’

Mindfulness-Based Approaches for

Children and Youth
Carisa Perry-Parrish, PhD,a Nikeea Copeland-Linder, PhD, MPH,b
Lindsey Webb, MS,c and Erica M.S. Sibinga, MD, MHSd

Mindfulness meditation is a useful adjunct to behavioral and
medical interventions to manage a range of symptoms, includ-
ing psychological and physical responses to stress, anxiety,
depression, and disruptive behavior. Mindfulness approaches
can be taught to children, adolescents, and their parents to
improve self-regulation, particularly in response to stress. Mind-
fulness may be particularly relevant for youth and families who
have an increased risk for exposure to chronic stress and unique
stressors associated with medical and/or social-contextual
considerations. Moreover, mindfulness parenting techniques
can augment traditional behavioral approaches to improve
children’s behavior through specific parent–child interactions.
A growing body of empirical studies and clinical experience
suggest that incorporating mindfulness practices will enable
clinicians to more effectively treat youth and their families in
coping optimally with a range of challenging symptoms.
Curr Probl Pediatr Adolesc Health Care 2016;46:172-178

Introduction to recognize that effective health approaches to mitigate

the negative effects of toxic stress and trauma may occur
any youth and their families are at risk of in the community, not only in medical settings.4
M experiencing stressors that may lead to malad-
aptive coping strategies to manage negative
Mindfulness has been described as “paying attention
in a particular way: on purpose, in the present moment,
affective experiences. And ethnic minority youth are and nonjudgmentally.”5 In essence, mindfulness is the
disproportionately exposed to a range of stressors.1 complete, nonjudgmental awareness of what is hap-
Although emotion regulation and coping may protect pening right now. Mindfulness instruction is intended
youth by reducing the impact of to enhance an individual's innate
negative stressors, continued expo- ability to be aware of what is
sure to stressors may overload their Mindfulness instruction is happening internally and exter-
coping resources. Significant, recur-
rent and/or ongoing stress may con-
intended to enhance an nally with open curiosity and
without judgment. Mindfulness
tribute to toxic stress, in which an individual's innate ability to interventions are theorized to
individual's ability to manage or cope be aware of what is hap- target regulation of emotion
with stress is overwhelmed.2 Increas- pening internally and exter- and coping processes associated
ingly, there are calls for broader think-
nally with open curiosity with stress,6 and may represent a
ing about how to treat toxic stress.
Pediatricians have been called to and without judgment. helpful branch of psychothera-
pies to address the suffering
understand the complex and inter- experienced by stressed youth.
twined systems that are disrupted by stress,3 as well as Formal mindfulness instruction entails a range of
techniques that help foster an intentional focusing of
From the aDepartment of Psychiatry and Behavioral Sciences, Johns
b
Hopkins School of Medicine, Baltimore, MD; Department of Pediatrics, attention on one's present-moment experience while letting
Johns Hopkins School of Medicine, Baltimore, MD; cDepartment of go of negative, self-critical judgments. This type of training
Pediatrics, Center for child and Community Health Research, Johns aims to help individuals accept unpleasant and painful
Hopkins School of Medicine, Baltimore, MD; and dDivision of General
Pediatrics and Adolescent Medicine, Center for child and Community
experiences without reactively attempting to change the
Health Research, Department of Pediatrics, Johns Hopkins School of experience. As moment-to-moment awareness through the
Medicine, Baltimore, MD. day is the ultimate goal of mindfulness programs, there is
Curr Probl Pediatr Adolesc Health Care 2016;46:172-178 also instruction of informal techniques that can be used at
1538-5442/$ - see front matter
& 2016 Mosby, Inc. All rights reserved. any time. As most of us would prefer to reduce or
http://dx.doi.org/10.1016/j.cppeds.2015.12.006 eliminate pain and discomfort as much as possible, some

