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School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Focused Question:
In children (ages 8-19) with mental illnesses, does relaxation techniques, yoga, and
Mindfulness-Based Interventions help improve self-confidence and increase social

Prepared By:
Madeline Dunlap and Mallory Viveros
Date Review Completed:
Clinical Scenario:
Mental illness is a condition that impacts a persons thinking, feeling or mood and may affect his
or her ability to relate to others and function on a daily basis (National Alliance on Mental
Health, 2015). Children are increasingly becoming prevalent to mental illnesses in the United
States of America, thus greatly impacting many childrens ability to participate in meaningful
roles such as student, classmate, friend, and family member. Approximately four million children
and adolescents in this country suffer from a mental disorder that causes functional impairments
affecting everyday participation at home, school, and with peers (National Alliance on Mental
Health, 2015). A childs development and occupational performance depends on how well their
psychosocial needs are being met just as much as their need for basic necessities such as food
and shelter are provided to them (Davidson, 2010). As the prevalence of children with mental
illnesses continues to rise, there too, is a rise in need to provide psychosocial support for these
individuals. Occupational therapy gained its start in mental health, and can be addressed in all
settings of practice, however focus should be placed on treating the behavioral symptoms of
children with mental illness to allow for optimal participation of occupation performance.
The primary occupations for children: play, education, and social participation require attainment
of self-confidence and social communication skills in order for children to achieve an optimal
level of occupational participation. However, achievement of both is challenging for children
with mental illnesses because attention, emotional regulation, and self-esteem are negatively

impacted as a result of symptomatic behavioral problems (Arbesman, Baztk, & Nochajski,

2013). Behavioral problems are common symptoms of mental illness that immensely make it
difficult for children to achieve self-confidence and engage in social communication. It would be
most effective to identify and address the psychosocial needs of children early as early
intervention minimizes long-term effects and allows appropriate social development (National
Alliance on Mental Health, 2015). Currently children with mental illnesses are being treated
pharmacologically with psychotropic medication to address symptoms such as attention, anxiety,
and mood disorders, and psychotherapy is an additional option of treatment (Fontanella, Hiance,
Phillips, Bridge, & Campo, 2014). Although both treatment options have been noted as
beneficial they may not have long lasting effects and may yield side effects as is this case with
medication, and it may not be feasible due to finances or lack of resources for many children and
their families. Mindfulness-Based Interventions, yoga, and relaxation techniques can be utilized
by skilled occupational therapists in both school and community based settings to greater meet
the psychosocial needs of children with mental illness.
Summary of Key Findings:
Summary of Levels I, II and III:
Level I: Research indicated that relaxation techniques, yoga, and Mindfulness-Based
Interventions effectively reduced behavioral disturbances commonly associated with
mental illness. Providing therapeutic interventions, with utilization of relaxation and
mind-body interventions, to children with mental illness has resulted in decreased rates
of problematic symptoms that have negatively impacted a childs ability to participate
in daily occupations. A Mindfulness Based Cognitive Therapy for Children (MBCT-C)
program, a combination of mindfulness and cognitive behavioral therapy decreased
problems with attention among children with stress and anxiety (Semple,Lee, Rosa, &
Miller, 2009, Level I). Psychoeducational programs such as Mindfulness-Based Stress
Reduction (MBSR) was effective at reducing anxiety, depression, sleep disturbance,
and low self-esteem leading to diagnostic improvement among children with various
mental health diagnoses. MBSR programs aim to teach children techniques for
obtaining mindfulness and a non-judgmental attitude (Biegel, Brown Shapiro, &
Schubert, 2009, Level I). Mind-body interventions are effective approaches to use in
schools to help produce positive school outcomes. Completion of mind-body social and
emotional learning program as part of childrens curriculum improved childrens
prosocial behavior and mathematics scores (Schonert-Reichl et al., 2015, Level I).
Research found yoga to be a positive addition to physical education programs for
children because it educates children in proper breathing, relaxation, and stress
management techniques that they may not otherwise be exposed to (Tells, Singh,
Bhardwaj, Kumar, & Balkrishna, 2013, Level I). For children with varying mental

illness, yoga has been effective for increasing emotional resilience and decreasing
anger symptoms (Khalsa, Hickey-Schultz, Cohen, Steiner, & Cope, 2012, Level I).

