CHAPTER SEVEN

What is the evidence in

evidence-based mindfulness
programs for children?
Kaitlyn M. Butterfield, Kim P. Roberts*, Lindsey E. Feltis,
Nancy L. Kocovski
Wilfrid Laurier University, Waterloo, ON, Canada
*Corresponding author: e-mail address: kroberts@wlu.ca

Contents
1. Definitions of mindfulness 192
2. Characteristics of the research on mindfulness programs for children 195
3. The concept of evidence-based programming 197
4. Pre-/post-test research designs with adequate controls 198
5. Barriers to program delivery 202
5.1 Lack of clarity over individual components of mindfulness programs 202
5.2 Monetization of programs 204
6. Conclusion and recommendations 207
6.1 Recommendation #1. Wider dissemination of the fundamental principles of
experimental design 207
6.2 Recommendation #2. Encourage the gold standard of active control groups
to evaluate mindfulness programs 208
6.3 Recommendation #3. Require researchers to disclose details about the
program elements 208
6.4 Recommendation #4. Register studies and store data in an online data
repository 209
References 209

Abstract
The prevalence of “mindfulness” in popular media, academia, and professional circles is
difficult to miss. Newspapers, magazines, online articles, clinical programs, podcasts,
scholarly and professional meetings, sports organizations, and many other outlets focus
on the benefits of mindfulness. Despite the intense focus on mindfulness in Western
society, it is astonishing that the evidence base (i.e., documented, scholarly, peer-
reviewed evaluations) for these programs is woefully inadequate. Varying definitions
of what mindfulness is, what it entails, what specific benefits to psychological function-
ing are observed (if any), and inadequate scientific testing all contribute to a lean knowl-
edge base. Evaluation of potential benefits of mindful practice with children is even

Advances in Child Development and Behavior, Volume 58 # 2020 Elsevier Inc. 189
ISSN 0065-2407 All rights reserved.
https://doi.org/10.1016/bs.acdb.2020.01.007
190 Kaitlyn M. Butterfield et al.

more difficult because children are a more heterogeneous group than adults; the dif-
fering developmental levels are likely to have profound effects on the efficacy of
mindfulness-based programming with children. We review these issues and provide
an explanation of the strength of different kinds of evidence, with suggestions for
(a) researchers who study mindfulness with children and (b) clinical professionals
and educators interested in developing mindful attitudes and techniques with children.

Consider the following scenario: Imagine that you have been waiting in line
for tickets to see your favorite band in concert. The first 300 people in line at
9 a.m. will receive a free ticket. You joined the line at 5 p.m. the day before
and it is now 10 a.m. You have tolerated the rain, the wind, the loud shouts
from a group of rowdy youth in front of you, being splashed in muddy rain
by the cars driving past, the stink from garbage bins, and you “slept” on con-
crete while listening to an orchestra of police and emergency sirens. Now,
imagine that you also have a big assignment due by midnight and cannot stop
ruminating about whether camping out in the rain for a concert ticket (and
thus not working on the assignment) was the right decision. You are tired,
hungry and angry (sl. “hangry”). You cannot stop thinking about your
assignment, you are worried that you are the 301st person in line or that
you may have entirely misunderstood the free ticket procedure, thinking
“they should have been given out by now.” You are anxious about how
you are going to manage to do all the research and writing for your assign-
ment. You listen to a voice inside your head: “You ALWAYS do this! You’re
going to be late on another assignment. Good job! Then you’ll fail the course and
won’t get into dental school and your parents won’t pay for tuition and you’ll be
in debt and you’ll spend the next 20 years paying off the debt and you won’t be able
to afford to have children....”
You may be able to empathize with this scenario; if not, you can prob-
ably identify these characteristics in other people. How different would you
(or other people) feel if the voice in your head sounded more like this: “Take
a breath and let out a long sigh. The only thing that matters is what is happening right
now in the present; not what led up to this moment, or what is coming afterwards. You
currently have no control over those things. Maybe it was the right decision, maybe it
wasn’t. Focus on your experience right now. Don’t judge, let the guilty feelings and
thoughts come, acknowledge them, but also let them float away.”
The latter voice in this example reflects a “mindfulness-based
approach”—paying attention to the present moment with awareness and
acceptance, without judgment (Kabat-Zinn, 2003). Thousands of people
have benefitted from practicing mindfulness in both clinical and non-clinical
Mindfulness and children 191

