2008). However, uptake refers to the extent of program reception and is measured by indicators such as the number of sessions attended by a child, time spent on formal and informal practice, and completion of homework practice (Montgomery et al., 2013). Although dosage and uptake are distinct concepts, many studies reported uptake as part of dosage, leading to confusion (Tudor et al., 2022). The final subdomain in implementation is goodness of fit, which comprises three constructs: responsiveness, feasibility, and acceptability. Responsiveness refers to the level of engagement and interest displayed by participants toward the program (Roeser et al., 2023). It goes beyond measuring quantitative aspects such as dosage and uptake, focusing instead on whether an MBP can foster a child’s motivation and engagement to learning and practicing mindfulness. Unfortunately, very few studies included children’s responsiveness and satisfaction as outcomes or moderators in their study design. In the largest trial of the school-based mindfulness MYRIAD project (Kuyken et  al., 2022), researchers surveyed students about their program acceptability, such as asking them if they would recommend the lessons to a friend on a 10-point scale. The program received an average score of 4.7 (SD = 2.9), with approximately 10% of students giving a score of 0 and around 3% giving a score of 10. The frequency of mindfulness home practice, measured on a scale from 0 (never) to 5 (almost every day), was consistently low post-intervention (mean (SD): 1.16 (1.07) out of 5) and at the one-year follow-up (mean (SD): 0.83 (0.93) out of 5). It is disheartening that the program was not well-received by many students. The low engagement of students with the mindfulness practice during and after the intervention highlights the importance of respecting adolescents’ preference and perspectives. Just as we have no issues respecting a child who dislikes arts or sports, it should be natural, albeit challenging, to acknowledge that many adolescents may

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not enjoy mindfulness and, consequently, may not benefit from it. D’Alessandro et  al. (2022) conducted semi-structured focus group interviews to gather participants’ feedback (n = 51) after MBPs, and their findings indicated that many students did not enjoy or feel motivated by mindfulness exercises in the classroom. Collecting comments from MBP participants can be valuable in understanding outcomes and barriers in the implementation process. Feasibility refers to the ease of implementing a program in a specific setting. Feasibility indicators may include identifying implementation barriers and support and calculating program cost and time per student and instructor (Emerson et al., 2020). Lastly, acceptability refers to the extent to which an MBP is considered suitable, satisfying, or appealing to program deliverers, participants, and other stakeholders, such as the school community, teachers, school staff, and parents (Bowen et  al., 2009). Acceptability encompasses participants’ responsiveness but also extends to the involvement of significant others in motivating children to learn and practice mindfulness, as well as the long-term adaptability and sustainability of the program. Establishing a support system may involve scaling up strategies to implement a specific program in multiple settings, which includes strengthening stakeholder motivation, capabilities, and opportunities, engaging leadership, allocating resources and infrastructure, and promoting public policy that supports the program’s human and material resources, transfer of learning, and collaboration (Leeman et al., 2017).

 ho Implements SMBP Better? The Roles and Outcomes W of Schoolteachers vs External Instructors There has been a debate regarding the effectiveness of SMBPs implemented by school teachers versus external instructors. A previous review by Waters et  al. (2015) found that MBPs led by school teachers showed more significant improvements compared to those led by external instructors (Waters et al., 2015). However, more recent large-scale trials led by teachers, such as Eva and Thayer (2017), Kuyken et al. (2022), and Volanen et al. (2020b), did not report significant overall outcome improvements. The discrepancy may be because some school teachers have a strong passion for teaching MBPs and can deliver decent-quality programs due to their familiarity with the school system and better relationships with students. In smaller trials, MBPs led by school teachers may have produced good outcomes. However, when studies are scaled up and more teachers are involved, it becomes challenging to find suitable teachers with adequate training and experience in delivering the program. Additional challenges arise when teachers are burdened with the training and workload of teaching MBPs, which can increase their job-­ related stress. Additionally, school administrators may face practical problems such as teacher turnover, which leads to extra costs for organizing training and limits program sustainability.

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Semple et al. (2017) observed the implementation of MBPs across projects and found that school teachers have an advantage in terms of training and program implementation, as they can incorporate the language and skills into their classrooms. The need for trained external instructors may improve the quality of implementation but also increase implementation costs, which could hinder long-term sustainability. School administrators may prefer to strengthen the training of school teachers with the goal of eventually eliminating the need for external instructors. However, it is important to note that external instructors are more likely to have extensive personal mindfulness practices, which may enhance their competence in teaching MBPs. However, it is worth mentioning that these observations have not been empirically verified. A recent qualitative study conducted in Hong Kong (Lo et al., in review) examined the implementation factors and compared the roles of school teachers and external instructors in an SMBP project. Interviews were conducted with 22 participants, including 16 school teachers and six external instructors, after they had completed their teaching of an eight-session SMBP based on the School-Based Mindfulness Program Implementation Framework by Baelen et al. (2023). Based on their experiences in delivering the program, both school teachers and external instructors shared their strengths, strategies, barriers, and challenges. School teachers found it helpful when their professional mindfulness training program was sponsored. While teachers may not be specialists in teaching MBPs compared to external teachers, their collaboration within the same schools allowed them to support each other. Experienced school teachers shared their knowledge with beginners and shared program materials such as tailor-made worksheets and PowerPoint files. Some teachers went above and beyond by planning additional mindfulness activities, such as incorporating brief mindfulness sessions during morning assemblies and providing coaching to students to self-regulation during times of stress and emotional challenges. Teachers affiliated with Buddhist educational bodies received additional support from their school management and found their previous meditation background facilitated their understanding of mindfulness and MBPs. Other teachers reported personal changes and transformation after receiving professional training, becoming more patient with students and adopting a less directive approach in guiding their learning. Teaching MBPs also provided them with opportunities to better understand students’ emotional needs and backgrounds, allowing them to offer care and attention. School teachers also demonstrated their wisdom in classroom management, adjusting their curriculum and tailoring the pace and content based on students’ characteristics and immediate class situations, drawing upon their solid understanding of the school and class culture. However, school teachers also shared their barriers and challenges. They expressed concerns about limited time for delivering MBPs to large classes of 20–30 students. They acknowledged that not all teachers are interested in teaching mindfulness, and administrative priorities sometimes assigned teachers to classes they were unfamiliar with. Teachers also reported limitations in training and venue availability, such as the retirement or resignation of trained teachers and the allocation of different classes in the same grade to SMBPs, making it challenging to