172 Curr Probl PediatrAdolesc Health Care, June 2016

mindfulness-based programs additionally adopt a dialec-
tical position of balancing desire for change alongside
intentional acceptance of the inevitability of suffering.7
The application of mindfulness meditation to reduce
suffering has been a feature of behavioral medicine in
the West for well over 30 years.8 Meditation practices
complement a group of established psychological
approaches to reduce stress and discomfort,9 including
cognitive-behavioral therapies and relaxation techni-
ques. Mindfulness-based stress reduction (MBSR) is
one of the more well-known programs, which initi-
ally was developed for use with adults presenting
with chronic pain, and other chronic and stressful
conditions.8 The common thread among these other
approaches is a dual emphasis on mindfulness and
behavioral change as core processes to alleviate suffer-
ing. In this article, we will review the literatures
pertaining to coping with stressors among youth, the
role of stress exposure/experience in regulation and
coping; and highlight the role of mindfulness-based
therapies to improve self-regulation among youth.
Review of Literature
Role of Stress Exposure in Youth
Stressors experienced in childhood and adolescence
have been linked to a number of negative mental health
outcomes, including internalizing problems, external-
izing behaviors, academic difficulties, and health risk
behaviors.10,11 Further, a number of cross-ethnic com-
parison studies suggest that ethnic minority youth
experience more stressors than their non-minority
FIG. Mindfulness instruction and improved self-regulation. Previously published in: Functional Symptoms in Pediatric Disease,
Ran D. Anbar editor. 2014. Springer, New York, p. 350.
Curr Probl PediatrAdolesc Health Care, June 2016
peers.12 Minority youth are more likely to experience
the death of a loved one, to have a family member who
has been arrested or jailed, to have to take care of a
loved one, and to be placed in a foster home.13
However, the effects of stress on coping and psycho-
logical functioning are important for all youth. Thus,
interventions that enhance children's and adolescents'
abilities to cope effectively with inevitable stress may
provide a protective effect.
Effects of Mindfulness on Self-Regulation
Empirical interest in the potential theoretical mech-
anisms of mindfulness-based treatments has grown
significantly since the initial introduction of mindful-
ness into psychotherapy. Mindfulness has been
broadly theorized to improve the self-regulation of
emotions, behavior, and cognitive processes,14 emerg-
ing from increased acceptance and self-awareness,
such as noticing unpleasant emotions and distress as
experiences that can be accepted, rather than impul-
sively reacted to, ruminated over, or chronically
avoided.9,15,16 This enhanced acceptance of one's
internal experiences is thought to lead to reduced
suffering and distress in response to stress. Mindful-
ness approaches emphasize approaching and accepting
one's experiences, rather than chronic efforts in avoid-
ing uncomfortable or undesired experiences.17 Our
theoretical model (Fig) reflects the range of potential
changes associated with mindfulness instruction,
including the intertwined self-regulatory processes
of improved coping, positive cognitive changes, and
improved psychological functioning.6
173
Mindfulness-Based Therapies: Empirical been adapted for use with children and youth. Adapta-
Evidence tions typically involve shortening the formal mindful-
ness techniques when they are introduced, with a
Mindfulness-based stress reduction (MBSR) was devel- gradual increase in duration as the course progresses;
oped in 1979 to reduce stress among adults with chronic clarifying and concretizing language used for instruc-
health conditions.16 The MBSR program is an 8–10 week tion; and providing age-appropriate mindfulness
group program of 2.5 h per session. MBSR instructional activities.21
content focuses on mindfulness meditation practice, self- This growing body of knowledge has provided