domains. With respect to positive outcomes with children, mindfulness has

been successfully used to alleviate stress (Zenner, Herrnleben-Kurz, &
Walach, 2014), anxiety and depression (Dunning et al., 2019), and pain
and chronic illness (Kohut, Stinson, Davies-Chalmers, Ruskin, & van
Wyk, 2017). Mindfulness has been incorporated into children’s cognitive
therapy, family therapy, and play therapy (Higgins-Klein, 2013); to increase
empathy and compassion (Cheang, Gillions, & Sparkes, 2019), and well-
being (Burke, 2010); and to manage symptoms associated with attention-
deficit hyperactivity disorder (Chimiklis et al., 2018; Leeth, Villarreal, &
Styck, 2019), autism (Semple, 2018), and other visible and invisible disabil-
ities (Whittingham, 2014). Mindfulness-based programs for children have
found their way into schools (Mak, Whittingham, Cunnington, & Boyd,
2018; Zenner et al., 2014), hospitals and clinical settings (Leeth et al.,
2019), and are used to target a vast array of outcomes. New applications
of mindfulness are constantly emerging.
In both scholarly and popular media, there has been a steady rise in the
attention paid to mindfulness and children in the last decade. A search using
Google Scholar© on all articles on mindfulness and children range from
approximately 12,200 hits in 2009 to 20,900 in 2018. Similar increases have
been seen in the scholarly literature (see the white bars in Fig. 1). Using
PsycInfo©, we searched for (mindful* AND child*) in the Abstract section
and saw an almost linear increase in publications from 38 in 2009, to 176
in 2018.
In this chapter we will evaluate the evidence base for using mindfulness
programs to promote well-being and healthy development in children. We
first consider how mindfulness is defined and the exact variations that are
used in different contexts. Despite using the label “mindfulness,” it becomes
clear that there are multiple interpretations. The plurality of mindfulness
definitions makes it difficult to locate even an adequate corpus of evidence
to support mindfulness programs with children. Second, we explore the
notion that not all evidence is equal. As with all program evaluation, there
are strong and weak tests of the efficacy of the mindfulness programs that
have been evaluated. Tests of mindfulness programming with children in
the scholarly literature (using PsycInfo®, a database maintained by the
American Psychological Association) comprise predominantly weak tests.
We outline key aspects of the scientific method (e.g., inclusion of control
groups) to shed some light on the strength of the current evidence base
and provide guidelines on how to design stronger tests. We then identify
barriers to the delivery of mindfulness programs to children by considering
192 Kaitlyn M. Butterfield et al.

200

180

160

140
Number of Publications

120

100

80

60

40

20

0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019*
Year

total peer-reviewed only

Fig. 1 Publications on the topic of mindfulness and children between 2009 and August
1, 2019.

the philosophical and methodological factors discussed in the previous sec-

tion, as well as financial barriers. We end with an optimistic look into the
future of mindfulness programming with children, how methodological
shortcomings can be overcome by scholars, and what practitioners can do
to interpret the evidence base.

1. Definitions of mindfulness
The role of mindfulness was popularized first for its potential in clinical
settings. Interventions such as Kabat-Zinn’s popular Mindfulness-Based
Stress Reduction program (MBSR; Kabat-Zinn, 1990) paved the way for
mindfulness to be incorporated more generally into “mindfulness-based
cognitive therapy” (see Segal & Ferguson, 2018; MBCT; Segal,
Williams, & Teasdale, 2002). Indeed, the most commonly-used formal
definition of mindfulness is attributed to Kabat-Zinn who describes mind-
fulness as the deliberate “moment-to-moment awareness, cultivated by
Mindfulness and children 193

paying attention in a specific way, in the present moment, as nonreactively,

nonjudgmentally, and openheartedly as possible” (Kabat-Zinn, 2015,
p.1481). Many definitions of mindfulness include attentional focus and
awareness as key features (Schonert-Reichl & Stewart Lawlor, 2010). As
aptly described by Schonert-Reichl and Lawlor (2010), mindfulness is the
opposite of operating on “auto-pilot.”
In contemporary Western society, however, “mindfulness” has become
an umbrella term used to characterize many practices, processes and charac-
teristics (Kallapiran, Koo, Kirubakaran, & Hancock, 2015; van Dam et al.,
2018). Mindfulness is historically rooted in Buddhism where the practice is
about calming and clearing the mind, opening the heart, and distilling atten-
tion (Kabat-Zinn, 2003). In Buddhism, mindfulness is more than a tool; it is
a way of being in the world and understanding the world (Kabat-Zinn,
2003). There is growing acknowledgment that the concept of mindfulness
in Western society has evolved in modern times into a definition more
reflective of a secular practice in a multiracial and multifaith context.
The difference between being mindful and engaging in mindful activities is
sufficiently blurred in Western society such that the goals of individual
mindfulness programs are often unclear. Some Western countries, such as
Canada, have nationwide bans on religious instruction within public (i.e.,
state-funded) schools. While delivering mindful-based programs in public
schools, the authors have occasionally met resistance from parents about
some of the activities used to encourage a mindful attitude. These concerns
stem from an awareness of the spiritual roots of mindfulness and associated
activities such as yoga. One parent, for example, refused to allow his daugh-
ter to participate in yoga until teachers explained that children are asked to
adopt physical poses that mimic animals (e.g., cat pose, cow pose) without
any instruction about ancient Indian spiritualism. As yoga and meditation are
often central pillars of mindful-based programming for children, they are
often considered to be synonymous with mindfulness. The focus on the
breath in yoga can encourage one to be mindful, but yoga and meditation
are technically separate, different practices (Chimiklis et al., 2018) that occur
in many contexts other than mindfulness programs. Refer to Table 1 for an
example of activities in mindfulness programs for children.
In contrast to holistic, spiritual philosophies, Western researchers and
practitioners have taken a deterministic approach by deconstructing the con-
cept of mindfulness to better understand the processes involved. Van Dam
and colleagues, for example, identified key features in meditation practice to
better allow comparison of studies in the literature (van Dam et al., 2018).
194 Kaitlyn M. Butterfield et al.