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access ideal mindfulness teaching spaces. Some teachers recognized their inadequate skills and competence in teaching mindfulness, particularly leading mindfulness practices and facilitating experiential learning through inquiry. They also expressed concerns about managing students with traumatic experiences in the classroom. For external instructors, two interviewees who had previously taught MBPs to children felt comfortable adapting their teaching experiences from clinical settings to a school environment, although they were aware of the necessary adjustments. They shared examples of how they facilitated students’ learning and expression of bodily sensations, acceptance of differences and unpleasant experiences, and attention to breathing. They had extensive experience in adjusting the types and durations of practices according to students’ needs, prioritizing their present conditions instead of strictly following the curriculum. However, external instructors also faced significant barriers and challenges in program delivery. Firstly, they found it difficult to communicate with schools regarding their needs and concerns during program implementation. There was often an unclear division of labor within the school system, making it challenging for external instructors to know who to reach out to for immediate assistance, such as when a student required additional attention and handling. Additionally, external instructors highlighted that they had limited background information about the students before teaching them. They opted to provide MBPs in small groups and expressed frustration at being unable to follow up on the students’ progress in applying mindfulness in school and their daily lives, and they were uncertain about the extent to which students were able to transfer their mindfulness skills beyond the program. This study questioned whether school teachers are unable to deliver SMBPs with high quality (Kuyken et  al., 2022). Specifically, teachers are better positioned to understand school culture, garner internal support, and follow up on students’ learning and application of mindfulness beyond the MBP. While experienced external instructors may develop greater competence in leading MBPs, the effectiveness of their program delivery in a specific context depends on the level of support they receive from the school system and other stakeholders. Collaborating with the school system is crucial when implementing MBPs for children, and each school should carefully consider contextual factors to identify suitable individuals to deliver the program.

Implications for Research Implementation science has emerged as a valuable approach for evaluating the process of MBPs, bridging the gap between rigorous clinical trials and the complex contextual factors involved in implementing MBPs, especially in school settings. As factors contributing to effective implementation are being identified, the next step is to apply this framework and investigate the relationship between these factors and outcomes across different contexts.

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While culture has been acknowledged as playing a role in implementation, most current studies on MBPs for children in schools have focused on developed countries in North America, Western Europe, and Australia. It is important to integrate the outcome studies of MBPs and SMBPs with implementation science frameworks such as the CFIR and the SBMP-IF particularly in other regions (Renshaw & Phan, 2023). Furthermore, implementation science should address the specific needs of MBPs for younger school-aged children. Existing implementation studies have primarily focused on adolescents, as it is easier to collect their views and data during implementation. Improved strategies for data collection should be developed to identify the diverse developmental needs of children and their implications for implementing MBPs across various contextual factors.

Implications for Practice Implementation science has provided a comprehensive framework for investigating the process of MBPs, but there is still a gap between ideal model of implementation and real practice. One significant concern in child MBPs is the inquiry-based learning process. Emerson et al. (2020) noted that while individual studies often refer to published manuals or curricula, very few explicitly explain how the inquiry process is conducted. In adult MBPs, inquiry involves exploration of participant’s practice experience and the application of mindfulness in stress management. However, the classroom and other child MBP contexts differ significantly. Inquiry goes beyond mere discussion and small group reflections; it may pose challenges for instructors, especially in a classroom setting. This issue may be related to contextual factors and the developmental nature of children. Forming groups of children with similar clinical diagnoses or social backgrounds could facilitate a more in-depth exploration of individual experiences and the application of mindfulness practice. However, in a classroom setting, it may not be suitable to address personal issues without adequate support for individual participants during and after class. Moreover, adolescents may face peer pressure, making it challenging for instructors to facilitate meaningful dialogs in an MBP. This creates a gap between the expected outcomes of core components in MBPs through inquiry and the alignment with instructor competence criteria. Therefore, the management of inquiry in MBPs for children should be developed with clarity, providing additional guidance on age-appropriate adaptations, especially for children with specific mental health or social challenges, and in classroom contexts. Another concern is the responsiveness of children in MBPs, particularly in a classroom setting. The MYRIAD project reported low responsiveness, including students’ ratings of program satisfaction and engagement in homework practice, which poses a challenge for program design and implementation (Montero-Marin, 2022). Innovative designs may be necessary to improve responsiveness among adolescents. Additionally, the responsiveness of other age groups should be investigated to help practitioners assess the suitability of existing MBPs. Program design

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should align with the expertise and competence of instructors, offering options to adjust the pacing of an MBP and apply different mindfulness practices based on children’s needs. Thoughtful choices in program delivery and implementation should be made to ensure a good fit.

