Introduction

CHAPTER-ONE

INTRODUCTION

Mental health, and especially primary preventive methods to improve mental health,

has gained attention in India. National Rural Health Mission (NRHM) projects across

India have taken special care to provide primary preventive measures to improve the

mental health of the rural population. However, child mental health services are at a

nascent stage in India currently. Awareness of childhood mental health issues and child

developmental issues is low but increasing.1 In her book, ―Mental Health in Indian

Schools”, Kapur2 has elegantly traced the early milestones of the school mental health

programme in India. Awareness regarding the psychological issues of children and

adolescents was meagre, and school mental health programmes were not present till the

seventies. Since the late seventies, there have been initiatives by child psychiatry or

psychiatrists towards a school mental health programme. The sparse child mental health

services that are currently available are restricted to the metropolitan cities where large

or well-established institutions with psychiatric facilities are present.1

There are a few initiatives to improve school mental health, primarily aimed at teachers.

There are very few efforts to directly help the children, except some training in life

skills building. There are only a very few initiatives to prevent mental health problems

in the high-risk adolescent population. The increasing mental health problems of Indian

children at the adolescent stage are of great concern. There are a number of problems

that are found, and anxiety is the most common psychological problem or disorder

among those found in school going children. Psychological intervention directed

towards anxiety-prone high-risk populations at an early stage of adolescence can

prevent mental health problems, specifically anxiety, or any other co-morbidity.

Considering the above situations, it has forced the investigator to implement some

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strategy in relation to managing the common psychological problems, especially

anxiety among school adolescents, with substantial efforts. At the time of preparing the

protocol, it was never thought that the current pandemic would exacerbate and

strengthen the problem. This has strengthened the necessity of the intervention.

Anxiety

Anxiety disorders are characterised by excessive fear, anticipatory worry, or rising

levels of concern and tension at the actual or imagined encounter of a feared

situation, and related behavioural alterations like avoidance of stimuli or situations that

trigger anxiety, with further limitations in functioning. In an anxiety disorder, the

stimulus, external or internal, produces disproportionate anxiety that is the source of

intense distress or significant impairment of functioning.3 Anxiety, to a certain degree,

is adaptive and natural, which prompts us to be watchful as per the demands of the

situation. However, excessive worry or anxiety is a disorder that needs to be taken care

of. The symptoms can be broken down into four main groups: mood-related, cognitive,

physiological, and motor symptoms.

The mood-related symptoms consist primarily of anxiety, tension, panic, and

apprehension. An individual suffering from anxiety experiences a feeling of impending

doom and disaster. Secondary mood symptoms caused by anxiety may include

depression and irritability. Cognitive symptoms in anxiety disorders revolve around the

doom and disaster scenarios anticipated by the individual. Because the individual‘s

attention is focused on potential disasters, the individual ignores the real problems at

hand and is therefore inattentive and distractible. As a consequence, the individual often

does not work or study effectively, which can increase his or her anxiety. The

physiological symptoms of anxiety are grouped into two categories: the immediate

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symptoms, including sweating, dry mouth, shallow breathing, rapid pulse, increased

blood pressure, throbbing sensations in the head, and feelings of muscular tension.

Hyperventilation, light headedness, headaches, tingling of the extremities, heart

palpitations, chest pain, and breathlessness reflect a high level of arousal of the

autonomic nervous system. Other immediate symptoms include if the anxiety is

prolonged. Delayed symptoms include chronic headaches, muscular weakness,

gastrointestinal distress, and cardiovascular disorders, including high blood pressure

and heart attack. Motor symptoms include restlessness, fidgeting, pointless motor

activities like toe tapping, and exaggerated startle responses to sudden noises.

The anxiety disorders recognised in the DSM-5 include separation anxiety disorder,

specific phobia, social anxiety disorder, panic disorder, agoraphobia, generalised

anxiety disorder, anxiety disorder induced by substances or drugs, and anxiety disorder

due to another sustained medical condition. Anxiety is presented in isolation as well as

co morbid with other mental disorders like depression and stress. Anxiety is

characterised by various components as shown below:

Figure 1: Components of Anxiety

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Additionally, anxiety may be classified as an anxiety state or trait anxiety. While both of

these anxiety parts of the spectrum have distinct characteristics in symptoms and

intensity, there is a basic factor that lumps them together. State anxiety is described as an

emotional situation marked by subjectively consciously experienced emotions of anxiety

and dread, as well as excitation or stimulation of the autonomic nervous system.