Table 1 Adapted overview of the Paws.b mindfulness program.

Lesson
number Activities
1 Introduction: prefrontal cortex
Discussion: ability to make choices
Exercise: breath counting
Home practice: breath counting
2 Recap
Introduction: attention, philosophy of mindfulness, and the
hippocampus
Exercise: (1) chest and tummy breathing (2) finger breathing
Home practice: breath counting and finger breathing
3 Recap
Discussion: “wobbly” feelings
Introduction: the insula
Exercise: feet on floor, bums on chair (FOFBOC)
Home practice: breath counting and FOFBOC
4 Recap
Introduction: amygdala
Discussion: reacting and responding
Exercise: “+2” respond rather than react
Home practice: “+2”
5 Recap
Discussion: worry
The “Hot Cross Bun” model of Cognitive Behavioral Therapy
Home practice: participants choice
6 Recap
Discussion: growing happiness
Exercise: practice all five mindfulness exercises
Planning for the Future
Adapted from Thomas, G., & Atkinson, C. (2017). Perspectives on a whole class mindfulness pro-
gramme. Educational Psychology in Practice, 33(3), 231–248.

Reference to a unitary construct of mindfulness is vague and impairs our

understanding of the empirical literature. Comparing results across studies
can be as informative as comparing apples and oranges. An awareness of
the different treatment of mindful constructs leads one to reconsider the
strength of the actual evidence base for mindful programming in children.
When seen in this light, the actual evidence base for the promotion of mind-
ful programming with children is surprisingly vague.
Mindfulness and children 195

2. Characteristics of the research on mindfulness

programs for children
We searched the academic database PsycInfo® for journal articles from
the last decade (2009–18) that had the search terms mindful*, child*, and con-
trol in the Abstract. This produced 166 journal articles. It is necessary to con-
sider the quality of studies and not just the volume of studies published. The
“quality control” in science is achieved by “independent peer review.” In
short, editors will not publish a study in an academic journal unless an
“arms-length” panel of renowned experts first review the submission in full.
These expert reviewers (usually 2–4) evaluate the design of studies, the reli-
ability of the data collection, the suitability of the analyses used, and the
interpretation of the analyses. This process results in the rejection of many
more manuscripts by editors than what is published with rejection rates
sometimes as high as 95% depending on the journal. It is rare for a panel
of experts to recommend publishing a submission on its first review.
Normally, the submission is either rejected or the authors are given an
opportunity to revise the manuscript which will, in turn, be reviewed by
an expert panel. The cycle continues until the editor makes a final decision
on whether to accept or reject the submission.
Peer review is important when considering the evidence behind claims
about the benefits of mindfulness programs with children precisely because
there are so many studies being published. It is necessary to filter out non-
peer-reviewed publications as they have not been subject to the scrutiny of
peer review and may, therefore, be scientifically challenged. The white bars
in Fig. 1 represent the total number of publications on mindfulness and chil-
dren in each year, and the colored/hashed bars show how many of these
were peer-reviewed publications. It is somewhat encouraging to see in
Fig. 1 that the proportion of publications that have been subject to stringent
peer review is increasing each year. However, using the statistics from Fig. 1,
only up to 65% of total publications in any given year were peer-reviewed.
After filtering out non-peer-reviewed publications, studies with adults,
opinion pieces, chapters without a study in-text, and reviews, we were left
with 87 articles from the pool of 166. We hereafter refer to the 87 articles as
“the Sample.” Of those 87 publications in the Sample, just about half
(n ¼ 43) documented school-based mindfulness programs. The remainder
took place in a youth justice setting (n ¼ 13), a clinical setting (n ¼ 9),
in the general population (n ¼ 7), at home (n ¼ 1), and online (n ¼ 1).
196 Kaitlyn M. Butterfield et al.

The setting was undisclosed in the remaining 13 studies (these and

other criteria are displayed in Table 2).
The literature on mindfulness programs with adults is much larger than
that with children despite a steady increase within the last decade. Clearly, it
is risky to draw conclusions about children and mindfulness based on the
adult literature given differences in developmental level, age, and program
objectives. Black (2015) indicated that adaptations of adult programs were

Table 2 Overview of N ¼ 87 research articles in mindfulness-based interventions

for children between 2009 and 2018.
Characteristic Results
Pre-/post-design
Yes 64
No 23
Control group
None 22
a
Controlled 65
b
Non-active control 47
Active control 18
Randomization
Yes 48
No 39
Location
School/classroom 43
Prison/rehab facility 13
Clinical setting 9
General population 7
Home 1
Online 1
Undisclosed 13
a
Note 1. Controlled refers to studies with any control condition (active or non-active).
b
Note 2. Non-active control refers to study’s whose control included a waitlist group, a business/treat-
ment as usual group, etc.
Data from PsycInfo®.
Mindfulness and children 197

needed for the intervention to be suitable for youth (e.g., shortening the
program, shortening sessions, making didactic instruction relevant for the
developmental needs of children, modifying intervention activities, and
reducing/omitting home mindfulness practice time). The growing interest
in applying mindfulness activities in clinical, academic, and vocational set-
tings requires a review of the quality of empirical evidence (Shonin, Van
Gordon, & Griffiths, 2013). As most of the studies in our sample were
administered in schools, we will now review the state of the evidence base
for school-based mindful programming.

