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A Randomized Trial of Mindfulness-Based
Cognitive Therapy for Children: Promoting
Mindful Attention to Enhance Social-
Emotional Resiliency in Children

ARTICLE in JOURNAL OF CHILD AND FAMILY STUDIES · APRIL 2009
Impact Factor: 1.42 · DOI: 10.1007/s10826-009-9301-y

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Randye J. Semple Jennifer Lee
University of Southern California Columbia University
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Dinelia Rosa
Teachers College
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Available from: Randye J. Semple
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A Keywords Mindfulness  MBCT  Children  randomized cross-lagged design provided a wait-listed Emotion regulation  Attention  Anxiety control group. Miller Published online: 27 August 2009 Ó Springer Science+Business Media. F. Reductions in attention problems children ages 9–13 years old. Duncan and his colleagues found that the strongest predictors of D. Miller Department of Counseling and Clinical Psychology. Program development is significant mediator of behavior problems (p = . College. Rosa  L. USA achievement by impairing attention and disrupting cogni- e-mail: semple@usc. attention and behavior problems. and may reduce child- matched controls. Twenty-one of 25 children were ethnic minorities. described along with results of the initial randomized Significant reductions in anxiety symptoms and behavior controlled trial. State-Trait Introduction Anxiety Inventory for Children. Cohen’s d = .1007/s10826-009-9301-y ORIGINAL PAPER A Randomized Trial of Mindfulness-Based Cognitive Therapy for Children: Promoting Mindful Attention to Enhance Social-Emotional Resiliency in Children Randye J. found between attention problems and behavior problems dren (MBCT-C) is a manualized group psychotherapy for (r = . Semple Æ Jennifer Lee Æ Dinelia Rosa Æ Lisa F. p \ . daily school activities present many program showed fewer attention problems than wait-listed potential stressors. Analyzing longitudinal data. USA and attention skills.J Child Fam Stud (2010) 19:218–229 DOI 10. Participants who completed the For some children.edu tive information processing. feres with a child’s ability to study and make appropriate p = . Attention has been consis- J.025. Lee tently associated with academic achievement outcomes Marist College. Results show that MBCT-C is a promising intervention for and (c) behavior problems than wait-listed age and gender. Anxiety is commonly associated with attentional biases (Ehrenreich and Gross 2002). although attention changes proved to be a non- enhancement of mindful attention. LLC 2009 Abstract Mindfulness-based cognitive therapy for chil. Some anxiety is certainly a helpful and controls and those improvements were maintained at three expectable response to stress.42]. pervasive. worries associated with anxiety interfere with academic MC 9074. Columbia University. NY. Department of Psychiatry and the Behavioral Sciences. Poughkeepsie. A strong relationship was academic progress. 1999). Teachers later achievement were school entry-level math. inner-city house- holds. J. Academic problems contribute to 123 . and a 3-month follow-up of children who completed the first trial. NY.965. We tested the hypotheses that children problems were found for those children who reported randomized to participate in MBCT-C would show greater clinically elevated levels of anxiety at pretest (n = 6). Mea- sures included the Child Behavior Checklist. Los Angeles. 9–13 (N = 25). reading. USA (Duncan et al. reductions in (a) attention problems. (b) anxiety symptoms. cognitive distortions and emotional lability (Mineka and Gilboa R. a second trial of MBCT-C. 1.01). and physiological hyperarousal (Joiner et al.678. 2007). It seems likely that the chronic. which was developed spe. accounted for 46% of the variance of changes in behavior cifically to increase social-emotional resiliency through the problems. and intrusive Keck School of Medicine. and Multidimensional Anxiety Scale for Children. 18) = 5.053). University of Southern California. mostly from low-income. Participants were boys and girls aged hood anxiety symptoms. CA 90033. Semple (&) 1998). but too much anxiety inter- months following the intervention [F (1. New York.