Additionally, state anxiety is referred to as the fluctuating portion of trait anxiety.4

State anxiety is the result of reactions to various situations faced by adolescents at

difficult times. Reasons for state anxiety may include exams, interviews, work

burden, and fatigue resulting from both mental as well as physical reasons. In

addition, it is usually seen that adolescents face more state anxiety about future events

or tasks than present problems.

Trait anxiety is defined as the tendency of an individual to worry and feel anxious, to

show excessive reactions under stress, and to give intensive excitement reactions

independent of environmental conditions.5 Trait anxiety is the consequence of

inherited temperament variations from our progenitors. Those qualities alert us to and

protect us from exterior dangers. There is, though, a distinction between normal and

abnormal responses. Additionally, if anxiety levels are elevated and it is tough to

regulate, anxiety disorders develop. Adolescents are expected to show traits of anxiety

when they view every experience as hazardous. In most cases, trait anxiety is stable

and follows a consistent pattern. Adolescents have distinct personalities, which

contribute to the intensity and length of anxiety. Trait anxiety is not seen externally in

teenagers' behaviour; rather, it can be evaluated solely through the monitoring of

anxiety reactions across time and under various circumstances.

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Adolescent and Anxiety

Adolescence is marked by dynamic and rapid development and growth in all domains

of human life. Physical and biological changes occur in the form of maturation and

growth. Physical growth and development start with puberty, and this is the

transformation of a child into an adult. Early puberty changes include breast bud and

pubic hair development and the start of a growth spurt for girls, and testicular

enlargement and the start of genital growth for boys.6 These biological factors

influence the psychological and personality frameworks of adolescents during the

developmental phase. A vast array of psychological changes and challenges are part

of this developmental period, such as concrete and progressive abstract thinking,

verbal ability, early moral concepts, progressive sexual identity development (sexual

orientation), personal identity and reassessment of body image, and adjustment

capacity.6,7 Other changes in the adolescent's interpersonal and social worlds can be

seen, too. The adolescent redefines the relationship. They tend to be more influenced

by peers and friends than parents. Peer identification, peer modelling, exploratory and

risky behaviour, and the desire to be part of a social group are manifested in this

period. The achievement of biological and sexual maturation, the development of

personal identity, the development of intimate sexual relationships with an

appropriate peer, and the establishment of independence and autonomy in the context

of the sociocultural environment are the primary challenges of this period, as stated by

Christie and Viner (2005).7 Thus, adolescent life is turbulent and stormy as a result of

these marked biological, psychological, and social changes, which occur in a rapid

and dynamic manner, as described by Hall(1983).8

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Observed data related to anxiety disorders points towards a very significant finding

that the period of adolescence is a high risk phase in terms of the onset and escalation

of anxiety problems.9 Studies suggest that anxiety disorders with a lifetime course are

most likely to begin in the puberty period, which is otherwise called the early

adolescent period10.A major cause is attributed to the developmentally sensitive

aetiologic model.10 Gamma-Amino Butyric Acid-A.(GABAA) receptors are one of the

biological factors that play a crucial role in anxiety and contribute to stress-triggered

anxiety at puberty. At the onset of adolescence, GABA receptors contribute to stress-

triggered anxiety by increasing in the dendrites of Cornu Ammonis (CA1) pyramidal

cells in the hippocampus, which in effect paradoxically reduces inhibition and

increases anxiety during the pubertal period.11-12

Anxiety may also be a consequence of genetic factors, environmental factors, and traumatic

childhood events. In contrast to all of this parental involvement, one of the primary sources of

anxiety for teenagers is peer pressure. Anxiety is also a result of stressful situations. Family

context and belief system are also significant factors in teenage anxiety, since teens often

disagree with societal norms or views.13 Numerous studies demonstrate that anxiety is not

caused by a single source. Rather than that, a variety of factors contribute to teenagers' anxiety.

Genetic predisposition is one such element that contributes to teenage anxiety. Significant

genetic loading indicates that adolescents with first-degree siblings suffering from any anxiety

illness have an increased risk of acquiring anxiety. The events of early infancy and the attitudes

of important people provide information on inclination factors. These tendency variables are

formed by experiences that occur throughout the early years, such as the loss of a close relative,

neighbourhood violence, authoritarian parenting, or excessive parental engagement during

infancy. These adversities disrupt the natural growth of feelings and the capacity to deal with

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them.14 Due to the intensity of the effect of such experiences, coping mechanisms may seem

inadequate, and teenagers may adopt alternative maladaptive methods to cope with their worry.