3. The concept of evidence-based programming

The “contemplative turn” in education, according to Ergas and Todd
(2016), began in the early 21st century as mindfulness-based practices
became increasingly common in educational settings. Examples of programs
are MindUP!© (2011), Happy Classrooms© (Arguı́s, Bolsas, Hernández, &
Salvador, 2012), and Learning to BREATHE (L2B; Broderick, 2010).
Educational applications are largely focused on improvements in academic,
social, and cognitive skills of students rather than any “spiritual awakening”
(Kim et al., 2019). Although there are some targeted interventions (selective
prevention with at-risk populations or indicated prevention for those with sub-
clinical symptoms), most programs in classroom settings are delivered uni-
versally. This has the benefit of providing training to all children without the
need for individual families to register for extra-curriculum activities
(Werner-Seidler, Perry, Calear, Newby, & Christensen, 2017). The objec-
tives of the Happy Classrooms Program, for example, are to enhance the
personal and social development of preschool, primary, and secondary stu-
dents, and to promote happiness in students, teachers and families. The
school environment is a particularly advantageous context to administer
and evaluate the effects of mindfulness-based programming because of access
to larger populations compared to at-risk populations (Werner-Seidler et al.,
2017). Practicing mindfulness during childhood and early adolescence may
be the “sweet spot” as cognitive processes including self-regulation and
executive function, and corresponding increases in brain density develop
most prominently over this time period (Dunning et al., 2019).
There is a growing consensus that conclusions about mindfulness pro-
grams and children is limited by the methodological quality of the research
(Goodman, Madni, & Semple, 2017). Variations in program duration, the
frequency of sessions, the actual activities and components in the program,
198 Kaitlyn M. Butterfield et al.

and the choice of comparison group (if there is one) prevents broad conclu-
sions on the potential benefits of mindfulness with children (Shonin et al.,
2013). For example, Borquist-Conlon, Maynard, Brendel, and Farina
(2017) selected five studies to include in their meta-analysis of mindfulness
programs for children aged 5–18 years old. There was wide temporal vari-
ability in the programs which ranged from 2 to 20 weeks, with sessions last-
ing between 60 and 90 min. The diversity of programs and outcome
measures makes it difficult to validate the findings through replication.
Goldberg et al. (2017) explicitly identified six factors that would improve
our understanding about mindful-based programming with children if they
were reported in scholarly studies; these were: (a) active control conditions,
(b) larger sample sizes, (c) follow-up assessments, (d) treatment fidelity,
(e) details about instructor training, and (f ) reporting of outcomes for par-
ticipants who did not complete the program (also see MacKenzie, Abbott, &
Kocovski, 2018, for a similar analysis of active control groups for adult mind-
fulness programs). We will now review the variety of research designs and
the consequences of their use for evidence-based practice.

4. Pre-/post-test research designs with adequate

controls
Scientific conclusions about the effect of one variable on another can
only be made once the outcomes of the treatment group (e.g., children in a
mindfulness program) are compared to one or more control groups. Two
types of control groups are of interest. First, a group that receives only
the services currently in operation without participating in a mindfulness
program. These groups are often referred to as “business as usual” (BAU)
or “treatment as usual” controls. In clinical settings, for example, the
BAU group comprises children on a waitlist for services. Improvement in
outcomes for children in the mindfulness group compared to the BAU con-
trols is often (mistakenly) referred to as evidence that the mindfulness pro-
gram led to observed benefits. It is just as likely, however, that the benefits
occurred due to program participation rather than mindful practice per se. In
effect, waitlist BAU control groups constitute passive controls and the two
groups can be just as well described as a group that participates in a program
versus children who do not participate in any program whatsoever. It is plau-
sible that the effects were simply due to the participants receiving treatment
whereas those on the waitlist received no services.
Mindfulness and children 199