volitionally alter feeling states by shifting attention. 234). and these effects may not be enhancement. ence. or non- by Silverman et al. or tially enhance specific components of attention. Bishop et al. No improvements in Borkovec 2002. Greco 2006. attention problems and anxiety symptoms (Lee et al. elaborative processing. strong cravings. controlled trial of MBSR with healthy adults found no ately effective in treating a wide range of childhood mental relationships between mindfulness and measures of sus- health issues. 2008) suggest that meditation techniques experience and a quality of relating to one’s experience may be useful in treating anxiety symptoms in children and within an orientation of curiosity. cognitive distortions. Mineka and Gilboa 1998). 2008). Little research has directly examined the effects of Semple (2005) conducted a 6-week pilot study to examine mindfulness practices on attention. Kabat-Zinn (1994) (Baer 2003). Jha and Avoidance of current experiences can involve selective her colleagues suggested that mindfulness might differen. 1996) practicing various forms of meditation have also judgments. and effectiveness of way: on purpose. (2004) proposed that and Slack 1997. many of which have been adapted from that meditation practice might improve concentration and Buddhist spiritual practices. and con. Largely. The reciprocal ADHD symptoms. The evidence. niques could be taught to children as young as 7 years old. stress. in the present moment. 2002) to examine children. acceptability. biasing of information. 4). child’s initial problems. Over-engagement can involve et al. researchers are just beginning to described mindfulness as ‘‘paying attention in a particular explore the feasibility. however. and aca. experiential openness. After 24 adults compulsive behaviors. Mean treatment effect sizes are few studies. However. after 18 weeks of 2002). Mindfulness-based interventions Valentine and Sweet 1999) and children (Rani and Rao aim to enhance attention and reduce chronic harsh self. relationship between mindfulness practices and attention ness (Weisz et al. bring a quality of nonelaborative awareness to current Zylowska et al. switching. participants reported significantly develop mindful attention using a variety of meditative lower test anxiety than matched controls. Linden (1973) conducted a controlled trial to and acceptance’’ (p. Participants in a Mindfulness-Based Stress Initial evaluations of MBCT-C suggest that mindfulness Reduction program (MBSR. Kabat-Zinn 1990. ticipants undergoing an intensive mindfulness retreat Hayes and Feldman (2004) suggest that emotions can be showed improvements in receptive attentional skills and regulated either by avoidance or by over-engagement. obsessions. cognitive inhibition. (2007) used the feasibility and acceptability of teaching mindfulness to the Attention Network Test (Fan et al. Jha et al. Linden suggested techniques. demic difficulties seem to maintain or exacerbate the Other controlled studies with adults (Semple 1999. thereby suggesting an approach that promises reported significant enhancements of attention capabilities. and nonjudg. chronic worry. Bishop et al. and depressive symptoms in adults mindfulness is and how to measure it. distraction. 2007). and in mood and anxiety symptoms. to break this vicious cycle. They concluded that mindfulness-based tech- three attentional subsystems: alerting. 2008).30. but may be limited in their directed attention (Anderson et al. of 3rd grade children (N = 26). Mindfulness is generally believed evaluate the effects that meditation training might have on to be a learned skill that enhances self-management of selected aspects of the cognitive and affective functioning attention (Baer 2003. mindfulness-based therapies seek to meditation practice. or and attention-related behavior problems. reading skills were found. 2006. Zylowska affective disengagement. as were the mindfulness least six months at an inpatient psychotherapy clinic found techniques and levels of participant training and experi- that these former child patients continued to show persis. which suggests only modest effective. adolescents. improvements were found in self-reported attention and escalates academic problems. Anxiety further disrupts MBSR program. justifies further investigation. performance tests of attention and interactions between anxiety. evidence for a relationship between tent psychiatric symptoms and ‘‘a considerably restricted mindfulness and attention does appear promising and quality of life’’ (Fleischhaker et al. The popularity of mindfulness-based psychotherapies is Mindfulness-based therapies are generally effective in growing even as researchers struggle to define exactly what reducing anxiety. Kumar 2002. Segal et al. this approach for children. Goodman 2005. Albeit limited. enhanced performance on the alerting component. Apart from these strength and durability. is not consistent. orienting. there is little evidence to substantiate a direct approximately . Definitions and measurements of attention lasting. however. 1994) can be taught to children and shows promise in alleviating demonstrated significantly improved orienting. 2006). Both of these emotion-regulation 123 . flict monitoring.J Child Fam Stud (2010) 19:218–229 219 negative self-judgment and increased anxiety (Gordon and 8 adolescents with ADHD completed an 8-week 1977. impaired attention. Kabat-Zinn 1994. (2008) explored the relationship between mindfulness rumination. Greco and Hayes 2008) mindfulness is ‘‘a process of regulating attention in order to and small-scale studies (Goldin et al. A few clinical reports (Fontana mentally’’ (p. 2004. A randomized Evidence-based psychotherapies (EBTs) can be moder. A 20-year follow-up of 104 children treated for at were different across these studies. 2008). while par. and particularly anxiety problems (see review tained attention. Boals 1978.