Level II: Massage, yoga, and relaxation interventions combined in the Self-discovery
Programme (SDP) had an effect on self-confidence, communication, and participation
in the classroom. As a result of learning yoga, breathing, and relaxation techniques,
children with behavioral and emotional difficulties were able to develop self-efficacy
and emotional regulation, thus allowing an increase in social participation and selfconfidence (Powell, Gilchrist, & Staple, 2008, Level II)

Level III: MBCT-C was effective in teaching children with depression skills necessary
to combat depressive episodes and was proven to reduce incidence rates of relapse
(Lee, Semple, Rosa, & Miller, 2008, Level III). Mindfulness exercises including bodyscan, sitting meditation, and breathing space effectively reduced problems with
attention among children with attention deficit hyperactivity disorder (ADHD) due to
the interventions focus on self-control, awareness, and enhancing attention (van de
Weijer-Bergsma, Formsma, de Bruin, & Bogels, 2011, Level III). Research found
mindful non-reactivity, non-judgement, and acting with awareness in response to
stressful situations to be the most effective mindful approach for adolescents to manage
daily life stressors. Increased awareness and non-judgmental thoughts are at the core of
mindfulness and is most effective in decreasing the likelihood of ruminating thoughts
and potential for dysphoric mood for adolescents experiencing stress (Ciesla, Reilly,
Dickson, Emanuel, & Updegraff, 2012, Level III). In addition research found atypicality behavioral symptoms including odd, asocial, and inappropriate behaviors
among children with autism spectrum disorder decreased as a result of participating in
a relaxation response program with yoga and dance over (Rosenblatt et al., 2011, Level

Summary of Level IV and V:

Level IV: No level IV were appraised
Level V: No level V were appraised
Contributions of Qualitative Studies:

No qualitative studies were appraised

Bottom Line for Occupational Therapy Practice:
The clinical and community-based practice of OT:
Mind-body interventions such as yoga, stress reduction, and relaxation techniques should

be considered in occupational therapy treatment as it has been shown to help children

with mental illnesses deal with anxiety, depression, ruminating thoughts, attention, and
behavioral problems. These interventions should be utilized to overall enhance
emotional well-being, establish social competence with peers, family, and teachers, and
promote quality of life to these individuals suffering from a mental illness.
Program development:
Mind-body interventions can be used in various settings among various populations with

different diagnoses to help alleviate stress, ruminating thoughts, and depression having an
overall impact on health and well-being. Developing a program that implements mindbody techniques for children suffering from a mental illness can overall improve behavior
and mood to help facilitate engagement in various occupations. Occupational therapists
should receive training in various mindfulness techniques to provide options for their
clients and match the needs of each individual client. Mind-body interventions can be
included during therapeutic interventions as both a preparatory component or as the
primary intervention. Once a client has received training and education in mind-body
interventions, then it can be a point of reference during future sessions to maximize
optimal performance during the rest of the treatment session.
Societal Needs:
Mind-body interventions would be beneficial to implement in schools and early

intervention community settings to help children with mental illnesses cope with the
everyday stressors of life, and decrease long lasting effects of mental illness. The need for
regulating behavioral difficulties and emotional responses in children with various mental
health problems is a very important concept that needs to be understood across the
profession of occupational therapy as well as other professions working with children to
help promote change in this population to overall better society.
Healthcare delivery and policy:
Due to the increasing amount of school aged children with low physical fitness, increased

behavioral problems, and mental health illnesses, mind-body interventions such as the
use of yoga and relaxation techniques could have a positive outcome on the lives of these
children and their health. Mental health symptoms of stress and decreased cognitive
control greatly affect a childs ability to concentrate in school, therefore it is important to
decrease these symptoms, especially due to the rise in stress among children.
Education and training of OT students:
OT students should be trained on what to expect when working with children who have

mental health issues and the common symptoms and problems they present with

according to various diagnoses. Additionally, OT students need to be educated on the

training made available to OT professionals if interested in specializing in a specific
mind-body training program. For example, MBCT is required to obtain certification and
additional training to be able to utilize the techniques formally in therapy. However,
various aspects of the Mindfulness-Based program, along with yoga and relaxation skills
can be used in treatment without certification. The OT students should understand that
when becoming a practitioner, they should be familiar with the skills involved in these
interventions, the diagnosis being treated, and the population they are working with.
Refinement, revision, and advancement of factual knowledge or theory:
Most research on mind-body training has been done on the adult population with various

diagnoses associated with this population. Further research needs to be done on mindbody intervention programs in children with and without mental illnesses, and inclusion
of longer post-intervention examination to assume more reliable results with the effects
of the program. The results and findings of mind-body interventions suggests that it is
beneficial to children and have positive outcomes on their health and well-being.
Review Process:

PIO areas chosen; quick search to ensure that literature was available for support of
Focus question identified and submitted to instructor for review and feedback
Revised and finalized focus question and submitted to instructor
Development of key terms
Exhaustive literature search through multiple databases
Full text articles were then reviewed
25 articles were of interest
15 articles were eliminated based on the inclusion and exclusion criteria
Inclusion and exclusion criteria applied; the articles that did not meet the criteria and did
not meet the PIO of the focus question were removed
15 articles were eliminated based on the inclusion and exclusion criteria
10 articles met the inclusion and exclusion criteria and were analyzed in the evidence
Completion of Critically Review Forms on all 10 articles and submitted to instructor for
Evidence table was created and reviewed with instructor
Independent consultation with instructor occurred throughout the entire process to answer
any questions and provide feedback

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:
Published peer-reviewed journal articles were chosen, along with published articles written in
English within the last 10 years, and outcome based research of Level I and III. Interventions
included Mindfulness-Based Interventions, relaxation techniques, stress reduction interventions,
physical exercise, and yoga.
Exclusion Criteria:
Articles which did not address the specific focus question, were non-English, and Level IV, V
reports, dissertations, and thesis were excluded as well. The specific populations excluded from
the table included participants that were over the age of 19 years old and participants that did not
have a mental health problem such as behavior, depression, anxiety, etc. Exclusions of
interventions included studies that did not involve mind-body interventions.
Search Strategies:
Patient/Client Population

Key Search Terms

Children; Adolescents; Youth; Mental illness; Mental health;
Mental illnesses


Mindfulness; Mindfulness body; Mind-body ; MindfulnessBased; Relaxation; Relaxation techniques; Yoga


Social communication; Social interaction; Social skills; Selfconfidence; Self-esteem; Behavior; Behavioral disturbances

Databases and Sites Searched

Google Scholar; CINAL; PsychINFO
Quality Control/Peer Review Process:

The focus question reviewed by instructor and provided necessary feedback

Search terms were developed based on the P, I, and O of the focus question
An exhaustive search of 3 databases was completed by the students using the identified
search terms
Following comprehensive literature review feedback, authors changed components of
focused question to increase clarity of question
Inclusion and exclusion criteria were applied and articles that did not meet the criteria

were removed
Instructor reviewed evidence table and provided feedback as necessary

Results of Search
Summary of Study Designs of Articles Selected for Appraisal
Level of

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized
controlled trials
Two groups, nonrandomized studies (e.g., cohort,
One group, nonrandomized (e.g., before and after,
pretest, and posttest)
Descriptive studies that include analysis of outcomes
(single subject design, case series)
Case reports and expert opinion, which include
narrative literature reviews and consensus statements
Qualitative Studies


Number of Articles

Limitations of the Studies Appraised:

Levels I, II, and III

Sample was largely female (Biegel, Brown, Shapiro, & Schubert, 2009, Level I)
Sample was largely male (Rosenblatt et al., 2011, Level III)
Small sample size (Rosenblatt et al., 2011, Level III; van de Weijer-Bergsma,
Formsma, de Bruin, & Bogels, 2011, Level III; Lee, Semple, Rosa, & Miller,
2008, Level III)
Exclusive self-report measures (Ciesla, Reilly, Dickson, Emanuel, & Updegraff,
2012, Level III; Rosenblatt et al., 2011, Level III; van de Weijer-Bergsma et al.,
2011, Level III)
Financial compensation (Ciesla et al., 2012, Level III; Lee et al., 2008, Level III;
Semple, Lee, Rosa, & Miller, 2010, Level I)
Brief or no follow up period (Biegel et al., 2009, Level I; Schonert-Reichl et al.,
2015, Level I)
Short duration of intervention (Ciesla et al., 2012, Level III; Khalsa, HickeySchultz, Cohen, Steiner, & Cope, 2012, Level I)
Treatment contamination (Lee et al., 2008, Level III; Schonert-Reichl et al.,