While a good first step in program evaluation, a passive waitlist control

group does not allow researchers to conclude that the mindfulness program
(and not simply any program) led to improvements in outcome measures. Of
the 87 publications in our selected sample, and despite the word “control” in
our search, 25% of studies did not in fact contain a control group. Of the 75%
of publications that did document a control group, the vast majority
included a passive or non-active control group (n ¼ 47). Thus, the conclu-
sions from these 47 studies needs to be attenuated in line with the actual
evidence.
In contrast to passive control groups, a more stringent control is to com-
pare outcome scores from children in a mindfulness program with those of
children who participate in another (non-mindfulness) program of similar
duration. Any benefits observed for children in the mindfulness group when
contrasted with outcomes for the active controls allows researchers to rule
out that mere program participation, time spent with a service provider,
time spent in the program, motivation and so on, led to the benefits.
Some suggestions of active control groups are social skills training, a literacy
intervention (Zelazo, Forston, Masten, & Carlson, 2018), an emotional lit-
eracy program (Devcich, Rix, Bernay, & Graham, 2017), and a relaxation
program (Volanen et al., 2019). Notably, the observed benefits of mindful-
ness training with children are less impressive than those documented in
studies with passive controls. For example, Crescentini, Capurso, Furlan,
and Fabbro (2016) found that teachers of children in a “mindfulness
+ meditation” program reported that the attention problems in children
were reduced compared to children in an emotional awareness program.
Self-reports from the children did not suggest any improvements; however,
Crescentini and colleagues concluded that the findings were “suggestive of a
positive effect …. on wellbeing” (2016, p. 1), clearly a more tempered con-
clusion than those asserted in the many passive-control studies.
Stronger evidence of program success is also present if student partici-
pants are randomly assigned to the treatment group (i.e., the mindfulness pro-
gram) or the active control group. Randomization greatly reduces the
chances that individual differences between groups (e.g., in motivation to
participate) confound the results. Some studies use randomization with
the “waitlist control group” to determine the efficacy of mindfulness train-
ing. For example, children voluntarily attending a behavioral regulation
clinic may participate in mindfulness training, and their outcomes compared
with children also assigned to the clinic but who are currently on a waitlist
for admittance. Although frequently described as “randomized control
200 Kaitlyn M. Butterfield et al.

trials,” we do not believe that is an accurate representation of the study

design. First, although there technically is a control group, the choice of
control group can only constitute weak evidence of any potential differ-
ences. This is because it is not clear whether improvements in the treatment
group are due to the mindfulness training per se, or to extraneous factors
such as those mentioned previously. Second, in many studies, details about
the sample are sparse: How many participants chose to not partake of the
mindfulness program even though they were assigned to this group?
Were these participants replaced in the mindfulness group? What was the
rate of attrition? As many mindfulness programs last 2–3 months, significant
attrition is likely. What was the threshold for determining how “much”
mindfulness was acceptable for membership in the mindfulness group?
Questions like these contain valuable information because they raise the pos-
sibility that inherent differences between the two groups are conflating the
results. Suppose, for example, that some of the children on the waitlist were
offered the mindfulness program but declined because they felt that it threat-
ened their religious beliefs. And in another example, suppose that the thresh-
old for referral to the clinic was raised resulting in the waitlist children being
more severe in their symptoms than those in the treatment group. These
cohort differences may contribute to score differences more than the mind-
ful program did.
A meta-analysis of mindfulness-based interventions with youth com-
posed exclusively of randomized controlled trials with active control groups
was reported in Dunning et al. (2019). While improvements were observed
for anxious and depressive outcomes, the authors suggest that these benefits
occurred only when the “gold standard research design” was adopted, par-
ticularly when a randomized controlled trial utilized active control. Analysis
of only those studies using active control groups yields a different picture of
the literature. Specifically, mindfulness programs were most effective when
directly treating mood disorders, anxiety, and depression, but yielded little
difference in behavioral or cognitive outcomes (Dunning et al., 2019;
Hofmann, Sawyer, Witt, & Oh, 2017).
A randomized controlled trial cannot exist, by definition, without an
active control condition, yet many mindfulness-based intervention studies
continue to use waitlist controls. Further, waitlist designs are sometimes
inaccurately referred to as randomized control trials. Thus, this body of lit-
erature contains studies that have a necessary control group, but only pro-
vides “soft evidence” for the benefits of mindful programming with
children. These findings can be used to make the valid conclusion that
Mindfulness and children 201

the mindfulness program resulted in benefits compared to the control group,

but it cannot be concluded that it was the mindful approach in the program
that led to its success. It is possible that the mindful component did. Some
researchers recommend that the outcomes of mindfulness-based interven-
tions be compared to current best-practice therapies such as cognitive
behavioral therapy (Goldberg et al., 2017). Further, active control condi-
tions should use similar language to the intervention group, benefit its
participants in some way, and match the intervention in all nonspecific
factors (Dunning et al., 2019; Goodman et al., 2017). Nonspecific factors
in child studies might include individual differences such as age, gender,
socioeconomic status, academic achievement, or the presence of identified
disabilities.
However, it is often difficult to adhere to the gold standards of study
design when conducting research in community settings. Schonert-
Reichl and colleagues identified a natural opportunity to use a strong test
design. In British Columbia, Canada, social responsibility in public schools
is one of the performance standards outlined by the relevant government
agency. Hence, all children in grades 4 and 5 participate in a social respon-
sibility program. In this study, a coin flip was used to randomly assign class-
rooms to the mindfulness program (in addition to the social responsibility
program) or just the regular social responsibility program (i.e., there was
50% chance to be assigned to either group). The authors reported that
the mindfulness group improved in cognitive control, empathy, perspective
taking, emotional control, optimism, school self-concept, mindfulness, and
reported fewer symptoms of depression and aggression than children in the
control group (Schonert-Reichl et al., 2015).
According to the statistics presented in the Dunning et al. (2019) review:
(a) approximately 50% of studies did not have a comparison condition at all;
(b) only 30% of studies included randomization of participants to conditions;
and (c) as few as 10% of studies employed active control conditions. Given
the lack of active control conditions within the literature, it is significantly
more difficult to draw accurate conclusions from reported outcomes.
In short, any control group is better than none. Our understanding of
mindfulness and children will best proceed, however, with the use of mul-
tiple control groups especially when participants are randomly assigned to a
mindfulness program group or an active control group. Thus, the evidence
needs to be evaluated with an understanding of the strength of the evidence,
not just in the number of published studies on mindfulness-based programs
for children.
202 Kaitlyn M. Butterfield et al.