awareness of the body during gentle yoga practice, and encouraging preliminary results regarding acceptabil-
discussion of barriers to the use of mindfulness practices. ity, feasibility, and benefit in pediatric samples. For
Since the introduction of MBSR, several other psy- example, in high school students, mindfulness instruc-
chological treatments emphasizing mindfulness and tion led to reductions in elevated blood pressure.22
mindful acceptance have emerged within the behavioral Additionally, mindfulness instruction has been studied
and cognitive-behavioral movement. A common theme in younger students (with age-appropriate adaptations,
among these third-wave behavioral approaches was a such as belly breathing, focusing on breath, and the use
new focus and legitimation of affect and emotional of “mind jars”), showing benefits in attention and
experiences as a primary target for executive function.23–25
treatment. For example, Dialectical Several studies have examined
Behavior Therapy (DBT) incorpo-
rates mindfulness and acceptance
Several studies have exam- MBSR adapted for youth, show-
ing feasibility, acceptability, and
practices to address severe emotional ined MBSR adapted for positive effects. Studies of MBSR
dysregulation. 18
Acceptance and youth, showing feasibility, from an urban outpatient primary
Commitment Therapy (ACT) acceptability, and positive care clinic have shown program
focuses on the importance of the effects. acceptability, feasibility, and po-
function and context of experiential tential benefit related to improved
avoidance to improve psychological relationships and coping, and
flexibility.19 Mindfulness-based cognitive therapy reductions in conflict engagement, self-awareness,
(MBCT)20 modified cognitive therapy as applied to anxiety, and stress.26–28 Also, a randomized trial of
depression in an effort to reduce risk for depressive MBSR compared with usual care for adolescents in
episodes by targeting processes involved in maladaptive outpatient psychiatric treatment showed significant
mood regulation. In addition to focusing on affect, these reductions in anxiety and depression and improvements
mindfulness-based approaches share another common in global psychiatric functioning.29
link that distinguishes them from other cognitive- Beyond clinic-based evaluations of mindfulness,
behavioral treatments. In CBT approaches, the clinician there are also school-based models for teaching mind-
helps an individual change the content of one's thoughts fulness to school-age youth, with research looking at a
(e.g., cognitive restructuring) and behavior (e.g., activa- number of different mindfulness programs. Random-
tion). In contrast, mindfulness-based approaches focus ized control trials of school-based MBSR compared
on changing the context in which those internal expe- with an active control program in urban settings have
riences occur. Thoughts and feelings are cast as shown improvements in psychological symptoms
experiences or events rather than facts.20 Thus, these (anxiety and depression), coping, somatization, self-
treatments based on mindfulness actively balance desire hostility, and reduced post-traumatic stress symp-
for changed experiences on one hand and mindful toms.30,31 Additionally, a teacher-implemented 6-week
acceptance of the present moment on the other. mindfulness intervention in a private school was
Despite decades of research in adults, studies associated with significant decreases in clinical symp-
of mindfulness-based interventions for use with chil- toms from baseline to follow-up for the both meditat-
dren and youth are still emerging. However, this ing and the non-meditating control group; in contrast,
small literature provides preliminary evidence that decreased self-harm tendencies were observed for the
mindfulness-based treatments are feasible and benefi- mindfulness condition only.32 Another study used
cial for use in pediatric populations and well-accepted the Mindful Schools curriculum in an elementary
by youth. A number of mindfulness programs have school with predominately ethnic minority students