2015, Level I; Semple et al., 2010, Level I)

Treatment co-intervention (Powell, Gilchrist, & Staple, 2008, Level II; Khalsa et
al., 2012, Level I)
Geographically localized to north of India (Tells, Singh, Bhardwaj, Kumar, &
Balkrishna, 2013, Level I)
Not ethnically diverse (Ciesla et al., 2012, Level III)
Wait-list control group (Biegel et al., 2009, Level I)
Trainers met before intervention to discuss effects of mindfulness (van de
Weijer-Bergsma et al., 2011, Level III)

Levels IV and V
Excluded from review
Articles Selected for Appraisal:
Biegel, G. M., Brown, K. W., Shapiro, S. L., & Schubert, C. M. (2009). Mindfulness-based stress
reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical
trial. J Consulting and Clinical Psychology, 77(5), 855-866. doi: 10.1037/a0016241
Ciesla, J. A., Reilly, L. C., Dickson, K. S., Emanuel, A. S. & Updegraff J. A. (2012).
Dispositional mindfulness moderates the effects of stress among adolescents: Rumination
as a mediator. Journal of Clinical Child & Adolescent Psychology, 41(6), 760-770. doi:
Khalsa, S. S., Hickey-Schultz, L., Cohen, D., Steiner, N., & Cope, S. (2012). Evaluation of the
mental health benefits of yoga in a secondary school: A preliminary randomized
controlled trial. The Journal of Behavioral Health Services & Research, 39(1), 80-90.
doi: 10.1007/s11414-011-9249-8
Lee, J., Semple, R. J., Rosa, D., & Miller, L (2008). Mindfulness-based cognitive therapy in
children: Results of a pilot study. Journal of Cognitive Psychotherapy: An International
Quarterly, 22(1), 15-28. doi:10.1891/0889.8391.22.1.15
Powell, L., Gilchrist, M., & Stapley, J. (2008). A journey of self-discover: An intervention

involving massage, yoga, and relaxation for children with emotional and behavioral
difficulties attending primary schools. Emotional and Behavioral Difficulties, 13(3), 193199. doi: 10.1080/13632750802253186
Rosenblatt, L. E., Gorantla, S., Torres, J. A., Yarmush, R. S., Rao, S., Park, E. R., Denninger, J.
W., Benson, H., Fricchione, G. L., Bernstein, B., & Levine J. B. (2011). Relaxation
response-based yoga improves functioning in young children with autism: A pilot study.
The Journal of Alternative and Complementary Medicine, 17(11), 1029-1035. doi:
Semple, R. J., Lee, J., Rosa, D., & Miller, L. F. (2010). A randomized trial of mindfulness-based
cognitive therapy for children: Promoting mindful attention to enhance social-emotional
resiliency in children. J Child Family Stud, 19, 218-229. doi: 10.1007/s10826-009-9301y
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. Dev Psychology, 51(1), 52-66. doi: 10.1037/a0038454
Tells, S., Singh, N., Bhardwaj, A. K., Kumar, A., & Balkrishna, A. (2013). Effects of yoga or
physical exercise on physical, cognitive and emotional measures in children: A
randomized controlled trial. Child and Adolescent Psychiatry and Mental Heal, 7(37), 116. doi: 10.1186/1753-2000-7-37
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. J Child Fam Stud, 21(5), 775-787. doi: 10.1007/s10826-0119531-7

Other References:
Arbesman, M., Bazyk, S., & Nochajski, S. M. (2013). Systematic review of occupational therapy
and mental health promotion, prevention, and intervention for children and youth.
American Journal of Occupational Therapy 67(6), 120-130. doi:
Davidson, D. (2010). Psychological issues affecting social participation. In J. Case-Smith & J.
OBrien (Eds.), Occupational therapy for children (6th ed., pp.404-433). St. Louis, MO:
Mosby Elsevier.
Fontanella, C., Hiance, D. H., Phillips, G., Bridge, J., & Campo, J. (2014). Trends in
psychotropic medication use for medicaid-enrolled preschool children. Journal of Child
and Family Studies, 23(4), 617-631. doi: 10.1007/s10826-013-9761-y
National Alliance on Mental Health. (2010). Facts on childrens mental health in America.
Retrieved from