In our sample of 87 studies, only 13 studies contained pre-/post-

measures, an active control group, and randomized allocation to the mind-
fulness and control groups. Thus, the majority of peer-reviewed, published
journal articles on mindfulness programs for children (85%) do not include
the adequate controls to validate the study authors’ conclusions. Mindfulness
programs are consistently described as evidence-based in guides for clinicians
(e.g., Mathis, Dente, & Biel, 2019) and self-help books (e.g., B€ ogels &
Restifo, 2014). Given the increased interest in mindfulness for youth by
educators, clinicians, researchers and policymakers, a concrete definition of
evidence-based mindfulness is required. In doing so, we need a thorough
understanding of what conceptualizes an evidence-based practice. The
National Institute of Health (NIH) Stage Model is “an iterative, recursive,
multidirectional model of behavioral intervention development” (Onken,
Carroll, Shoham, Cuthbert, & Riddle, 2014, p. 9). When Dimidjian and
Segal (2015) examined the extant evidence using the National Institutes
of Health (NIH) Stage Model, they found that evidence reported in
mindfulness-based program studies were heavily saturated in Stage I (the most
preliminary testing), with much less research in Stage V (the final stage where
empirically-supported practice is implemented in the wider community).

5. Barriers to program delivery

5.1 Lack of clarity over individual components
of mindfulness programs
A barrier to program delivery concerns the lack of consistency in individual
mindful activities across studies. Although mindfulness-based programs
are thematically consistent with each other (e.g., many include a focus on
relaxation, compassion, breathing, awareness, meditation), the activities
employed to illustrate these concepts vary significantly. More specifically,
programs tend to have very little direction when it comes to intensity, group
size, exactly what the activity should look like, and whether the activities are
developmentally appropriate for the target age group. A half-hour session on
mindful listening, for example, may require the teacher/trainer to make dif-
ferent sounds with different items. A program manual may note that research
shows the activity is effective, but it falls short in specificity—which sounds
were used? Are loud or quiet sounds best? Should these sounds identify
with nature or everyday classroom items? It is not yet known whether
any of these questions impact hypothesized outcomes.
Mindfulness and children 203

Many studies describe activities related to mindfulness, but the mindful

component is missing. In a study on mindful movement, for example, it
is not clear how the activities related specifically to mindfulness:
Kindergarten children in the mindfulness program were encouraged to
“write numbers on the shelves of the climbing equipment or on targets
to hit” presumably to focus and maintain attention (Shoval, Sharir,
Arnon, & Tenenbaum, 2018, p. 357). Similarly, while meditation can be
used in mindful practice, the mere act of meditating does not qualify
as mindfulness. The key element missing in some programs is mindful
awareness and acceptance; trying to stop rumination, for example, is not
part of the mindfulness approach.
Aside from activity description, programmers sometimes stray from pub-
lished evidence. For example, if listening to nature sounds promotes mind-
fulness and well-being it cannot be automatically assumed that listening to
music will deliver similar effects. Indeed, further research can be employed
to see whether mindful listening is generalizable to a variety of different tasks
and stimuli.
Some programs have been tested by their creators and provide supportive
evidence for the efficacy of the program. This evidence is notable, but it is
also important for program developers to allow their programs to be inde-
pendently evaluated by an outside source. As succinctly described by Crane
et al. (2017), “it remains an empirical question for each new adaptation
whether it improves its accessibility and usefulness…each adaptation needs
to commit to building its own evidence base” (p. 996). The next step in cre-
ating an evidence-based mindfulness program would be, then, to specify
how the effective research was conducted (temporal factors, order of events,
script used, etc.) and encourage rigor in implementation.
Presenting the exact activities in different programs is also important
because different activities may have distinct effects on children. For exam-
ple, Valk et al. (2017) suggested that the relation between the form of
training and the physiological and psychological stress differ according to
the type of mindfulness-based practice utilized. When participants com-
pleted affect training (loving-kindness meditation and dyadic interaction)
significant changes in cortical thickness from right insula to temporal
pole were observed. When participants completed perspective training
(e.g., observing self-thoughts in meditation and practicing perspective
taking with a partner) significant increases in cortical thickness in the left
parietal region were observed. Notably, only the practices associated with
204 Kaitlyn M. Butterfield et al.

affect and perspective taking were linked to a decrease in cortisol (a stress

hormone), when compared to participants who practiced presence training
(e.g., breathing meditation, body scan).

5.2 Monetization of programs

The term “McMindfulness” was coined by the writer, teacher, and activist
David Forbes as he described the role capitalism has played in turning mind-
fulness into a “booming industry.” In the United States alone, the medita-
tion industry generated USD$1.2 billion in revenue in 2017 (Kim, 2018).
Mobile phone applications, including Calm©, Headspace©, Insight timer©,
10% Happier©, and Buddhify© are in the “pursuit of mindfulness” with an
estimated 60 million plus users to date (Rabang, 2019).
There is also commercial success with child-oriented mindfulness-based
applications. Example financial costs are listed in Table 3. Although some

Table 3 Examples of mindfulness apps for children on the app store.