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Tudor, K., Maloney, S., Raja, A., Baer, R., Blakemore, S., Byford, S., Crane, C., Dalgleish, T., De Wilde, K., Ford, T., Greenberg, M., Hinze, V., Lord, L., Radley, L., Opaleye, E. S., Taylor, L., Ukoumunne, O. C., Viner, R., MYRIAD Team, et al. (2022). Universal mindfulness training in schools for adolescents: A scoping review and conceptual model of moderators, mediators, and implementation factors. Prevention Science, 23, 934–953. https://doi.org/10.1007/ s11121-­022-­01361-­9 Volanen, S.-M., Lassander, M., Hankonen, N., Santalahti, P., Hintsanen, M., Simonsen, N., Raevuori, A., Mullola, S., Vahlberg, T., But, A., & Suominen, S. (2020b). Healthy learning mind – Effectiveness of a mindfulness program on mental health compared to a relaxation program and teaching as usual in schools: A cluster-randomised controlled trial. Journal of Affective Disorders, 260(1), 660–669. Waters, L., Barsky, A., Ridd, A., & Allen, K. (2015). Contemplative education: A systematic, evidence-based review of the effect of meditation interventions in schools. Educational Psychology Review, 27, 103–134.

Chapter 10

Ethical Issues in Teaching Mindfulness to Children and Adolescents

 thics from the Perspectives of Religious E and Psychological Practice As MBPs gain popularity and become more ingrained in mainstream culture, there is a growing need for a critical examination of the ethical considerations surrounding these programs. Particularly, questions arise concerning the transparency and diversity of the programs, as well as their integration with clinical and educational adaptations, given their Buddhist origins and ethical foundations (for a few of them, e.g., Brown, 2017; Kabat-Zinn, 2010, 2011; McCown, 2018; Langer Primdahl, 2022). The chapter begins with a concise review of ethical dimensions found within early Buddhism. In early Buddhist thought and practice, the Pāli word sīla holds multiple translations, including ethics, morality, and virtue. Sīla plays a central role in the entirety of Buddhist thought and practice and is the foundation for the entire spirituality envisaged by Buddhism (Keown, 1996; Stanley, 2015). Buddhist ethics encompass the teachings of sīla, which pertain to moral duties and virtues. These teachings emphasize refraining from acts of killing, stealing, sexual misconduct, lying, and the consumption of intoxicants. The core virtues of Buddhism revolve around nonattachment, benevolence, and understanding, countering the three roots of evil, including greed, hatred, and delusion (Keown, 1996; Stanley, 2015). Ethical teachings in Buddhism also encompass intention and action. The moral quality of an action is determined by its intention, and all thoughts, words, and deeds carry moral value. Mindfulness facilitates greater awareness of one’s mental states, particularly intentions, and motives (Harvey, 2000; Stanley, 2015). It is important to avoid reducing the practice of mindfulness to a solely mechanistic function, as this would be considered “wrong mindfulness.” Instead, mindfulness should be practiced with moral integrity, known as “genuine mindfulness” (Anālayo, 2003). This ethical component urges individuals practicing mindfulness to discern between wholesome and unwholesome actions (Purser & Milillo, 2015). © The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7_10

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Mindfulness practice is not limited to personal growth and enlightenment; it also encompasses social engagement, focusing on alleviating worldly suffering and oppression (Hanh, 1976). Genuine mindfulness leads to the restraint of the senses and the cultivation of wholesome thoughts, speech, and actions, ultimately leading to enlightenment and liberation (Amaro & Singh, 2022). For a comprehensive understanding and practicing of mindfulness, it is crucial to incorporate systematic ethical teachings, particularly those related to the reduction and transformation of suffering (dukkha). One significant framework in this regard is the Four Noble Truths and the Noble Eightfold Path (Gunaratana, 2001). Within the Noble Eightfold Path, three ethical teachings are directly pertained to meditative practice: 1. Skillful Effort: This teaching focuses on recognizing and overcoming the fetters and hindrances that can hinder positive mental states while cultivating and maintaining positive states of mind. 2. Skillful Concentration: This teaching emphasizes wholesome concentration, free from greed, hatred, and delusion, and the five hindrances. It involves developing one-pointedness and complete concentration, which integrate with mindfulness. 3. Skillful Mindfulness: This teaching encourages clear awareness, providing insight into impermanence, aversion, and the absence of an unchanging self. Additionally, there are another five other ethical teachings within the Noble Eightfold Path (Gunaratana, 2001): 1. Skillful Understanding: This teaching involves comprehending cause and effect and the four Noble Truths. 2. Skillful Thinking (or Intention): It relates to one’s purpose or role in life, encompassing qualities such as generosity, loving-friendliness, and compassion. 3. Skillful Speech: This teaching emphasizes refraining from lying, using malicious words, engaging in harsh language, or indulging in useless talk. 4. Skillful Action: This teaching encompasses the observance of the five precepts, which include refraining from killing, stealing, lying, engaging in sexual misconduct, and using drugs or alcohol. 5. Skillful Livelihood: This teaching emphasizes pursuing a profession or livelihood that does not harm others or oneself, avoids breaking moral precepts, and promotes a settled mind. Maex (2013) also highlights the importance of the three jewels in Buddhist traditions, Buddha, Dharma, and Sangha. While the significance of the first two jewels, representing the Buddha and the Dharma, is expected, the Sangha extends beyond the community of monastics in the context of MBPs to include the community and support of mindfulness instructors and researchers. It is worth noting that although this summary of ethical teachings in the Noble Eightfold Path may appear simplified, concerns have been raised about the omission of explicit ethical Buddhist teachings in secular MBPs. Critics argue that these moral principles have traditionally been core components of mindfulness practices.