Demographics by sex. contin.220 J Child Fam Stud (2010) 19:218–229 strategies require one to shift attention from present events of an adult mindfulness-based intervention may enhance toward past or future events. thoughts. decentering has been hypoth. and body sensations began the program and completed all three assessments. children completing the work well for a large minority of children because their MBCT-C program would show fewer (a) attention prob- emotion regulation deficits are not adequately addressed. increasing emotional self-regulation. (b) anxiety symptoms. 12-week Neurologically. Results of the first randomized Many children with anxiety disorders show poor emo. the sample consisted of a representative group of sensations may come to be perceived as transient. Twenty-five children (15 girls and 10 boys) their own anxious thoughts. Segal et al. This hypothesis was observe internal and external experiences without distor. thereby reducing the affec- characteristic of depressive affect (e. and body sensa- tions are simply phenomena to observe rather than to judge Methods (including observing the experience of judging) and as events to be described rather than changed. Teasdale et al. There were no other mindful attention is simply to continue observing whatever initial screening or clinical inclusion or exclusion criteria. and catastrophic outcomes). tion from affective. tion regulation skills. cognitive. elsewhere (Lee et al.. ma- children tend to selectively allocate information processing nualized group psychotherapeutic intervention for children: resources toward threat stimuli. improve sustained affective resiliency and coping skills. mindfulness Twenty-nine children (74%) enrolled in the study. integrated them with cognitive anticipatory failures. that changes in attention would mediate behavioral changes. often missing or ignoring mindfulness-based cognitive therapy for children (MBCT- other. Essentially. 2000) and the feasibility and acceptability of MBCT-C is reported mindfulness and emotion regulation (Davidson et al. MBCT proposes that thoughts. inner-city children struggling with academic problems. and shame). feelings. Research needs Program completion was defined as attending at least eight to continue on childhood interventions targeted to of the twelve scheduled training sessions. 1995). remorse. 1999). Sched- can be regarded as a form of intrapsychic exposure with uling conflicts prevented two children from participating. The blame. techniques from Buddhism. The process of decentering supports one child was withdrawn due to parental concerns related affective equanimity and produces a shift in the mental to religious issues. university clinic-based remedial reading tutoring program mata (Safran and Segal 1990). 2003). With practice. C). Based on initial findings. 2008). and one child was excluded due to the representations that define an individual’s relationship to age criterion. enrolled in a easily decenter from previously conditioned anxiety sche. obsessive worries. age. A developmentally appropriate adaptation are shown in Table 1. and (c) behavior problems. Individuals with anxiety were referred by the clinic’s educational psychologist as disorders tend to have strong thoughts and feelings of having significant reading difficulties. more relevant information (Taghavi et al. race. the anterior cingulate cortex seems to be group intervention. By experi.g. In lems. ages 9 to 13. tive disregulation associated with childhood anxiety. Evaluation of attention and emotion regulation (Bush et al. It teaches mindfulness techniques with part of an attention regulation circuit that serves to regulate the aim of enhancing self-management of attention. controlled trial of MBCT-C are reported here. pro- both cognitive and emotional information processing. Thirty-nine hypervigilance and avoidant behaviors. or catastrophe that promote some indicators of associated stress or anxiety. a supplemental greater affective stability. and developed an age-appropriate. guilt. ually shifting intrapsychic events. moting decentering. is present. (Teasdale 1999. and class grade self-regulation. emotions. in completing the English version of the Child Behavior Anxiety disrupts attention and interferes with affective Checklist. 2002). MBCT-C is a developmentally appropriate. self. emotions. and body Thus. Most displayed impending threat. Hannesdottir and Ollendick (2007) We initially put forth three hypotheses: as compared to suggested that cognitive-behavioral treatments may not age and gender-matched controls. while future-oriented thinking is first two authors (RJS and JL) adapted concepts and applied associated with anxious affect (e. Parents of four participants spoke little or no English. or physiological reactivities. domains would be maintained at three months following esized to be the core mechanism of change that produces treatment. Anxious therapy techniques.g. The study was conducted in 123 . Participants encing intrapsychic processes independent of external events. Past-oriented thinking is self-management of attention. danger. The practice of children were invited to participate. response prevention. Neuroimaging studies have found connections between and developing social-emotional resiliency. Decentering is the ability to hypothesis was generated and tested. We the context of mindfulness-based cognitive therapy further hypothesized that improvements in these three (MBCT. mindful awareness allows an individual to more English speaking children.. Mindfulness-based interventions offer a promising avenue Native Spanish language translators assisted these parents for exploration.

n = 13) were evaluated against data from the 5 2 (2) 6 (6) wait-listed CONTROLS (C and D. Groups A and C consisted of Problems Scale is composed of three separate subscales children who were 9 or 10 years old. which consisted of 13 (Achenbach 1991). Each 12-week program Race consisted of one. an Internalizing Problems Scale. who were blind to the chological Association and the Columbia University group assignment of the participants. There scores for each scale are converted to T-scores (M = 50. data from the WINTER treatment group 4 4 (3) 4 (4) (A and B. to explore 6 2 (2) 3 (1) the study as an open trial. participants per group. Test administration and scoring sent forms (English or Spanish) and child participants were conducted in accordance with the test developers’ signed assent forms. gram during the winter school semester. Raw consisted of children who were 11–13 years old. First.59 (SD = . scored the assessments. somatic complaints). n = 12). Phase II completed the ‘‘cross-lag’’ element Boys Girls of the design. Second. materials for participants’ parents.368 children ages 4–18. (completion sample. as a randomized con- 3 0 (0) 2 (1) trolled trial (RCT). N = 25. and a Total Problems Participants were first matched by age and gender. The SPRING group therefore consisted of the 12 are rated on a 4-point scale. or studies with adults (Baer 2003) provided a nominal esti. Parents provided the only source