Monthly
Download membership
Application Objective Ages cost cost
Headspace for Kindness, focus, sleep, calm, 0–5, Free $12.99
kids waking-up 6–8,
9–12
Smiling mind Meditation exercises 4+ Free None
Sleep Guided meditations 6–8 Free $3.99 +
meditations presented as bedtime stories
for Kids
Calm Mindfulness, relaxation, sleep 4 + Free $12.99
stories
Mindful Voice-guided mindfulness 6–8 Free $6.99
powers sessions, focus timer
Stop, breathe Sleep, calm, learning to 6–8 Free $12.99
and think kids breathe, conflict resolution
Mindful Emotion regulation, improve 6–8 $2.79 None
minutes concentration, healthy habits
Bunny Mindful breathing 6–8 $1.39 None
mindfulness
Magical Bedtime meditation 6–8 $2.79 None
adventures 2
Mindfulness and children 205

apps meet the threshold of accessibility allowing potential users to download

the app for free, many of these apps require a monthly membership fee for all
but the most basic features. In-person mindfulness programs are also avail-
able for a price as shown by a simple internet search for regional mindfulness
programs for children (e.g., Learning to BREATHE, and Happy Classroom;
Arguı́s et al., 2012; Broderick, 2010; see Table 4 for costs associated with
these programs).
Are commercial mindfulness programs “value for money”? Duarte and
colleagues identified seven studies on mindful-based programs that included
a full cost-benefit analysis (Duarte, Lloyd, Kotas, Andronis, & White, 2019).
Three of these studies reported cost-effectiveness for these interventions
(Duarte et al., 2019). For example, Kuyken et al. (2008) reported a cost

Table 4 Examples of mindfulness programs and their associated cost.

Minutes Length
per of
session program Cost
Program Sessions (min) (weeks) Population Pace (CAD)
A Friend in Me: 8 75 8 7–11 1/ $392.96
Adventures in week
mindfulness,
empathy and
kindness
Imagine IF 7 90 7 5–10 years 1/ $195
mindfulness, theater week
and play
Inner kids 2 30 8 Early 2/ FREE
elementary week
school
Kindness curriculum 24 20 12 3–6 2/ FREE
week
Mindful me anxiety 6 30 6 Children; 1/ $169.50
unspecified week
age range
Minds on kids 8 60 8 5–8, 9–12, 1/ $230
teens week
Yoga and 6 60 6 8–12 1/ $175
mindfulness for kids week
Note: Costs do not include program-specific training.
206 Kaitlyn M. Butterfield et al.

savings of $439 for every depressive relapse/recurrence and $23 per

depressive-free day. Duarte et al. caution that the generalizability of their
findings may be low because the identified studies varied in key program
characteristics. Also, none of these studies evaluated the costs and benefits
to society of school-based mindfulness programs.
Monetization of mindfulness programs is not in itself problematic but
there are several things to bear in mind. First, as there is no external appraisal
of the content and delivery of some for-profit mindfulness programs, objec-
tive evidence from an independent body is preferable This may raise the
quality of programming and, at least, protect consumers from purchasing
non-evidence-based programs. As noted by van Dam and colleagues, pro-
grams lacking empirical support may harm rather than help individuals (van
Dam et al., 2018). This is especially relevant when the end-users are chil-
dren. For example, past research has highlighted adverse effects in adults,
including, but not limited to inability to sleep, increased anxiety, extreme
pain, and severe headaches (Cebolla, Demarzo, Martins, Soler, & Garcia-
Campayo, 2017). Second, the credentials of the mindfulness trainer may also
reflect the quality of the programs available for purchase. The International
Mindfulness Teachers’ Association accredits training programs at the profes-
sional (200-h) and advanced (500-h) levels. The IMTA training accredita-
tion, however, does not cover individual programs. Most mindfulness-based
programs require their trainers to undergo a separate program to gain the
program-specific skills before they can train others.
The monetization of programs may, however, disproportionately bar
individuals from participating in mindfulness-based programs because of cost
constraints. The presentation of anxiety and depression is associated with
socioeconomic inequalities (Santiago, Wadsworth, & Stump, 2011) and
low-income individuals may also experience poverty-related stress. The
issue is illustrated in Van der Gucht, Takano, Van Broeck, and Raes’s
(2015) feasibility study of a mindfulness intervention for low-income adults.
The adults showed improvement (reduction of symptoms) in stress, anxiety,
overgeneralization, depression, and cognitive reactivity.
As the goal of school-based mindfulness programs is to enhance social-
emotional development, decrease anxious and depressive symptoms, and sup-
port academic achievement, we argue that these programs should be available
to all, including vulnerable or at-risk populations. Unfortunately, cuts to
funding in education, the non-profit sector, and basic socioeconomic barriers
sometimes prevent the availability of mass mindfulness training. Also, having
rigid standards in place for mindfulness trainers impacts on the ability to
disseminate mindfulness more broadly.
Mindfulness and children 207