To fully grasp the nature of anxiety, it is necessary to examine how teenagers perceive, interpret,

and evaluate their life events. Frequently, it is noticed that certain teenagers overestimate the risk

of each occurrence. Adolescents are constantly stressed as a result of this behaviour. As

teenagers are constantly stressed. Because all occurrences are regarded as dangerous, teenagers

experience considerable perceived difficulty, discomfort, and severe anxiety. It is discovered

that connecting comparable occurrences increases their pressure. Additionally, anxiety develops

as a consequence of training with undesirable stimuli. This results in the acquisition of

avoidance techniques for circumstances that cause worry. These methods of coping with

anxiety offer teenagers with temporary respite. These techniques are ineffective in permanently

resolving anxiety.15

*Adopted from the study titled Panic! Its prevalence, diagnosis and treatment by Carlbring P.

Figure 2: The shows the sequence of events in anxiety cycle16

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Prevalence of Anxiety

There is no conclusive data available on the prevalence of Indian children. However,

different studies report the presence of anxiety in children ranging from 10 to 25%.17-23

The age of onset is reported to be 11 or above in most studies. The prevalence of anxiety

was found to be less than 3%, or 11 as reported by Mohapatra, Satyakam.24 The global

prevalence rate is reported to be 4.0% to 25.0%, with an average rate of 8.0%.25-26 The

reported rate could be lower than the actual as it goes unnoticed most often due to its

internalizing nature.

The research evidence suggests that there is an age difference in anxiety. During

adolescence, girls are more likely to develop an anxiety disorder.27-29 Onset puberty in

girls is a factor that causes anxiety. Research evidence suggests that girls who

experience puberty earlier than their peers are more likely to experience anxiety

symptoms compared to peers who develop "on time" or later.30 During this stage,

panic attacks,7,27 social phobia,31 and obsessive-compulsive disorder32 are common.

The most commonly reported anxiety types are social anxiety and panic disorder.33

A panic attack or panic disorder is an intense fear experienced out of the blue,

accompanied by frequently occurring physiological symptoms. Though it lasts only

for a few minutes, it provokes anxiety in different ways. The first is the anticipated

fear of the same experience in the future. The second is the cognitive meaning

attached to the experience that provokes anxiety. The last one is the forceful

behavioural changes brought to avoid future attack causes stress and worry.

Hypervigilance, conative interpretation and avoidance behaviour are reinforcing the

anxiety. It occurs with or without agoraphobia which is an anxiety state where in one

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feel the situation in which one has little chance of escape. The onset of panic attack is

in mid to late adolescent. 1% of adolescent experience panic attack or panic disorder

and 15% of the affected seek help and about half of the would suffer agoraphobia

along with panic attak.34-35

Social anxiety is an anxiety disorder or anticipated fear of being judged or evaluated by

others in a social situation. The constant fear of embarrassment forces them to avoid all

possible social situations. The cognitive scheme of judgement and evaluation in social

situations and the avoidance of such situations are characteristics of social anxiety. It

appears in adolescents in the early adolescence period. Therefore, the early adolescent

years are likely a difficult time for the individual due to the increasing social pressure

faced by adolescents.34 This is the most common and most widely reported and treated

kind of anxiety. Females are reported to be more vulnerable than males.36

Generalized anxiety is excessive, untamed, uncontrollable, and pervasive worry about

most aspects of daily life, resulting in several somatic symptoms. Among adolescents,

worry pervades aspects like the future, school, class performance, friends and

relationships.37 The onset is usually in the late adolescent period.

Obsessive compulsive disorder is characterised by intrusive and obsessive thoughts or

images that provoke anxiety and in order to cope with the anxiety, compulsive

behaviour is used. It has repetitive or many repetitive cognitions and accompanying

compulsive behaviours to cope with, which usually reduces anxiety at that point.