infor- mate of mean effect size of d = . and social and aca- of participants needed to reasonably detect significant demic competencies. Children in the SPRING group participated in MBCT-C and then were evaluated for treatment effects Age (Time 3). The Attention Problems scale. teachers. A meta-analysis of mindfulness forms can be independently rated by parents. n = 20) Measures accordance with ethical guidelines of the American Psy. MASC items ask winter school semester. and the Total Problems Scale were outcome The randomization was concealed from participants and variables of interest for the present study. The mation used in this study. Parents signed informed con. children who participated in the 12-week MBCT-C pro. an Externalizing Problems Scale. and then redefined as the SPRING about anxiety-related thoughts.05 and a power of 80% was calculated to be nine Specific Problem Scales. and Scale. Groups C and D March 1997. direct observers. March and Parker 1999) is a 39-item self- were initially defined as wait-listed CONTROLS during the report inventory for children aged 8–19. age. based on a national standardization sample of I of the study was a pretest (Time 1) posttest (Time 2) 2. Design Child Behavior Checklist: Parent Report Form (CBCL. feelings. Social Anxiety. Participants and their parents received manuals. All child participants spoke and read adequate English. lems Scale. Four separate factor scores are children who were randomized as wait-listed controls provided: Physical Symptoms. Harm 123 . supplemented with brief daily home Caucasian 2 (1) 2 (1) practice exercises. Achenbach 1991) is designed to obtain multi-axial data on A power analysis was conducted to determine the number emotional and behavioral problems. mindfulness training African American 2 (2) 4 (3) session per week. At Time 3. The CBCL consists of 113 sample size to detect a significant group difference at problem-behavior items and provides sub-scores for eight alpha = . which group. data from all four groups 7 2 (1) 0 (0) (N = 25) were combined. were six or seven children in each of the four groups.41). Groups A and B ized behavioral inventory with good reliability and validity were defined as the WINTER group. The CBCL is a well-standard- randomized trial of a two-group design. Spanish speaking research assistants were avail- modest financial compensation for completing assessments able as needed to translate English language assessment and travel reimbursement. Phase SD = 10). small group. WINTER group participants were 9–10 4 (3) 9 (8) assessed for maintenance of any treatment effects reported 11–13 6 (5) 6 (4) at the end of Phase I (Time 2). Latino 6 (5) 9 (8) This design offered an opportunity to analyze the Grade resulting data in two ways. Groups B and D (withdrawn. Trained graduate research assistants. The Internalizing staff before recruitment. in children. Three separate CBCL mean group differences. administered and Institutional Review Board. anxious/depressed. race. Internalizing Prob- then randomly assigned to one of four independent groups. Intention to treat sample. 90-min. and class grade during Phase I. and actions.J Child Fam Stud (2010) 19:218–229 221 Table 1 Participant demographics by sex. Multidimensional Anxiety Scale for Children (MASC.

Twenty items each measure state ences (visual. MBCT does not require the involvement of C. alternating between focused sensory consistency for TA is . Both the adult and child programs combine ency. taste. focusing attention on internal and external events in spe- while MBCT-C is a 12-week program consisting of weekly cific sensory modes (sight.. The SA scale rates kinesthetic sensations) and intrapsychic events (thoughts.g. we modified and enriched the types of mind- (March 1997). been shown to improve student achievement in elementary However.71 for girls (Spielberger et al. depressive relapse in adults with recurrent major depres. more repetitious MASC Total Anxiety Scale is very good (alpha coefficients practices to be more developmentally appropriate than the between . and movement. anxiety disorder (71% correct classification rate. Unlike cognitive therapy. (b) the 20 to 40-min seated breath and kinesthetics). mindful body scan and and Kaufman 1984). Thornton 1983. gustatory. Third. MBCT-C differs from the adult MBCT program school settings (Moustafa 1999. olfactory. Children use for Children more concrete operational modes of thinking (Piaget 1962) and the cognitive-elaborative component of childhood Mindfulness-based cognitive therapy for children (MBCT. fulness exercises employed: (a) MBCT uses three primary State-Trait Anxiety Inventory for Children (STAIC. short breath meditations. upset..698 than adults to stay engaged in a single activity for long children and adolescents. tactile. (b) because latency age children have limited verbal flu- sive episodes. In addition. feeling overwhelmed). while in MBCT-C parents of the young adult patients with one therapist. Internal course of a session. Based on a normative sample of 2. the internal consistency of the periods. and yoga postures). quent exercises practiced in 3 to 10-min blocks in MBCT. verbal exchanges. and (c) educational pro- tion. so we considered the shorter. sometimes. 1994). (b) an Intro- typically have less developed memory and attentional duction to Mindfulness was held before the children’s capacities than do adults (Posner and Petersen 1990. For example. 1973). sound. meditation. mindful movement exercises body meditations in MBCT were replaced with more fre. very upset. and anxiety (SA) and trait anxiety (TA). and Separation Anxiety. Internal mindfulness exercises are more varied than MBCT over the consistency for SA is . The MASC is useful to differentiate longer duration adult practices. anxiety may be less prominent. 2002).78 for boys and . and (c) each MBCT group typically consists of up to 12 family members. activi- oriented interventions to help patients achieve affective ties. (Gaines 1997. visualization practices. practices were implemented for several reasons: (a) Adult psychotherapies depend largely on the patient’s ability to Treatment: Mindfulness-Based Cognitive Therapy apply abstract thinking and logical analysis. while naire developed to assess state and trait anxiety in children MBCT-C uses a variety of simple sensory exercises to in grades four through six. intensity (e.89). 1993). abstract reasoning.65 for boys and .87 for girls.222 J Child Fam Stud (2010) 19:218–229 Avoidance. activities. Test–retest reliability of SA over an movements. (b) children also generally find it more challenging of score validity. and stories are integrated into treatment protocols self-regulation through the development of mindful atten. Experiential mindfulness exercises used in MBCT- First. and conceptualization skills. no effort is made to grams using a variety of multisensory approaches have restructure or change existing thoughts and emotions. who MBCT is a group intervention developed to reduce report more generalized fears (i. (b) the group interactions in MBCT are largely scale rates frequency (hardly-ever. The MASC also Siegler 1991) and therefore may benefit from shorter ses- contains an inconsistency index.. 