174 Curr Probl PediatrAdolesc Health Care, June 2016

(n ¼ 409) at two intensity levels: the first group received
15-min sessions three times per week for 5 weeks, the
second group received a 15-min weekly session for an
additional 7 weeks, for a total of 12 weeks.33 This
naturalistic field evaluation design suggested that
students across both groups improved on teacher
ratings of behavior, including improved attention,
self-control, participation, and respect for others.33
A third study examined the school-based, teacher-
delivered Mindfulness in Schools Program curri-
culum.34 A non-randomized, controlled study was
conducted to appraise the feasibility of the program.
Schools were selected for the intervention if their
teachers had prior training in the curriculum, while
control schools were selected to match intervention
schools on a range of social/demographic consider-
ations (e.g., academic achievement, private vs. public
status; total n ¼ 522). Results of this study indicated
reduced depression and stress, and increased well-
being.34 A randomized-controlled trial was conducted
to examine the school-based MindUp program.35
Fourth or fifth grade classrooms were selected from
four schools (one classroom per school) to be random-
ized into either the MindUp program or a control
course that discussed social responsibility (n ¼ 100).
The results of the study suggest that the MindUp
curriculum helped to increase empathy, mindfulness,
and optimism, and to decrease depression and aggres-
sion compared with the control.35 Taken together,
these results are promising, yet all of these studies
denote the need for ongoing research that adhere to
rigorous study design to enhance the methodological
evaluation of mindfulness instruction for youth
(e.g., randomization, active control arm, raters blind
to assignment).
Fewer studies address the effects of the other
mindfulness-based programs for children and youth.
A small feasibility trial of mindfulness-based cognitive
therapy for children (MBCT-C) found support for
acceptability and reduction of internalizing (e.g.,
anxiety and depression) and externalizing symptoms
(e.g., disruptive behavior) among a non-referred sam-
ple of preadolescents.23 Another randomized trial of
MBCT-C found reductions in attention problems.36
The authors also found a strong association between
attention problems and behavior problems and specu-
lated that MBCT-C could help promote improved
behavioral functioning by reducing in attention.36
Dialectical behavior therapy (DBT) is a cognitive-
behavioral therapy that incorporates mindfulness to
Curr Probl PediatrAdolesc Health Care, June 2016
treat individuals with emotional dysregulation. DBT
involves four major treatment modules: mindfulness;
distress tolerance; emotion regulation; and social/inter-
personal effectiveness. DBT has been modified for use
with adolescents (DBT-A) to include an emphasis on
improving parent-child interactions. Among adoles-
cents with oppositional defiant disorder, 16 weeks of
DBT-A skills training reduced self-reported and
parent-reported internalizing and externalizing symp-
toms.37 A year-long trial of DBT-A in a small sample
of adolescents with bipolar disorder demonstrated
feasibility and acceptability, and indicated significant
improvements in feelings of suicidality, self-harm,
emotional dysregulation, and depressive symptoms.38
DBT-A was well received among adolescents with
severe emotional dysregulation (e.g., significant self-
harming behavior); mindfulness and distress tolerance
skills were rated as particularly helpful components
of the intervention by adolescents.39 DBT-A reduced
behavior problems among incarcerated adolescent
females with comorbid mental health and substance
problems40 and decreased premature terminations from
residential treatment facilities due to self-harm and
psychiatric hospitalization; it also reduced the number
of days spent in psychiatric hospitals among a sample
of predominantly White adolescent young women.41
In addition to interventions that provide individual or
group-based treatment to target individuals, there is
also a growing body of mindfulness-based approaches
that target parents of youth.42 An early study inves-
tigated mindfulness instruction with a small cohort of
four mothers and their young children (ages 4–6 years
old) with developmental disabilities; mindfulness train-
ing was associated with decreases in children's aggres-
sive behavior and improved social skills.43 A larger
study (n ¼ 432) focused on youth in middle school in
integrated mindfulness practices into a well-established
parenting program (strengthening families).42 Parents
and youth participated in seven 2-h weekly group
sessions; parents and youth met separately for 1 h and
then together for the second hour. This mindfulness-
enhanced parent training program was as effective as
standard parent training in improving parent–youth
relationship quality and improving youth behavior
management.42
In summary, evidence suggests that mindfulness-
based interventions are beneficial for children, adoles-
cents, and parents to enhance self-regulation and
coping, which are aspects central to the management
of psychological symptoms associated with stress.
175
Recommendations for Future Research mindfulness instruction is evaluated. In this article, we
and Clinical Care reviewed clinic-based and school-based instruction, as
well as interventions targeting parents of youth. Other
Mindfulness meditation instruction has been shown exciting avenues for future research could target other
to improve mental health and qual- important social figures in the lives
ity of life. Mindfulness instruction of children and youth, including
leads to reduced stress and Mindfulness instruction teachers. There are several pro-
enhanced self-regulation, which leads to reduced stress and grams under investigation that pro-
can be thought of as the inter- enhanced self-regulation, vide mindfulness instruction to
twined processes of psychological
which can be thought of as teachers; this 44model may provide
functioning, cognitive functioning, sustainability. Finally, future
and coping (Fig). In particular, the intertwined processes of research needs to continue to probe
mindfulness reduces psychological psychological functioning, for the potential mechanisms of
symptoms, such as anxiety, and cognitive functioning, and change associated with mindful-
improves emotion regulation; coping. ness instruction. Assuming that
improves attention and the ability mindfulness instruction does lead
to focus; and reduces maladaptive to positive changes for youth, it
coping and rumination. These outcomes have been will be important to identify which emotional and
associated with increased calm, improved relation- psychological processes are changed, and how they
ships, and reduced stress and anxiety. There is a great are improved.
deal of enthusiasm among many who study mindful- Mindfulness techniques represent a group of com-
ness instruction for youth and are hopeful for the plementary treatments that are beneficial for children
benefits that mindfulness practices presenting with a range of behav-
may yield. However, as noted ioral, emotional, and somatic
above, there is still a need for symptoms, as mindfulness instruc-
rigorous scientific evaluation of The application of imple- tion supports a positive change in
mindfulness interventions for chil- mentation science to efforts the relationship to one's experien-
dren and youth. to disseminate mindfulness ces. When considering integrating
There are several promising direc- instruction will play a critical mindfulness techniques into the
tions for the future of mindfulness- care of youth and their parents, it
based interventions for children and role in the success of deliv- is essential to identify mindfulness
youth. Chief among the possibilities ering high-quality mindful- instructors with rigorous training
is the continued goal of improving ness programming. and excellent experience, and
the methods for evaluating mindful- ongoing support for their practice.
ness instructions to ensure that chil- In the right hands, mindfulness
dren and youth have access to optimal clinical care that meditation instruction has extraordinary potential for
is evidence-based. Mindfulness interventions need to benefit.
demonstrate the same level of clinical and psychological
value as other evidence-based treatments, and dissem-
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