Adolescents usually know the irrationality of repetitive thoughts and the futility of

compulsive behaviour. The onset is in childhood or adolescence, with a prevalence

rate of 1-2%.38 According to a few studies, boys are more likely than girls to develop

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this disorder during childhood, 39 but the prevalence rate is equal in both sexes during

the adolescent period.40

Separation anxiety is another type of anxiety that mostly affects children. It can last

into adolescence, but it is usually diagnosed in childhood.41 It is an anxiety concerning

separation from home, from the attachment figure. It involves excessive distress when

separation is anticipated or occurs, refusal to attend school because of the worry of

separation, being unable to be alone without the attachment figure and physical

symptoms of anxiety when separation is anticipated or occurs.42

Screening of Adolescent Anxiety

The task of assessing and screening is anxiety in adolescent should follow a

systematic step wise progression lest it may result in error. There are many methods

adopted to screen the anxiety in adolescent, namely, detailed clinician administered

interview, self-report measure by the adolescent and caregiver report measures. The

recommendation of the American academy of child and adolescent psychiatry states

that screening should begin with the self-report scale, followed by care giver report

and finally formal evaluation by the clinician with includes semi structured interview

and other physiological test if suspected of any other physiological conditions.43

Preventive Measures

The anxiety problem can be treated by medicine, psychological therapy and

integrated treatment with both means. Psychotropic medications are found to be

effective in reducing anxiety symptoms especially antidepressants like Selective

serotonin reuptake inhibitors(SSRIs).44 Walk up et al (2008) conducted a large study

in children and which indicated that combination of SSRIs and psychotherapy

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especially cognitive behaviour therapy (CBT) was more effective than medicine

alone or placebo in reducing the symptoms of anxiety.34,45 There are certain

considerations to weigh down medication for adolescents. The first is, at the early

age of adolescence, it may not be clinically so prominent to treat them with

medicine. The second is medications have serious side effects like suicidal

ideation46, anorexia, and fatigue headache and stomach pain.47 The third is the chance

of developing drug dependence or addiction and paradoxical reaction including

disinhibition and aggression.42 Therefore, psychological intervention is an apt choice

because it helps the children to overcome the current symptoms and also it prevents

symptoms to advance to any specific anxiety disorder or any other co-morbid

conditions.

There are various psychological interventions to treat anxiety which are empirically

supported. These treatments have many similar elements. The psychological

treatments are not very direct or very simple as medication. It involves step wise

implementation, progression and tailored according to symptoms and population.

Every module of psychological interventions and every kind does not suit to the

every patient. This is very reason we have various kind of psychological intervention

for anxiety. Psychoeducation, relaxation, exposure and response prevention (ERP),

systematic desensitization, cognitive behaviour therapy (CBT) and mindfulness

based intervention (MBI) are major form that are used.

Psychoeducation is a didactic approach in which the patient or caregiver is informed

about all the anxiety. It includes information about its prevalence, type,

symptomatologic presentation, aetiology, identification of triggering or warning

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signs, and the behaviours that can reduce or increase anxiety.48 The aim is to make

people aware of all aspects of anxiety, and the presumption is that better awareness,

better management. The primary care giver applies psychoeducation. However, most

often, psychoeducation alone does not work well with anxiety because of the skill

deficiency to manage the symptoms that they are aware of. Therefore, it is used

along with other therapies, and it is most often an important ingredient in all other

therapies currently used because it creates awareness, which in turn motivates the

parents or children to actively participate in the intervention planned.

Relaxation is widely used to treat anxiety. Relaxation strategies such as deep breathing,

progressive muscle relaxation, and guided imagery are commonly used techniques. The

adolescents are trained in the session, which they can practise at home in anxiety

provoking situations. The aim of the intervention is to create a notion that the

adolescent can create or generate relaxation and well-being of their own choice, and it

can be utilised across a variety of life situations, though it was trained for a particular

situation in the therapy room. It is found to be very effective for the adult population

with generalised anxiety and those who experience strong somatic components of

anxiety.49 However, experts say that using relaxation techniques can make people more

likely to avoid situations and keep their anxiety symptoms going for a long time.42 It is

also clear from the research that when relaxation techniques are used with other

techniques, they can help a lot with anxiety symptoms.50

Exposure and response prevention (ERP) techniques are widely used in mental

health and set up by an expert with necessary precautions. This is a complex

intervention to conduct. The expert forces the client to expose themselves to the

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anxiety provoking situation, preventing them from using any avoidance behaviour.