12-week program began. they mindfulness-based theory and practices with cognitively may better engage in psychotherapy when games. and often).g.47 for girls and for TA exercises.42) Second. auditory.87 and . Forty short self-statements are heighten non-judgmental awareness of perceptual experi- rated on 3-point scale. and (c) MBCT-C elementary-school aged children (Platzek 1970). smell. we made three structural modifications: (a) MBCT C are intended to enhance mindfulness by repeatedly is an 8-week program consisting of weekly 2-h sessions. The rationale for these changes is: (a) children therapist-conducted mindfulness sessions. the body scan. and (c) children often children with anxiety disorders from those without an require more individual attention than adults. address children’s needs for physical activity. test) and somatic symptoms of anxiety than do adults.31 for boys and .81 for girls (Walker activities. These modifications to traditional mindfulness is . Stark et al. Wislock in three important domains. and not upset). which provides a measure sions. touch. kappa . (c) co-therapists led parents 123 . children C) is a group intervention adapted by two authors (RJS frequently report more specific fears (e. while MBCT-C groups participants were invited to engage with the program in a consist of up to eight child patients with one or two number of ways: (a) Parents were invited to attend two therapists. The TA emotions). and drawing or writing 8-week interval is . and 90-min sessions. 1973) is a 40-item self-report question. failing a math and JL) from the adult MBCT program (Segal et al.82 for boys and .e. forms of traditional mindfulness training practices (a breath Spielberger et al. while the group interactions in MBCT-C The STAIC has established reliability and validity for include games.

2 the MBCT-C participants (Groups A and B) and the wait. treat data (N = 25) and on the completion data (n = 20). two of and B was combined with Time 2 data from Groups C and whom carried an existing diagnosis of Attention-Deficit 123 . Because of the cross-lagged design employed. Reviewing the enrollments in clinical trials. Semple et al. (d) parents were invited to ask Groups A and B was combined with Time 3 data from questions during the initial session and to talk with the co. An alpha of .001]. Controls) and TIME as the within-subjects variable (three levels: Time 1. (e) the therapists Wilcoxon signed ranked tests for related samples were encouraged parents to participate in the home practice conducted for each dependent measure of interest. 2008) that might continue to cultivate and support their child’s shows the flow of participants through the study.013] and the completion sample [Z (n = 20). Cohen’s d = . and (h) each child received were enthusiastic about having their children participate in materials to take home at the end of each session. p = . 18) = 2. exercises with their children and to model mindful inten- tions. The effectiveness of randomization of participants to groups the time-lagged crossover interaction was significant [F (1.03. relation. p = . ing of each session and allowed them to better participate Twenty children (80%) completed the program..172]. and eight attended all 12 sessions. D to create a pooled PRETEST group. of sessions attended by the 20 program completers was ment can enhance outcomes (Kaslow and Racusin 1994).42. pooling the data to simulate an open trial and conducting and Time 3 (follow-up) were not expected to be linear for any two-tailed Wilcoxon signed rank tests for related measures dependent variable. and study. hypotheses were tested using on the pooled pretest and posttest data. six attended 11 for these changes is that children are firmly integrated into sessions. therapists throughout the program. Detailed clinical descriptions of the specific session aims All sessions were videotaped. MASC total anxiety score.023.025]. Time 2. breath medi. including MBCT-C and 29 of 39 (74%) enrolled their children in the written session summaries. ability evaluation (Lee et al. eating a raisin). All treat analysis (N = 25) of the time-lagged crossover inter- subsequent analyses were conducted on the intention-to. 10. 23) = 5. 1. (f) a Review and Participation Dialogue session for parents was held at the conclusion of the program.965.9 (SD = 1. Therefore. defined as attending at least eight of the twelve sessions. Significant reduc- a quadratic. An intention-to- completion sample (n = 20) were found at pretest.4%. No significant group differences in the medium treatment effect size of d = . Groups C and D to create a pooled POSTTEST group. speech. analyses of the intention-to-treat sample [Z (N = 25). 3. The magnitude of treatment effect was listed control participants (Groups C and D) to independent calculated using Cohen’s d. action showed comparable outcomes. F (1. The rationale children attended ten or more sessions. Time 2 data from tation. secondary analyses were conducted in which data were pooled for all participants to Five children were reported to have clinically elevated simulate an open trial design. (g) parents had opportunities to share their Response and attendance rates exceeded expectations. which indicated a small to measures t-tests. experiences of MBCT-C and to discuss ways in which they Figure 1 is a CONSORT diagram (Boutron et al. home practice instructions.493. repeated-measures ANOVA for each of four tions of attention problems over time were found with dependent measures of interest (CBCL attention subscale. CBCL total score). Each analysis used GROUP as the between. Seventeen in the mindfulness exercises with their child. Clinical Effectiveness of MBCT-C for Reduction Time 3).34. Time 2 (posttest).46. Parents mindfulness practices at home. 2006). p = . subjects variable (two levels: MBCT-C. The tapes were reviewed by and interventions are published elsewhere (Semple and Lee the authors as part of the program feasibility and accept- 2008. so family involvement in treat. p = . STAI-C state anxiety scale.05 was used for all tests. Mean number their family environment. ANOVA Table 2 and Fig. p = . was confirmed by subjecting pretest assessment scores for 1. show these results. and behaviors at home. of Attention Problems To explore changes over time.3) with an overall attendance rate of 90.g. First Hypothesis: MBCT-C for Reduction of Attention Results Problems Preliminary Analyses Although the TIME X GROUP interaction between T1 and T2 by itself was not significant [F (1. 18) = 5.179. a substantially higher percentage than is typical for a log to record the daily home practices. Time 1 data from Groups A (T-score C70) attention problems at pretest. We further examined changes in attention problems by ships across assessment Time 1 (pretest). 2008).J Child Fam Stud (2010) 19:218–229 223 through several mindfulness exercises (e. and 2. Program completion was session materials offered parents a systematic understand.

