This review provides information to assist clinicians who are considering mindfulness meditation for their patients.
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST
Meditation can be divided into 5 types (Table 1). Mindfulness falls under the category of focused attention, which has recently received considerable attention.
Since the 1990s, mindfulness meditation has been studied in healthy groups and increasingly in clinical populations in adults. The research is quite robust in adults with depression and anxiety, but research in youths with the same conditions is just starting. Jon Kabat-Zin brought mindfulness into the clinical realm with mindfulness-based stress reduction (MBSR). Defining this state of mind, he shared this awareness that emerges through purposeful attention, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.1 With the possible exception of sleep, all that we do each day can be done mindfully.
Mindfulness practices have been used primarily to aid in stress reduction and the promotion of health and well-being in various populations, including those with chronic pain, depression, anxiety, or other mental health conditions. Mindfulness practices often include body relaxation, mental imagery, breathing practice, and mind-body awareness.
MBSR is a manualized approach. This 8-week group intervention meets once a week for 2 and a half hours with an all-day session during week 6. Each meeting includes one of the mindful practices along with mindfulness to daily activities.
Mechanisms of mindfulness meditation
Neuroscience research has found 3 possible mechanisms through which mindfulness meditation increases self-regulation:
1. Increased attentional control
2. Improved emotional regulation
3. Modifying self-awareness
Within attentional control is alerting and orienting as well as conflict monitoring. With the experienced meditation practitioner, there is greater alerting enhancement, whereas the beginner experiences better conflict-monitoring and orienting.
Neuroimaging studies have supported both functional and structural changes in the anterior cingulate cortex and the dorsolateral prefrontal cortex. Specifically, there is a thickening of the gray matter in these specific areas along with activation. In addition, there is a decrease in amygdala activation.2,3 The research is so compelling that Tang and Leve2 suggest that mindfulness meditation interventions are a possible prevention strategy. However, this needs to be further studied in translational neuroscience.
Mindfulness meditations specific to clinical populations
Research in mindfulness meditation and youth has been primarily in healthy populations with research conducted in community settings such as schools. Two of many such programs are The Hawn Foundation MindUp4 and the Inner Resilience Program by Lantieri and Goleman.5
Different interventions have evolved with the perceived need of different clinical populations (Table 2). The 2 most popular are MBSR and mindfulness-based cognitive therapy (MBCT), which was adapted from MBSR.6 Both have a manualized group protocol, but MBCT has an added component of cognitive interventions to disrupt repetitive negative thought patterns. The intent is to identify the intrusive thoughts as “just thoughts,” to practice a nonjudgmental approach; to observe the thoughts, to recognize them rather than avoiding them or returning to habitual thought patterns.7
With children and teens, modifications have allowed for developmental differences such as increased repetition and reduced time spent in meditation. The MBCT-C protocol has been tested in children aged 8 to 14 years. Parent training happens as well to further support the child. The MBSR-T protocol is specific for teens aged 14 to 18 years. With children and teens, an all-day workshop is typically not used.
A meta-analysis of mindfulness in children and adolescents
Zoogman and colleagues8 reviewed the current state of research in youth. They focused on the value of mindfulness meditation, and on which symptoms or sample populations would benefit most. Twenty studies met inclusion criteria. Based on their data, the researchers concluded that mindfulness interventions with youth were helpful; moreover, there was no iatrogenic harm. Effect size was in the small to moderate range (0.23, P > .001), which indicates mindfulness interventions were better than the active control. Of note, there was a significantly larger effect size for psychological symptoms when compared with other dependent variables as well as for clinical samples compared with non-clinical samples.
Of the 20 studies reviewed, most were conducted in schools and used a variety of intervention types: 3 used MBSR, 3 used MBCT-C, 5 used part of MBSR, and 9 used other mindfulness interventions. The participants were aged 6 to 21 years. Although most comprised nonclinical populations, 4 studies included clinical samples; 12 studies had active controls. Measures included psychological symptoms such as anxiety or depression; general function such as social skills; and measures of mindfulness.
A moderate effect size in the clinical population was 3-fold higher than the effect size of the nonclinical sample. This suggests that mindfulness may be most helpful in clinical populations. Mindfulness appeared to address symptoms of psychopathology quite well when compared with other outcome measures.
Depression and anxiety disorders
Biegel and colleagues9 undertook one of the largest randomized controlled studies in youths: 102 adolescents in a psychiatric outpatient clinic were randomized to either treatment as usual (TAU) or TAU and an 8-week MBSR program facilitated by trained personnel. Significant improvement in mental health measures were seen in the MBSR group (P = .0001) and at follow-up (P = .0001). Important to this study is the correlation between time spent in mindfulness practice and the improvement in clinician-rated functioning and self-reported depression and anxiety symptoms from baseline to 3-month follow-up (P = .05).