The aim is to habituate the client with the feared stimuli, and in the process, the

stimulus threshold falls short of provoking the anxiety symptoms. The process of

exposure involves creating a hierarchy of symptoms that provoke anxiety symptoms

and then taking all necessary precautions that can cause harm to the client. Finally,

the client is encouraged to be exposed to the least and most anxiety-provoking

situations.51 The ERP is complicated and sometimes fails to achieve a goal due to

cognitive avoidance, which cannot be controlled by the expert. Therefore, the effects

of it on adolescents are not readily available. Paired with other techniques, it is found

to be effective in adolescents.56,58

Cognitive behaviour therapy is another kind psychological intervention used to treat

symptoms of anxiety. CBT is found to be more preferred choice and scientifically

more effective. It combines all above mentioned interventional techniques along with

its characteristic components. The characteristic components are thought behavioural

connection making and cognitive restructuring. This is structured and empirically

evident intervention. It stresses that thought and feeling as the cause of a particular

behaviour and therefore situation that is apparent cause is mediated by the thought

and feeling of a person. This cognitive behaviour connection is made at the very

early session and further nature of thoughts and it development in demands and core

belief are brought forth to the awareness of the client through aforesaid other

techniques. Finally the client is helped to challenge his own thoughts that disabling

the person which otherwise called cognitive restructuring. This will help the person

to manage one‘s own anxiety symptoms. This intervention gives much importance to

the home work to practice the skills learned in therapy in the daily life. The aim of

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the therapy is to identify and change the cognitions and behaviour that provoke that

are perpetuating the anxiety thus to manage the anxiety symptoms effectively.58

Beyond doubt, it is established that CBT is an evidence-based therapy for anxiety,

especially for the adult population. In recent times, there have been efforts to adapt this

intervention to adolescents and children. The techniques like psychoeducation,

relaxation exposure, and cognitive restructuring were used, but by simplifying the

language and examples, thus helping the adolescent understands the rationale of the

treatment. The parents were included with the adolescents in the therapy to help the

children.34,42 Currently, this downward extension of CBT has been developed for

anxiety disorders.59,60 These are found to be effective for treating anxiety in

adolescents.61–64 In spite of this, the research findings suggest that CBT in this particular

age group is less effective than in late adolescence. The reason could be that CBT

demands a lot of cognitive exercises that are complex in nature, and therefore, this

particular age group is not able to handle the demands of CBT.65 A second reason

suggested is that some disorders have only limited evidence of effectiveness.34,66

A third reason is that it demands a lot from adolescents and their parents, so adherence

to therapy is found to be low. However, the third wave of CBT is less complex than the

original CBT, which applies certain exercises that are used to change the distorted

cognitive schema of the child. The third wave of CBT, especially Mindfulness-Based

Cognitive Therapy (MBCT), Acceptance Commitment Therapy (ACT), and Dialectical

Behavioural Therapy (DBT), allows the person to attend to and understand the

cognitive process through various daily activity exercises and enables them to accept it

without any cognitive judgement or dissonance, rather than forcing a change in the

cognitive schema.

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MBI is a valuable addition to behavioural and medicinal therapy for the management

of a variety of symptoms, including psychological and physical reactions to stress,

anxiety, depression, and disruptive behaviour. Children, adolescents, and their

parents can be taught mindfulness practises to help them improve their self-

regulation, particularly in reaction to stress. Mindfulness may be especially

beneficial for adolescents and families who are at a higher risk of chronic stress and

specific pressures connected to medical and social factors. Additionally, mindfulness

parenting techniques may be used in conjunction with established behavioural

approaches to help children modify their behaviour through targeted parent-child

interactions.68 MBI programmes come in a variety of forms, including mindfulness-

based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).69

Semple, Lee, and Miller (2006)70 suggest that mindfulness-based approaches may be

suitable interventions for anxiety, depression, and/or conduct disorder in adolescents.

It can also improve cognitive and academic performance, manage academic stress,

and affect the whole development of a person.71 Thompson and Gilbert(2008)72 found

out that mindfulness training creates the potential for greater self-awareness,

improved impulse control, and decreased emotional reactivity to challenging events.

Rationale for Mindfulness Based Cognitive Therapy for Children

In this study, psychological intervention based on mindfulness-based cognitive

therapy was preferred over pure CBT. Several analyses show that CBT is not

completely effective for half of all children29,30 and especially at this age, the

effectiveness is less compared to the later stages of adolescence.31 Thirdly, the pure

CBT intervention might create a barrier for some children to fully engaging in the

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therapy process due to its complex nature. A fourth reason is that some disorders

have only limited evidence of effectiveness. The fifth reason is that it demands a lot

from adolescents and their parents, so adherence to therapy is found to be low.