However. Cohen’s behavior problem scores [t (4) = 3. Assessed for eligibility (N = 39) C = mindfulness-based cognitive therapy for children Excluded (n = 14) Declined to participate (n = 13) Enrollment Did not meet inclusion criteria (n = 1) Randomized (N = 25) Allocation Allocated to MBCT-C (n = 13) Allocated to wait list (n = 12) Received intervention (n = 10) Baseline assessment (n = 12) Did not attend >8 sessions (n = 3) Lost to follow-up (n = 0) Allocated to MBCT-C (n = 12) Posttest assessment (n = 13) Received intervention (n = 10) Lost to follow-up (n = 0) Did not attend >8 sessions (n = 2) Follow-ups 3-month maintenance (n = 13) Posttest assessment (n = 12) Lost to follow-up (n = 0) Lost to follow-up (n = 0) Intention-to-treat (n = 13) Intention-to-treat (n = 12) Data Analyses Completion per protocol (n = 10) Completion per protocol (n = 10) Excluded from analyses (n = 0) Excluded from analyses (n = 0) Pooled data open trial analyses Intention-to-treat (N = 25) Completion per protocol (n = 20) Excluded from analyses (n = 0) Hyperactivity Disorder (ADHD). from the STAIC or the MASC. 1 CONSORT flow diagram. p = . p = . The Symptoms CBCL internalizing problems scale showed significant reductions in the completion [Z (n = 20). but no and intention-to-treat [Z (N = 25).38].019] for this d = .46. 2. 123 . 3.819. p = . Significant reductions were found in atten.224 J Child Fam Stud (2010) 19:218–229 Fig. We further examined changes in negative affect subgroup. intention-to-treat analysis using a one-tailed paired ADHD) still showed clinical elevations on the attention samples t-test between pretest and follow-up did show problems scale. a combined one- just one of the children (a child with an existing diagnosis of group.041] significant group differences were found via self-report analyses. Note MBCT. p = .884. At the third assessment.033] Some reductions in anxiety symptoms were shown. p = .02.136. by pooling the data to simulate an open trial and con- ducting two-tailed Wilcoxon signed rank tests for related Second Hypothesis: MBCT-C for Reduction of Anxiety measures on the pooled pretest and posttest data.018] and CBCL total the course of the study [t (24) = 2. significant reductions in mean STAIC State Anxiety over tion problems [t (4). 2.047.