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Kabat-Zinn (2011) acknowledged the influence of Theravada teachings, along with concepts from Mahayana schools and Chan (Zen) traditions, in the development of MBSR, the foundational program for most MBPs. However, he emphasized that individuals bear the responsibility to attend to the quality of their inner and outer relationships personally and professionally. Additionally, the ethical foundation of MBPs is grounded in their affiliation with professions that uphold their own ethical guidelines. In response to these criticisms, discussions have emerged, and ethics guidelines for teaching MBPs have been formulated (Monteiro et  al., 2015; Monteiro, 2017). Indeed, there has been criticism of MBPs or secular mindfulness for potentially losing their connection to Buddhist ethics and becoming a diluted version of Buddhism that focuses solely on mindfulness as a therapeutic tool, neglecting the liberating potentials of the dharma. Kabat-Zinn (2011) acknowledges that MBP instructors, who often come from professional backgrounds such as clinical psychology, are bound by their own professional ethical guidelines. These guidelines serve various purposes (Gauthier et al., 2010), including guiding professionals in good behavior, preventing harm, establishing rules of conduct and disciplinary procedures, assisting in the resolution of complaints, promoting social change for the betterment of society, establishing a common ground of skills and knowledge, providing moral principles for ethical decision-making, and serving as a tool for training in ethical practice. Certain ethical principles can be considered universal and applicable across cultures and contexts (Gauthier et  al., 2010). These principles include respect for the dignity of individuals, competence in caring for the well-­ being of individuals, integrity, and professional and scientific responsibility to society. MBP instructors should refer to the guidelines and code of conduct established for their respective professions in their own countries. MBPs can be seen as one stream flowing from the same ocean, acknowledging the human potential for learning, growing, connecting, healing, transformation, realization, and liberation (Kabat-Zinn, 2019). In a dharma combat, Jon Kabat-Zinn responded to Venerable Ben Huan about what MBSR is by stating that “There are an infinite number of ways in which people suffer: therefore there must be an infinite number of ways in which the Dharma is made available to them.” When asked about the tradition he teaches, Kabat-Zinn answered, “I teach in the tradition of the Buddha and of Hui Neng,” highlighting the primary point of nonattachment. As MBP instructors, it is important to continually tend to and deepen our own meditation practice, which is firmly grounded in the Dharma. While the expression of this teaching may not adhere to specific cultural and religious forms of Buddhadharma, it is seen as a universal dharma that each instructor must understand, realize, find ways to articulate, and authentically share with others (Kabat-Zinn, 2009). Each MBP instructor should engage in introspection and reflection, asking themselves what they are teaching and how they should ethically teach it. In the context of MBPs, it is essential to consider the extent to which the origin of mindfulness and Buddhist ethics can inform and inspire the ethics of MBPs when applied in secular contexts, particularly in relation to MBPs for children and adolescents. Criticism has been raised regarding the association of mindfulness for

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children with neoliberal logic, which emphasizes self-promotion, self-discipline, and individual responsibilities for well-being and success (Purser, 2016). When mindfulness is introduced in schools, its association with Buddhism is often strictly avoided to prevent accusations of religious indoctrination. Students are sometimes portrayed as lacking the ability to self-regulate their emotions, with mindfulness teachers assuming the role of saviors who can teach them skills to overcome their deficiencies, potentially overclaiming the effects of MBPs (Purser, 2016).

Common Ethical Issues in MBPs In response to these criticisms, efforts have been made to reestablish the ethical stance of MBPs by addressing various aspects related to program development, implementation, teacher training, and the potential misappropriation of mindfulness practices by participants (Monteiro et al., 2015; Monteiro, 2017).

 thical Considerations Relating to Program E Development of MBPs MBPs have evolved from Buddhist meditations and practices, with the development of MBSR by Jon Kabat-Zinn (2011). To make MBPs acceptable to individuals with diverse religious or non-religious backgrounds, many developers of MBPs have downplayed their Buddhist foundations and chosen vocabulary that conceals mindfulness as an essential aspect of Buddhist teachings (Brown, 2017). While most MBPs acknowledge their Buddhist origins to program instructors, explicit references to Buddhism are often omitted for program participants, which becomes more complex when developing MBPs for children and adolescents, or individuals with limited knowledge about Buddhism. While MBPs for adults may emphasize the spiritual qualities and intentions of mindfulness, including nonjudging, patience, beginner’s mind, trust, nonstriving, acceptance, and letting go (Kabat-Zinn, 1990), MBPs for children often integrate social-emotional learning components to strengthen their self-regulation and emotional skills. Some program developers choose alternative names for child MBPs to avoid direct association with Buddhism. For example, one of the earliest children’s MBP in elementary schools in the United States was called the Attention Academy Program (Napoli et al., 2005). Saltzman (2014) named her pioneer child MBP the Still Quiet Place. The Learning to BREATHE program frames mindfulness as inner-­ strength training (Broderick, 2013). In Hong Kong, practitioners and researchers interested in MBPs have chosen a different approach compared to other Chinese societies, like Taiwan or Mainland China. Instead of using the concept of “right mindfulness” as the core teaching in the Noble Eightfold Path of Buddhist teachings, they have created a new label called