Besides all this, MBCT is widely used to treat anxiety, and the efficacy of MBCT

has been empirically established. In addition to all the above, MBCT has CBT

components and simultaneously creates an environment where each child can have

full and free collaborators in a shared process because of the very nature of the

therapy. DBT and ACT, though a third wave therapy with mindfulness elements,

were not preferred choices. The main reasons are that they are mindfulness-informed

therapies, which means they use some general concepts of mindfulness and some

mindfulness skills; and furthermore, they are complex, less CBT format and less

economical in terms of time and effort. Anxiety and mindfulness Worry and anxiety

refer to thoughts, images, and emotions that are negative in nature and occur in a

repetitive, uncontrollable manner, which is a result of proactive cognitive risk

analysis made to avoid or solve anticipated potential threats and their potential

consequences.73 Despite the fact that anxiety is an adaptive mental activity, chronic

anxiety that is repeated and automatic in nature is considered pathological.74

Mindfulness emphasises making one‘s thoughts more conscious in nature and

accepting the thoughts non-judgmentally. Therefore, it can be posited that

mindfulness training may be beneficial in reducing habitual worrying or anxiety.

There was greater somatic and autonomic modulation (reduced breathing patterns

and higher vagal responsiveness during invocation of cardiac defence) and better

emotional meta-cognition (better understanding of emotions) in people who practise

mindfulness.75 Several recent studies have also found that, in contrast to people who

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sustain chronic worry, mindfulness decreases chronic anxiety by strengthening

emotional and physiological regulation systems.74-76 Anxiety can be described as a

response to a moderate challenge when the individual has inadequate skills to deal

with the situation.77 It is a series of unpleasant, affect-laden thoughts and pictures

that are generally uncontrolled.74 It is a part of preservative cognition, i.e., a

collective term or continuous thinking about negative events in the past or in the

future. It is experienced as concern or anxiety about a real or imagined situation and

is a natural response to anticipated future problems. Mindfulness focuses on the

present and has an attitude of acceptance toward what comes up in the stream of

consciousness. This contrasts with habitual worrying, which is marked by a focus

away from the present and a non-accepting attitude toward the object of concern.

Habitual worrying was found to be associated with test anxiety by Verplanken and

Fisher (2014) and dispositional mindfulness somewhat mitigated this relationship.

Second, mindfulness training made chronically anxious adolescents more tolerant of

disturbing images. Furthermore, they propose that mindfulness can serve as an

antidote to the negative repercussions of habitual worrying.74

Nature of Mindfulness Based Cognitive Therapy for Children

MBCT-C78 is a manualized intervention for children aged 9 to 18 years old who have

anxiety problems. It was created as a downward adaption of MBCT (which was

originally used for adults with major depression) and MBSR (which was originally used

for children with major depression) (developed for use with adult chronic pain patients).

The seven primary goals of MBCT-C are as follows: 1) Acceptance; 2) identifying

mindfulness practise difficulties; 3) developing personal incentives; 4) mindfulness of

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thoughts, feelings, and physical sensations; 5) non-judgmental awareness; 6) decentring;

and 7) identifying decision points. MBCT-C was designed to be used in a group setting.

Six to eight children are in each group, which is led by one or two therapists. At the end

of each class, home practise activities are assigned. Between sessions, children are

required to engage in brief mindfulness activities (10–15 minutes each day). Additional

instructions for applying MBCT-C in individual therapy, where the therapist must play a

more active role, are included in the treatment manual. Individual sessions can also be

cut down from 90 to 45–60 minutes.

Need of Mindfulness Based Cognitive Therapy for Children

Three key developmental distinctions between adults and children are identified by

MBCT-C. It is based on three major factors in adolescent life. To begin with, children

are less able than most adults to verbalise their thoughts and feelings. Limited verbal

fluency can make it challenging for them to express their emotions. Instead, they may

use behaviours to express their feelings (e.g., hitting someone, giving a hug, isolating).