We also found significant Source df MS F g9 p improvements in CBCL total behavior problem scores in this sub-group of anxious children [t (5) = 2.172 61 p = .873 Error 18 337.417 behavior problems. p \ . no significant group nitive therapy for children differences were found at posttest or at follow-up.014]. Of the 20 children generated and tested. During the course of the program. Signif- 63 Groups C & D (spring) icant reductions in behavior problems over time were 62 found with a completion analysis [Z (n = 20).033 5. CBCL Child Behavior Checklist.922 Time 9 group 1 80.001 . problems for WINTER and SPRING intervention groups at pretest. To test the the CBCL anxiety/depression subscale at pretest. 2 Group means of Child Behavior Checklist (CBCL) attention CBCL were only slightly elevated at pretest (&.001 .025* effect size [t (24) = 4. maintained at the 3-month follow-up. p \ . a post hoc hypothesis was experiencing greater levels of anxiety. and 3-month follow-up. By the end of the program.133 . Cohen’s 56 d = .4 SD). WINTER intervention (T-scores C70). P = . mean behavior problems reported on the Fig. A model of vated anxiety (T-score C70) on the STAIC.014* p = . attention would mediate behavioral changes. 55 54 Clinical Effectiveness of MBCT-C for Behavior Problems Time 1 Time 2 Time 3 Assessment For the most part. 2.763. SPRING interventions groups (C and D) showed little change during the waitlist period.965* . reductions in the overall mean group anxiety to MBCT-C Reductions in attention problems accounted for 46% of the training. A significant relationship was found between changes in CBCL attention problems and Although it was not possible to attribute self-reported changes in CBCL behavior problems (r = . To further explore changes in behavior problems. The * p \ . SD = 10).026 . however.27. Between subjects p = . which suggested a small treatment effect.05. or this hypothesized mediation is shown in Fig.025 The CBCL total score was used as a general measure of Error 18 13. The intention-to-treat analysis of behavior problems approached significance [Z (N = 25). two-tailed Wilcoxon signed rank tests for related measures were CBCL Attention Problems (mean T-scores) 64 Groups A & B (winter) conducted on the pooled pretest and posttest data. Mean Child nificant behavior problems at the start of the program Behavior Checklist (CBCL) attention problems are reported as standardized T-scores (M = 50. Note * p \ . CBCL total score was defined as a measure of 123 .44]. and then Post Hoc Hypothesis: Changes in Attention Problems as showed similar reductions in attention problems as those shown by the WINTER intervention groups.817 .08]. 3.35.5 SD were found following both the WINTER and SPRING interventions Pearson product-moment correlations between the four dependent measures were calculated to examine relation- Clinical Effectiveness of MBCT-C for Anxiety Symptoms ships between variables.010 .678.J Child Fam Stud (2010) 19:218–229 225 Table 2 Quadratic ANOVA for CBCL attention problems following post-test assessment. Only three children were reported to have clinically sig- posttest. six reported clinically ele. paired samples t-test of the pooled pretest 58 and follow-up data found significant reductions in behavior 57 problems over the course of the study with a medium P = .05 magnitude of treatment effect was calculated as Cohen’s d = . the MASC.657. no child was groups (A and B) showed reductions in attention problems that were reported to have significant clinically behavior problems. found in a sub-group of children who initially reported Based on these findings.249 . 60 P = .01). MBCT-C mindfulness-based cog. Mean reductions in attention a Mediator of Behavior Problems problems of approximately . clinically relevant reductions in anxiety were variance in the reduction of behavior problems. This hypothesis was that changes in who completed the program. only three children reported clinically the MBCT-C intervention (n = 20) elevated levels of anxiety. Group 1 8.617 Third Hypothesis: MBCT-C for Management Within subjects of Behavior Problems Time 1 . 1. behavior problems declined.045].459. At the hypothesis.001 (two-tailed). 59 A one-group.

b values for the effect [t (24) = 2. pretest behavior problems on posttest behavior problems are from a multiple regression analysis with attention change and pretest Children who Failed to Complete the Program behavior problems as predictors of posttest behavior problems Five children completed all three assessment batteries.86. 3 Mediating effects of changes in attention problems on nificant differences between girls and boys except on the behavior problems. Children who dropped (1986) were followed.31. indicating that pretest behavior problems were difficult to participate in any form of group psychotherapy. p < . any group differences between those who completed the tion change (pretest minus posttest) was used as the program and those who did not.226 J Child Fam Stud (2010) 19:218–229 Attention should be noted that the b value of 1. The clinical interest to better understand how MBCT-C might result of this analysis was statistically significant (b = . p < . attention and anxiety problems. This study reports that MBCT-C is effective sion analysis indicated that the effect of the mediator in reducing attention-related problems and shows promise variable (attention change) was not statistically significant in managing anxiety symptoms and behavior problems in in this model (b = -. clinic- dependent variable (posttest behavior problems) was still referred children displayed significantly fewer attention statistically significant (b = 1. p \ . a simple linear regression analysis was conducted.68. p = . and atten.033]. Age and Gender Differences Pretest Posttest behavior behavior No significant relationships were found between the age of problems = .048] than the 20 chil- predictive of the dependent variable (posttest behavior dren who completed the program. p = .001 problems the children and any dependent variable. Independent samples t-tests of each dependent variable found no sig- Fig. aged children.31.405. It with Attention Deficit Hyperactivity Disorder.001) and not problems than were reported at the beginning of the pro- reduced when compared to the model without attention gram. The pretest CBCL total score was used attended fewer than eight sessions. out reported higher separation anxiety on the MASC The first step in the test of mediation was to confirm that [t (24) = . independent variable (pretest behavior problems) on the After participating in 12 weeks of MBCT-C. MBCT-C is a 12-session.637.001). the posttest CBCL tests were conducted on each pretest measure to identify total score was used as the dependent variable. was reduced when the effect promoting decentering from thoughts and emotions.08). The results of this multiple regres. but can be explained by the high level of correlation among the three variables included in this = . These results are of problems) via a simple linear regression analysis. p = .68. Note b value for the effect of pretest behavior pretest somatic complaints scale of the CBCL. The third step was to determine if the effect of the manualized group psychotherapy that aims to enhance self- independent variable (pretest problem behaviors). but behavior problems.001 = -.025] and less aggressive behavior on the independent variable (pretest behavior problems) was the CBCL [t (24) = -1. Results showed that MBCT-C might hypothesis was not supported: attention changes did not have some attention and behavioral benefits for children mediate changes in the behavior problems in this study. p \ . This difference disappeared by of attention change on posttest behavior problems and the effect of the end of the study. The procedures of Baron and Kenny ences were found on two sub-scales. and of the mediator variable (attention change) was included in increase social-emotional resiliency in elementary school the regression model. as management of attention.86 (1. improve affective regulation by demonstrated in the first step. predictive of posttest behavior problems. The second step was to ensure that the independent variable (pretest behavior problems) was predictive of the Discussion mediator variable (attention change). Again. be made more acceptable to children who might find it p \ .576.08 is unusual in that it change is greater than one. 123 . Significant pretest differ- mediator variable. p = .053 model. However. the mediational month follow-up. Therefore.053).08. Independent samples t- as the independent variable (n = 20). Boys ini- problems on attention change is from a simple linear regression tially reported more somatic complaints than girls did analysis with pretest behavior problems as the independent variable and attention change as the dependent variable. while the effect of the children with clinically elevated levels of anxiety. These improvements were maintained at the three- changes as a predictor. p = . The result showed that Mindfulness-based cognitive therapy for children (MBCT- pretest behavior problems were predictive of attention C) was developed as an intervention for children with change (b = .001).