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jingguan. Jingguan can be translated as serene contemplation or observing in silence and has its roots in a famous Confucian text by Chinese philosopher Cheng Hao (1032–1085), based on his famous text “all things can provide contentment when viewed with serene contemplation.” This term gained popularity with the rise of MBPs in Hong Kong (Lau, 2022). Similarly, practitioners may develop specific labels for MBPs for children that are culturally relevant. For example, the .b program frames mindfulness training as “puppy training” for our “puppy minds,” emphasizing the need for firmness, patience, and kind repetition (Mindfulness in Schools Project, 2014). Another child MBP called Mindfulness Matters, developed by Eline Snel and promoted in various countries, uses a frog as a metaphor for the quality of nonreactivity, highlighting the ability to sit still, breathe, and gain control over the inner world without rejecting or repressing (Snel, 2013). In MBPs for adults, Kabat-Zinn (2011) suggests that explicit teaching of ethics is not necessary as the mindfulness practice itself enables participants to discover their own innate ethical tendencies. This approach aims to be inclusive and avoid potentially offending participants with different religious backgrounds, whether they are atheists, Christians, Muslims, or have other beliefs (Cheung, 2018). The secular framing of MBPs often involves the removal of linguistic and visual markers, and explicit associations with religious traditions and practice, promoting an approach focused on attention or capacity training (Brown, 2017). When MBPs are implemented in clinical practice or education, cultural sensitivity becomes a concern for policymakers and school administrators, particularly in government-­ operated or supported organizations or services, such as hospitals or public schools (Jennings, 2016). Among the ethical principles, informed consent is applicable in MBPs and any situations where an individual’s rights of personal autonomy and self-determination should be respected. Service providers and instructors of MBPs should provide clients with full and accurate information to facilitate decision-making based on their personal values, desires, and beliefs (Faden et al., 1986). While it may not be feasible to explain the entire historical background of MBPs and meditative traditions to children and adolescents, it is important to provide a briefing session or information sheet to parents and other stakeholders to ensure transparency regarding the origins of MBPs. The assertion that MBPs are evidence-based is a common secular framing. Mindfulness has gained attention in scientific publications, and there are studies reporting the efficacy of MBPs for children and adolescents (Dunning et al., 2022; Saunders & Kobers, 2020). Instructors should be equipped with the general knowledge that can explain how mindfulness contributes to child development and well-­ being and benefits specific populations in laypeople’s language. It is ethically problematic to make claims about mindfulness that exceed the available evidence, as such claims have the power to convince potential participants and sponsors. If possible, instructors should communicate the levels of evidence with adequate information, such as preliminary evidence or feasibility based on pilot study, and efficacy studies based on RCTs that include comparisons with standard care or other evidence-based approaches (Saunders & Kobers, 2020).

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Ethics Relating to the Implementation of the MBPs When it comes to ethics in the implementation of MBPs, rather than setting a series of principles or standards that can be universally applied, there is a concern that ethics should be universal in a way that respects the values of social or religious identification that participants may hold. This includes respecting the parents of children engaged in MBPs (Schmidt, 2013). Ethics should be expressed in terms of intentions based on an understanding of universal human nature, rather than imposing religious values on MBP participants (Monteiro et al., 2015). McCown (2018) proposes an ethical standard that focuses on the actions between those teaching and learning mindfulness in a program. In his conception of ethical space, instructors and participants engage in the actions of the program, constantly learning the mindfulness practice, and being shaped in the present moment through the expressivity of quality, expressions, gestures, and bodily comportment. Teaching intentions include unfolding new possibilities, cultivating compassion, discovering corporeality, and moving toward acceptance. Non-doing dimensions of MBPs include non-pathologizing, non-hierarchical, and non-instrumental qualities and experiences. Instructors should not assume a higher status as someone who knows and should embrace a stance of “not knowing” without hierarchy of experiential value. Finally, there is a “no fixing” rule, whereby instructors simply stay with what arises in the moment, including challenging physical or emotional experiences. With permission from Hanger (2015), I have modified and expanded the “Bill of Responsibilities” that serves as a reminder for child MBP instructors regarding respect, intolerance of oppression, and the importance of skillful communication. As most MBPs are offered in groups, instructors often encounter children with diverse backgrounds and intentions. These reminders serve as a guide for child MBP instructors to ensure conduct and respectful engagement with children. Here are the modified reminders: 1. Cultivating Space: Show deep listening and empathy through actions, leaving a space for children. Being quiet can be a suitable action, recognizing our privileged position as instructors. 2. Being Nonjudging: Avoid asking a child to represent the opinions of others and acknowledge that each child has the right to be an individual with their own thoughts and experiences. 3. Not Knowing: Do not make assumptions about a child’s identity, diagnosis, or family background. Treat each child as a unique person, avoiding mention of their identity, diagnosis, or information received from parents, teachers, or friends in a class or group setting. 4. Validating Identities and Experiences: Recognize that a child may have multiple identities. Appreciate the diversity within each child, acknowledging that they may exhibit qualities that align with certain identities while also having unique experiences.

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5. Being Present for Children in a Powerless Position: When we hear or see discrimination or prejudice, instances of racism, homophobia, gender bias, or any other prejudice, support children as best we can, and avoid being a bystander. 6. Being Authentic: Speak in a natural manner without imitating the child’s inflections or pretending to appreciate things they like music, food, trends, games, and heroes. 7. Respect for Not Responding: Be content if the child chooses not to answer questions about their life or identity. Recognize that their decision may not be about you and respect their reasons for not sharing. Do not rely on the child to correct us or make you feel better. When they choose to share their story with us, it should be on their own terms and wishes.