Both MBCT and MBCT-C focus on cultivating non-judgmental observation of thoughts

and feelings, as well as developing mindfulness awareness through breathing and body

techniques. MBCT-C also has short, interactive exercises for children that help them

become more mindful through touch, sound, sight, scent, and movement.79

Second, children's attention spans are shorter, and they have a lower tolerance for

boredom. To address these concerns, the length of the sessions is reduced from two

and a half hours per week for eight weeks to 90 minutes per week for twelve weeks in

MBCT-C. Furthermore, unlike adult groups, MBCT-C groups contain fewer children

and a greater therapist-to-patient ratio, allowing for more individualised care. MBCT-

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C includes a broader range of brief hands-on activities than MBCT. Third, because of

the interconnectedness of children with their parents or caregivers, MBCT-C makes it

a point to include caregivers in the programme. Although adult caregivers do not

attend the child sessions, they are invited to a separate 2-hour group orientation

session that introduces the programme, allows parents to participate in numerous

activities that their children will engage in throughout the program, and discusses how

they can support and participate in their child's activities at home and invites

questions. The written session summaries and home practise assignments provided

out each week are also urged to be shared with parents. Throughout the programme,

parents and therapists maintain open lines of contact. Finally, at the end of the

programme, parents attend a group review session to explore ways to support and

maintain their own and their child's ongoing mindfulness practise.

Dual Participation in Mindfulness Based Cognitive Therapy

Therapists are encouraged to develop and maintain a personal mindfulness practise

for two reasons. First and foremost, the MBCT-C is an acceptance-based approach

rather than a change-oriented one. For therapists who generally conduct traditional

therapies that focus on modifying beliefs or actions, this can be new ground.

Facilitators exemplify present-moment mindfulness and non-judgmental acceptance

of what is going on in the moment, both inside and outside. Every instant, on the other

hand, is different, asking us to be conscious of our thoughts, feelings, choices, speech,

and behaviours on a moment-by-moment basis. Second, understanding is not the same

as knowing. Teachers who just have a theoretical understanding of mindfulness

principles such as present-moment awareness and nonjudgment or how to perform

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mindfulness activities are unlikely to be effective. Effective MBCT-C facilitators,

according to Semple and Lee (2010)78 exemplify mindfulness. To learn to play

basketball, one must first pick up a basketball and practise with it. Therapists must try

to bring awareness into their own lives in order to embody mindfulness. This implies

that we must make a commitment to cultivating a personal practise. There are no

requirements for practise frequency, duration, or type. The goal is to put what we're

trying to teach into practise. The therapist's own mindfulness practise can serve as a

framework for youth to be present in the face of intense emotions and thoughts.

Modelling mindfulness in the patient-therapist relationship may also help young

people learn these skills and better control their own internal experiences.79

Process of Mindfulness Based Cognitive Therapy for Children

A well-structured and progressive process is formulated for the sessions of the

therapy. Each session begins with an introduction, a review of home practise, and a

discussion of the session's goals. Then, the children are asked to use a Feely Faces

Scale to rate how they're feeling right now.74 Following that, the youngsters take part

in session activities. Each session concludes with a reading of a poem or tale relevant

to the topic of the week, a Feely Faces Scale check-in74 and a review of the assigned

home activities for that week.

The first three sessions are devoted to introducing children to mindfulness and

teaching them specific techniques for developing mindful awareness. They are

introduced to the concept of automatic pilot, which occurs when one's thoughts are

diverted from the present moment. Children learn about turning off automatic pilot

and how it can benefit them during several hands-on introductory mindfulness

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activities. They practise connecting with their breathing to bring awareness to the

present moment. Despite the simplicity of the activities, children begin to understand

the difficulties that come with developing a mindfulness practice. Mindfulness is

defined as a new way of being present in one's life. The children learn that they can

practise mindful awareness and awareness of breathing and body sensations whenever

they want. The concept of distancing oneself from one's thoughts is introduced.

Decentring, or de-fusion, is the metacognitive ability to experience thoughts, feelings,

and body sensations as internal experiences rather than facts about reality. With

openness and non-judgmental awareness, children practise observing and describing

their own thoughts, feelings, and bodily sensations. Mindfulness practise results in

increased awareness of both internal and external events. This enables the children to

gain a better understanding of their options at any given time. They practise this new

way of being through breath anchored awareness, body scans, visualisation exercises,

and listening to the sounds of silence.