However. istic of the entire spectrum of anxiety disorders. This finding has promising corrections for multiple analyses were made. conclusive of having a mediating effect on behavior problems (p = . Although original trials of MBCT using multilevel modeling that behavior problem scores did change in the predicted corrected for IGC. It seems likely that statistical sig- nificance may have been achieved with a larger sample Conclusion size. A variety of attention problems is character. problems. but needs to be replicated with a larger clinical participants in this study were a representative group of sample. behavior problems at the start of the program. a subsequent mediation sample probably limited the power to detect group analysis showed that attention was suggestive. is generally treated with medications or impair attention and promote emotionally reactive behav- behavioral management techniques. no significant differences between groups were ferent from the original. Baldwin et al. Analyses of data from iors that interfere with the development of good study the Multimodal Treatment Study of Children With Atten. this reductions in behavior problems over the course of the concern probably had very little effect on the results of the study. may offer employed are not worthwhile—but rather. we choices. Mean behavior problems across all participants were (2008) examined this issue by reanalyzing the data for the only slightly elevated at pretest (SD & . However. However. Williams found. 83). Most would not meet diagnostic associated with reductions in attention problems. any par- clinically elevated levels of anxiety at the beginning of the ticipant may have either a positive or a negative effect on study. in attention problems accounted for 46% of the variability The restricted variability within this mostly non-clinical in behavior problems. Furthermore.053). success than improvements in adult-perceived functioning. we applied of the program. regardless of treatment modality. The authors suggest that improvements in peer further evaluated with larger groups of children diagnosed relationships are a more stringent measure of treatment with ADHD. The MBCT-C model offers additional promise for the Existing research suggests a relationship between attention treatment of attention deficit hyperactivity disorder and mindfulness. Therefore. However. skills. no significant behavior problems. ‘‘It is not that social skills training. This influence violates the cialized in reading remediation and were not pre-screened independence of observations assumption of parametric for anxiety disorders. but not differences. Only three participants showed clinically significant present study. they are clearly therapeutic benefits for the other types of attention-related not sufficient’’ (p. One obvious rationale is that the two members of a group to influence treatment effects for majority of children in the study were not evidencing other members. The results were not significantly dif- direction. emphasis on reported at the end of the program but comparable acting with awareness. For example. so it seems reasonable that increased mindfulness tion Deficit Hyperactivity Disorder (Hoza et al. Thus. uncorrected analyses. Anxiety can ADHD children.4). 2005) would be associated with less anxiety and fewer academic found that. inner-city children sharing a common stress of struggling Reductions in behavior problems were significantly with academic difficulties. and the other peer interventions we self-management of attention. an They conclude. this impression needs to be tionships. 123 . Participants were referred from a clinic that spe. approach that remediates attention deficits and enhances behavior therapy. By the end As a preliminary randomized controlled trial. Williams et al. MBCT-C includes specific elements problems. thus implications for the treatment of childhood behavior increasing the possibility of Type I errors. The hyperactivity and impulsivity often seen in across the spectrum of anxiety disorders. such as MBCT-C. (2005) suggested that reductions in anxiety symptoms were found for the six a Variance Inflation Factor be added to the power analysis children in the program who initially reported clinically and subsequent analysis of results to take account of this elevated anxiety. ADHD problems. post hoc analyses of data for all groups and his colleagues concluded that the concerns of Baldwin.J Child Fam Stud (2010) 19:218–229 227 since only five children began the study with clinically children remain significantly impaired in their peer rela- elevated attention problems. were not able to attribute reductions in anxiety to the One limitation of this study is the potential for one or effects of the intervention. that logically could contribute to improved peer relation- Significant reductions in anxiety symptoms were ships: its group format. pooled to simulate an open trial did show significant Murray. and practice making conscious improvements were found across groups. Changes criteria for an anxiety disorder or attention deficit disorder. it is notable that significant statistical techniques. Therefore. Within a psychotherapy group. the other members of the group. and Shadish were likely overstated. present-moment focus. Attention-related problems are pervasive (ADHD). intragroup correlation (IGC). no child was reported to have clinically less conservative analyses to the data.

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