Teaching parents and children MBSR using either formal home practice with an instructor or informal practice at home can have added benefits. In a study by Saltzman and Goldin,10 informal practice decreased self-reported depressive symptoms in the adults (P < .05) and increased cognitive control of attention in children (P < .05), thereby increasing family harmony.
Meditation and ADHD
A high theta/beta ratio is associated with some forms of ADHD. Although mindfulness techniques are usually associated with decreases in anxiety, which has an indirect effect on attention, the use of transcendental meditation showed improvements in attention associated with changes in the theta/beta ratio of EEG.11
In a pilot study, 18 children were randomized to either transcendental meditation or a control group.12 Significant decreases in theta/beta ratios of EEG were recorded at Cz in the transcendental meditation group (P = .05) that correlated to improvements in ADHD symptoms. There were significant increases from pretest to 3-month post-test in letter fluency for the transcendental meditation group (P = .017) on the Delis-Kaplan Executive Function System test. There were also significant improvements on parent rating scales in the ability to focus on schoolwork, organizational abilities, ability to work independently, happiness, and quality of sleep. All of these results were maintained at 6-month follow-up.
Although this is a small trial, it shows that transcendental meditation warrants further study as a possible adjunct treatment, especially for ADHD. These findings correlate with results from a magnetoencephalography study that demonstrated that transcendental meditation increases activity in prefrontal executive circuits and anterior cingulate attention circuits.13
Meditation and PTSD
A mind-body technique referred to as meditation/relaxation has been used for PTSD by Catani and colleagues14 in a randomized comparative study. This study was conducted within the first 5 months after a tsunami in the northeastern part of Sri Lanka. Thirty-one children were randomized to either 6 sessions of a meditation/relaxation technique or 6 sessions of narrative exposure therapy for children (KIDNET). PTSD symptoms (avoidance, intrusions, and hyperarousal) and impairment in functioning were significantly reduced at 1 month after treatment and remained stable over time at the 6-month follow-up. The effect size for the KIDNET group was 1.76 (confidence interval [CI], 0.9-2.5) at post-test and 1.96 (CI, 1.1-2.8) at the 6-month follow-up. The effect sizes for the meditation/relaxation group were 1.83 (CI, 0.9-2.6) and 2.20 (CI, 1.2-3.0). At the 6-month follow-up, recovery rates were 81% for the children in the KIDNET group and 71% for those in the meditation/relaxation group.
Meditation and autism
Mind-body techniques may show some promise in children with autism spectrum disorder (ASD). Rosenblatt and colleagues15 designed a program that engaged the unique sensory features of patients with ASD using yoga and music. Twenty-four children (ages 3 to 18) participated; parents were given a CD and guidelines on how to practice at home. Results using BASC-2 (Behavioral Assessment System for Children, Second Edition) demonstrated that the behavior symptom index changed for all participants. The change was greater for the latency-aged group (P < .01) compared with all ages (P < .05). Unexpectedly, the post-treatment scores on the atypicality scale of the BASC-2, which measures some of the core features of autism, changed significantly (P = .003). For the latency-aged children, there was a trend toward improvement on the irritability scale of the aberrant behavior checklist (P = .06). Although small, this study suggests that body-mind techniques may be especially beneficial in latency-aged children with ASD.
Although data on mindfulness specific to youths with mental health problems are limited, it is clear that there is a foundational improvement in psychological function and resilience in the healthy youths studied. In the meta-analysis, there was strong effect size for reduction in psychological symptoms in the clinical population-mindfulness interventions had the strongest outcome measure.
Areas of future study to consider would be attempts to replicate the impact of meditation in areas of the world where trauma is prevalent. These interventions can be taught to health care workers in underserved areas. It can be a safe and effective intervention in high distress zones. Another area of future study is to see whether mindfulness meditation practice affects the dose of or need for medications in ADHD, anxiety, and depression.
Finally, it is important to study which forms of meditation are of most benefit to which disorder. For example, body-mind techniques that utilize music and yoga might be better suited to autistic children than traditional mindfulness techniques.
Dr. Pentz is Assistant Professor, Department of Psychiatry and Behavioral Science, University of New Mexico, Albuquerque, NM; and she has a small private consultation practice. Dr. Simkin is Clinical Assistant Professor at Emory School of Medicine, Atlanta, GA, and is in private practice in Destin, FL. The authors report no conflicts of interest concerning the subject matter of this article.
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