6. Conclusion and recommendations

Despite media hype and the increase in peer-reviewed publications
(see Fig. 1), the evidence base for mindfulness programs for children is
not robust. Reports of positive benefits of mindful practice for children is
plentiful suggesting that the practice has the potential to result in numerous
advantages for children’s personal, social, cognitive, and academic develop-
ment. There are several methodological issues that need to be improved,
however, to build up a stronger evidence base for universal mindfulness
practice in schools.
Several threats to the generalizability of the literature have been identi-
fied, namely (a) differences in the interpretation of what “mindfulness”
means to different people and organizations, (b) a lack of information about
the exact activities and teaching in individual programs thus preventing
comparison across studies, (c) inadequate control groups, and (d) lack of ran-
domization. Many studies are titled as “randomized control trials” (RCTs)
but only a minority of studies include randomization and an active
control group.
The increasing popularity of school-based mindfulness programs suggests
that administrators are receiving the message that these programs will foster
various socioemotional, personal, and academic benefits, and are evidence-
based. We believe that this is premature based on the extant body of liter-
ature. It is currently unclear whether it is the focus on mindfulness itself, or
the benefits accrued from children being in a positive skills training program
that underlie the alleged benefits of mindfulness training with children. This
is because there are few studies that compare post-mindfulness program ben-
efits with an active control group who also participate in a positive skills pro-
gram (e.g., socioemotional learning, social responsibility training).

6.1 Recommendation #1. Wider dissemination of the

fundamental principles of experimental design
A deeper understanding of the evidence base for intervention programs
could be offered in workshops at academic and professional conferences,
through accessible articles in professional newsletters and trade magazines,
or through a “Latest News” section, podcast, blogs, or vlogs. Although some
practitioners are accomplished researchers, expertise in research methods is
often outside the job description. This highlights the need for researchers to
summarize the principles of research design in accessible language and
methods appropriate for the type and level of expertise of users.
208 Kaitlyn M. Butterfield et al.

6.2 Recommendation #2. Encourage the gold standard of

active control groups to evaluate mindfulness programs
Researchers should be encouraged to build active control groups into their
study design. Examples of active control groups in recent studies include an
8-week emotional literacy program (Devcich et al., 2017), an 8-week socio-
emotional learning program (Qi, Zhang, Hanceroglu, Caggianiello, &
Roberts, 2018), and a social responsibility program (Schonert-Reichl
et al., 2015).
It is also critical that researchers give full disclosure about how the sam-
ples evolved over the course of the study. Even when researchers and clini-
cians take the trouble to randomize treatment and control groups, selective
bias can creep in as in situations where someone gives consent to participate
in a mindfulness intervention but never attends the meetings. It could be
that the participant prefers to stay on the waitlist than participate. All of
this information is important and the CONSORT group provides guide-
lines for transparent reporting in intervention studies (see www.consort-
statement.org).
If it is not possible to run an active control group in a study, as can be the
case when working with families in the community (e.g., waitlist designs),
the strength of the evidence should be explicitly attenuated so as not to mis-
lead educators and practitioners.

6.3 Recommendation #3. Require researchers to disclose

details about the program elements
Although there are numerous publications on the benefits of mindfulness
programs for children, there is a wide variety across mindfulness programs
in definitions of mindfulness, program goals, activities, duration, session
frequency, the absence/presence of follow-up assessments, instructor
expertise, and fidelity to the program. The field can move forward if these
details can be compared across studies because readers can evaluate the pro-
grams for themselves, and researchers can attune their conclusions.
Including these details may exceed word constraints in different publica-
tions so an alternative is to include program information in a supplement
that is available to readers and users. In practice, detailed program charac-
teristics also raises the probability that other units (e.g., teachers, agencies,
health networks) can deliver a similar program. This is especially important
in cases where financial constraints prevent participation in mindfulness
programs.
Mindfulness and children 209

6.4 Recommendation #4. Register studies and store data in an

online data repository
There is a bias to report positive results in the academic literature. In other
words, studies of mindfulness programs for children are more likely to be
published if benefits were seen post-program. It is not clear how many stud-
ies have been carried out where no positive benefits were reported. Further,
it is not clear even in published studies whether other outcome variables
were included in the study but not reported because of a lack of positive
findings.
A better understanding of the effects of mindfulness programs with chil-
dren is possible with registered reports. It is increasingly common in the aca-
demic and clinical fields to register the design of the study before it is carried
out. When the researchers add their findings to the relevant registered
reports, it is possible to see the entire set of outcome variables and determine
whether there is improvement post-program. It is also possible to see
whether the results of a study were replicated, an important part of a strong
evidence base. Registered reports are archived, for example, at www.
clinicaltrials.gov and professional societies sometimes also have their own
repository.
In hand with registering studies, many associations and journal editors
now require anonymized study data to be deposited before publication.
This means it is possible for researchers to explore the actual results of a
study, and possibly even run further tests that will provide more information
about the effects of mindfulness programs. An example depository can be
found at www.nyu.databrary.org
In conclusion, there is great promise in the benefits that mindfulness pro-
grams can bring to children. The conclusions from the body of literature to
date, however, cannot be generalized without further research using active
control groups as a comparison to mindfulness program outcomes. We owe
it to society’s children to ensure that they are participating in programs
supported by a strong evidence base.

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