Teacher Training and Development Teacher training and development in the context of mindfulness-based programs (MBPs) for children is an important aspect to ensure effective and ethical instruction. Here are some considerations and concepts related to teacher training and development in this field based on a model of teaching and learning mindfulness for children by Willard (2015): 1. Intentions: Instructors working with children should begin with the intention of “listen, breathe, respond.” We should work with ourselves, which is the foundation of teaching, as embodiment can guide us in the process. 2. Boundaries: Instructors must maintain clear professional and personal boundaries when working with children. While it is natural to develop care and affection for the children, it is important to ensure that the professional relationship remains within appropriate boundaries. Mindfulness practice can evoke emotional openness in children, and instructors may encounter their own limitations in terms of time, scope of work, and knowledge. Seeking support from other professionals such as teachers, social workers, therapists, or psychiatrists to step in. Instructors should be aware of local resources that can provide additional support for children. 3. Teaching Mindfulness Beyond MBPs: Instead of solely focusing on teaching mindfulness to children during MBPs, it is crucial to extend the practice to caregivers, teachers, and schools and the larger community. Creating a caring and supportive environment for children involves promoting mindfulness and care among those who interact with them regularly. 4. Integrating Mindfulness with Our Lives: Instructors should embody mindfulness and integrate it into their own lives beyond teaching mindfulness exercises. While some children may not be initially interested in mindfulness exercises, the impact can be greater when instructors embody mindfulness in an ongoing manner. Instructors’ body awareness and embodiment serve as a pathway to influence and inspire children.

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5. Impact on School Leadership and Environment: Teachers have a crucial role to play in promoting mindfulness skills and mindsets beyond offering MBPs to students. By incorporating mindfulness into their own lives, teachers can enhance their resilience, engagement in teaching, and overall well-being. This, in turn, can improve the classroom climate, relationships with students, and student motivation and engagement in learning. Supporting teachers and parents should also be emphasized for MBP instructors, as it strengthens the transformation of mindfulness within schools and society at large. Setting a Community of Practice: In order to provide a supportive community for teachers, programs such as the CALM program, which has been reviewed in Chap. 8, aim to create a space where teachers can receive support. Additionally, teachers and other MBP instructors can form support groups to foster awareness and embodiment for effective teaching. Just like anyone else, teachers and MBP instructors face stress, and a community of practice specifically for mindfulness teaching can help ensure ethical teaching practice (Taylor et al., 2019).

 wareness of the Impact of Mindfulness Practices A on Participants Who May Misapply In addition to the principle of “no fixing” in MBPs, two common developmental issues, namely trauma and challenging behaviors, have garnered significant attention in terms of ethical considerations for instructors delivering MBPs. Over the last decade, there has been a substantial focus on using MBPs when working with individuals who have experienced posttraumatic stress or adverse childhood experiences (ACEs). The prevalence rates of ACEs have varied widely across studies from 41% to 97% (Carlson et al., 2019). National representative samples reported that Iceland and Denmark reported rates of 79% and 83%, respectively, emphasizing the significant impact of ACEs on child mental health (Bödvarsdóttir & Elklit, 2007; Elklit, 2002). It is crucial not to underestimate the effects of trauma on individuals. While mindfulness can support trauma survivors in becoming more aware of their trauma-related symptoms and helping integrate their traumatic experiences, it is important to note that engaging in mindfulness exercises can also trigger overwhelming thoughts, physical symptoms, and unpredictable emotional reactions in unprepared individuals. When this occurs, survivors may become discouraged and blame themselves for their distress, leading to a strong sense of hopelessness (Treleaven, 2018). To address these concerns, a modified trauma-sensitive approach has been proposed for this specific population in Trauma-Sensitive Mindfulness by Treleaven (2018). When teaching mindfulness exercises to children, instructors should ensure that they stay within the window of tolerance. The window of tolerance is the internal zone within which survivors feel stable, present, and regulated, without exceeding their capacity to handle challenging experiences (Siegel, 2010). MBP instructors

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should support children in regulating their attention during mindfulness practice to promote safety and stability. They should also adjust their guidance based on individual differences and moment-to-moment experiences. However, it is important to acknowledge the difficulties of implementing these principles in MBPs, which are typically taught in group settings or classrooms. MBP instructors may encounter vulnerable children who struggle to articulate their challenging experiences during mindfulness exercises, particularly in programs targeting marginalized social groups with a high prevalence of physical violence. In some cases, children may not even recognize that their experiences of hyperarousal or hypoarousal during mindfulness exercises are related to their previous traumas. To effectively manage these potential situations, MBP instructors should possess basic knowledge about trauma-sensitive care. It is important to communicate with MBP participants using simple and child-friendly language, ensuring that they understand the potential unfavorable impacts of regular mindfulness practice on the body and mind. Participants should be aware that they can seek individual help from instructors or other professionals after the classes. Instructors should also be sensitive to how oppression and power dynamics manifest in social contexts. Engaging in an inviting dialog with children and discussing the rationale behind using mindfulness as a therapeutic tool can help address necessary cultural appropriation. Such preparation is vital for children to develop a sense of safety and trust in MBPs and demonstrates the core value of recognizing one’s own and others’ dignity and worth. Lastly, instructors should have basic knowledge about possible negative outcomes of mindfulness, particularly those that are described as challenging, difficult, distressing, functionally impairing, and requiring professional support (Britton et al., 2021; Lindahl et al., 2017). Recent studies have focused on understanding the adverse effects of MBPs on adults. However, it is important to conduct separate studies for children, as younger participants may face difficulties reporting adverse effects in mindfulness practice through structured interviews, similar to those used in studies involving adults (Lindahl et  al., 2017). These studies should address important research questions concerning preexisting experiences of adverse effects and the relationship between mindfulness practice and specific factors such as duration, valence, and impact, beyond posttraumatic stress disorder (Britton et al., 2021). Another significant issue in the delivery of MBPs, particularly in relation to children, is challenging behaviors. Many MBP instructors expressed concerns about difficulties in classroom management, especially for external instructors who may have limited background knowledge and previous experience in handling children’s difficult behaviors. Studies conducted on non-MBP interventions have reported harmful effects that could be attributed to peer contagion in group-based interventions for early adolescents (Dishion et al., 2006). Mager et al. (2005) conducted a study comparing the outcomes of pure group condition (consisting only of adolescents with conduct problems) and the mixed-group condition (consisting of adolescents with and without conduct problems) in problem-solving skills training groups. The results indicated that adolescents in the pure group condition showed greater improvements in terms of their adaptive in-session behavior, as well as parent and teacher ratings of externalizing behavior, compared to those in the mixed-group

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condition. While the relevance of such evidence to other programs, including MBPs, is uncertain, policymakers and MBP instructors may consider its implications. Similarly, based on the outcomes of psychotherapy for children with externalizing disorders such as aggressive behaviors and conduct problems, individually delivered interventions are considered more effective (Dishion et al., 2006; Lochman et al., 2019). Some experienced child MBP instructors implement special measures to exclude children with severe conduct or behavioral problems. They may use a task adapted from the Autism Diagnostic Observation Schedule (ADOS) (Gotham et al., 2007), where applicants for MBPs are invited to participate in a task to determine if the child can engage in a conversation with the parent and instructor without constant interruption. Continuous interruption of the conversation by the child indicates that they may not be suitable for participating in a group-based MBP. Given that most instructors of child MBPs are healthcare professionals or school teachers, it is essential to emphasize that ethical practice should be based on the ethical consideration of their respective professions. In daily practice, an implicit ethic emerges from the embodiment of MBP instructors and how it is conveyed to participants (Grossman, 2015). It is crucial to maintain integrity in offering mindfulness teaching (Gonsiorek et al., 2009).

Implication for Research Ethics in teaching MBPs to children received little attention in previous research. More studies should be conducted to understand how MBPs for children and adolescents are guided by ethical principles that can inform the safe and effective use of MBPs. Possible topics include but are not limited to: 1. Development of MBP Program Contents in Secular Settings Across Cultures: Research should be conducted on understanding how MBPs are culturally sensitive and inclusive, taking into account the diverse backgrounds and beliefs of children and adolescents. 2. Development and refinement of teaching assessment criteria for child MBPs, particularly in developing behavioral descriptions of embodiment when teaching MBPs for children and adolescents. 3. Effectiveness of Training and Supervision for Child MBPs: Research should examine the effectiveness of training and supervision programs specifically for child MBP instructors. This can help enhance their sensitivity to ethics and competence in program delivery. 4. Development of Practice Guidance for Child MBP Instructors: Research should focus on developing practice guidelines, particularly in managing challenging situations such as trauma and challenging behaviors. 5. Defining and Measuring Adverse Effects in MBPs for Children and Adolescents: Future research is needed to define and measure adverse effects and understand the potential negative impacts of mindfulness practice specifically for children and adolescents.

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Implications for Practice In response to the significant ethical concerns of MBPs that are delivered for children in groups or classrooms, the potential harmful effects due to undetected traumatic stress or peer aggregation effects should be avoided. MBP instructors should receive adequate training and support through: 1. Instructors who deliver MBPs to clinical populations should possess adequate knowledge and skills to address the specific needs of children. Instructors delivering MBPs in classroom settings should have a basic understanding of the school’s background and culture to ensure effective implementation. It is important to provide information sessions or screening time to gather relevant information. This allows instructors to assess the suitability of individual participants for MBPs, while also preparing students for the program. By considering these factors, instructors can tailor the MBP to meet the unique requirements and characteristics of the participants. 2. Instructors should be mindful that many children are unfamiliar with mindfulness and may not initiate participation in an MBP. To improve engagement and elicit positive responses, instructors can employ various strategies and arrangements, such as dividing a class into smaller groups, separating male and female students, and integrating developmentally appropriate program components into the MBPs. It is crucial for instructors to provide sufficient attention to individual participants, ensuring their needs are addressed effectively. 3. Instructors should be aware that children require time to become familiar with mindfulness practice and inquiry. Creating a nonjudgmental and accepting environment may involve letting go of certain effective behavioral management measures such as natural consequences, rewards, and punishments. While instructors may face challenges in certain contexts, this can be a skillful approach to foster the intention to learn and practice mindfulness. It also includes inviting children to express and behave in ways that align with how they wish to treat others and be treated themselves. 4. In the context of MBPs in schools, external instructors should ensure support from school teachers or teaching assistants who possess a deeper understanding of the students. The collaboration is particularly valuable in managing the classroom environment and addressing the challenging behavior of individual children who require special attention. 5. Individual approach to MBPs, such as the Soles of the Feet (Singh et al., 2011), may be more suitable for children and adolescents with severe challenging behaviors and persistent aggression. Delivering MBPs individually can help prevent harmful effects that may arise from peer aggregation and contagion and enhance effectiveness. It is crucial to prioritize the well-being and safety of children when they participate in MBPs, and tailored approaches can provide the necessary support and protection. 6. MBP instructors should have an awareness of the limitations that arise when translating evidence from MBPs in adults to children or when adapting MBPs to

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new contexts. Evaluation of outcome and quality of implementation should be embedded if the evidence in a particular is limited. In situations where there is limited evidence available, it becomes crucial to incorporate evaluation of outcomes and the quality of implementation. This ensures that the effectiveness and appropriateness of the MBP in a specific context are continually assessed. 7. It is important to develop practice guidelines that provide instructors with clear guidance on how to implement MBPs safely and ethically. This necessitates collaboration between experienced child MBP practitioners and researchers, who can work together to identify assessment criteria and competencies required for instructors to enhance their skills in MBPs. 8. Trainers of child mindfulness professional training programs should maintain close monitoring of both applicants and graduates. It is strongly recommended that MBP instructors have professional affiliations and adhere to ethical standards within their respective professions. This helps to ensure the competencies and integrity of MBP instructors, and it is advisable to avoid accepting trainees without any basic professional training and backgrounds. By implementing these measures, the field can safeguard the quality of MBP instruction and maintain high standards. Acknowledgement  The authors thank Elsa N.  S. Lau, Angie Bucu, Stanley K.C.  Chan, Anita Y.W.  Wong, Stephanie M.C.  Cheung, and Yonnie W.Y.  Ng for their comments and suggestions regarding the preparation of this chapter.

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Index

A Adaptation, 5–12, 19–22, 24, 37, 60, 78, 103, 107, 120, 141, 147, 151, 152, 156, 161 Aggression, 49, 70, 73, 74, 78, 82, 92–94, 99, 106, 123, 141, 171 Anxiety, 5, 16, 25, 55, 59–61, 76, 78, 87–90, 92, 94, 95, 99–101, 105, 106, 121, 124, 126, 138, 139 Attention-deficit/hyperactivity disorder (ADHD), 69–75, 79–81, 92, 93, 95, 107, 120–122, 127 Autism spectrum disorder (ASD), 69, 71, 75–77, 79, 80, 93–95, 120, 122, 123 B Behavioral measurement, 35–41 Biomarker, 35–42 Buddhism, 161, 163, 164 Buddhist meditation, 3, 4, 164 C Challenging behaviors, 76, 77, 123, 168–171 Children, 5, 15, 31, 49, 70, 87, 115, 135, 147, 163 Cognitive development, 21, 35 Context, 3–8, 10–12, 17, 20, 22, 25, 26, 34, 37, 39, 42, 52, 54, 56, 60, 62–64, 71, 75, 79, 93, 97, 102, 106, 107, 119, 120, 136, 137, 140–143, 147–152, 155, 156, 162, 163, 167, 169, 171, 172

Core components, 8, 18, 21, 26, 149, 151, 156, 162 Curriculum, 3, 6, 7, 12, 17, 20, 23, 25, 49–64, 77, 91, 135, 140, 141, 151, 154–156 D Delivery, 6–8, 10, 54, 62, 64, 77, 79, 94, 96, 104, 126, 148–150, 152, 155, 157, 169, 170 Depression, 4, 5, 24, 25, 40, 55–57, 60, 61, 78, 89–92, 95, 96, 98, 99, 101, 103, 105, 106, 117, 120, 121, 126, 139, 148 E Effectiveness, 8, 23, 42, 51, 55, 61, 63, 70, 71, 78–80, 91, 92, 95, 96, 98, 99, 105–107, 123, 125, 126, 128, 136, 137, 148, 153, 155, 170–172 Efficacy, 5, 12, 23, 24, 77–79, 92, 96, 102, 106, 122, 137, 165 Ethics, 161–167, 170 F Fidelity, 7, 10, 53, 61 I Implementation, 5, 8–12, 17, 26, 42, 53, 57, 58, 60–64, 75, 78, 80, 107, 127, 128, 140–143, 147–157, 164, 166–167, 171, 172 Intellectual disability (ID), 69, 75, 77–80, 82, 93, 120, 122, 123, 139

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. H. M. Lo, Mindfulness for Children, Adolescents, and Families, Mindfulness in Behavioral Health, https://doi.org/10.1007/978-3-031-51943-7

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176 M MBP for children, 12, 16–23, 36, 38, 39, 41, 42, 49, 50, 54, 69–82, 87–107, 142, 147–157, 163–165, 167, 170, 171 Mental health, 4–6, 8, 16, 22, 24, 25, 41, 53, 59–64, 69, 75, 76, 80, 87–107, 116, 123–125, 137, 140, 142, 143, 147, 150, 152, 156, 168 Mindfulness, 1, 15, 31, 49, 70, 88, 115, 135, 147, 163 Mindfulness-based program (MBP), 2–9, 12, 16–26, 31–42, 49, 52–63, 69–82, 88–107, 115–129, 135, 139–143, 147–157, 161–172 Mindful parenting, 72, 115–129 O Outcomes, 8–11, 16, 23–25, 31, 34–39, 41, 42, 50–53, 55–64, 71–73, 76–80, 88, 90, 92, 93, 95–98, 103, 104, 106, 116, 119–121, 123–125, 127, 128, 139, 140, 142, 148, 150, 152–156, 169, 170, 172

Index P Parents, 7, 8, 15, 20, 24, 38, 39, 42, 69–76, 78–81, 89, 90, 92–95, 99, 104–106, 115–129, 136, 139, 147, 153, 165, 166, 168–170 S Schools, 3, 22, 32, 49, 69, 87, 135, 147, 163 Secular, 3–5, 15, 162, 163, 165, 170 Socioemotional development, 21, 25 Spirituality, 3, 15–17, 161 Standardized measures, 128 Students, 4, 23–25, 32, 34–35, 40, 41, 49–58, 60–64, 77, 78, 89–94, 103, 104, 135–143, 151–156, 164, 168, 171 T Teachers, 4, 8, 12, 20, 23, 24, 42, 51–57, 62–64, 71–73, 77, 78, 80, 89, 94, 120, 135–143, 147, 150, 153–155, 164, 166–171