The middle sessions concentrate on developing attention in all of the senses. To begin

with, youngsters use their sense of taste to explore awareness. They compare mindful

eating to how they eat on a normal basis. Children investigate the concept that their

ideas, feelings, and bodily experiences do not define who they are, and that they may

or may not correspond to situations or events in their existence. They learn that being

aware of their ideas, feelings, and bodily sensations can help them make better

decisions. Children are introduced to mindful hearing, which allows them to obtain

fresh perspectives on sounds in the world while also enhancing their understanding of

music's intricacy. They investigate the thoughts, sentiments, and bodily sensations

evoked by various sounds. Children take turns acting as ―conductors‖ and practising

21
 Introduction

making emotional sounds. They get feedback on how other adolescents received their

composition, which is frequently different than what they planned. Children also talk

about the value of nonverbal communication. They are taught how to gaze mindfully

and how to look clearly. The subjectivity concept is also introduced: children learn the

distinction between judging and noting (non-judgmental observation) and how

thoughts and feelings influence their affect, mood, or felt experiences. They discuss

how various factors influence visual experiences, which are a combination of what is

actually seen, cognitive interpretations, and emotional responses. Mindfulness-of-

seeing activities improve attention and increase the ability to shift attention

intentionally. Children practise perspective taking by concentrating on various aspects

of their environment. They are taught about choice points, which are characterised as

moments in which deliberate choices can be made rather than emotionally reactive,

frequently counterproductive responses. They have the ability to select how they

respond to their own thoughts and feelings in particular. Touch mindfulness and

mindful smelling are two examples of how judgments can alter perceptions. The final,

or termination, sessions concentrate on transferring and maintaining mindful

awareness abilities. Children discuss how they might develop mindfulness in their

daily lives. The importance of attentive awareness in coping with or responding to

powerful emotions is being investigated. Children are given the opportunity to think

about and express their personal understandings of mindfulness using art. To

commemorate the MBCT-C shared experience, they are planning a graduation party

for session 12. Therapists and kids talk about how to remember to incorporate mindful

awareness and skilful choices into their daily lives, brainstorm potential barriers to

continuous practise, and figure out how to overcome that barriers.78

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 Introduction

Rationale for Resilience

The school based mental health frame work suggests that three dimensional approach

programme are more efficacious.80 The three dimensions are skill training, treating

and promoting preventive and protective factors. Aaron Antonovsky, a professor of

medical sociology, developed the word "salutogenesis" in 1979 to refer to the

elements that promote human health and well-being rather than sickness.81 The

strengths-based approach does this by concentrating on the characteristics of persons

that promote health, rather than on the symptoms and pathologies that cause illness.82

Rather than treating the weaknesses and risks that contribute to mental disease,

advocates of the strength-based paradigm believe that it is equally vital to improve

an individual's potential for resilience during treatment of mental illness.83 Numerous

variables, including childhood adversity, parental dysfunction, physiological

changes, peer pressure, and bullying, can contribute to teenage anxiety. However,

there is always the possibility that not everyone who is exposed to these elements

develops anxiety, or that if they do, their degrees of anxiety are not the same, and

their methods of managing anxiety are not the same. The argument is that not

everyone's personal ability or intrinsic protective factors to withstand adversity are

not same. In other words Resilience is a key aspect in explaining the difference.84-87

In those cases where intrinsic protective factors are not sufficiently strong to manage

anxiety, the MBCT-C can help them to enhance their resilience to the point where

they will be able to manage anxiety more effectively.

Resilience Defined

The word "resilience" comes from the Latin root resalire, which means "to bounce

back" or "to spring back." As a result, it might be defined as a person's capacity to

recover from adversity or life challenges. It is an extension and application of the

23
 Introduction

capacity to face life squarely and cannot be reduced to a competency. Resilience is

described in a variety of ways from different theoretical perspectives by various

people. Rutter defines resilience as the ability or strength to maintain adaptive

functioning in the face of significant risk.83 As Masten and Wright say, resilience is

"the ability to adapt and grow in the face of major threats to one's life or function."88

Tugade defines psychological resilience as the ability to recover from negative events

by living with positive emotions.89 Resilience, according to Grotberg (1996), is a

universal quality that permits an individual, organisation, or community to avoid,

mitigate, or overcome the negative consequences of adversity.90 Werner 91 refers to it

as an individual's potential to adapt, cope with, and respond successfully to life

stresses after exposure to stressful life events, whereas Neil92 refers to it as a

psychological quality to adapt and cope with, and respond effectively to, life stressors

following exposure to stressful life events. Whatever the theoretical perspective, be it

developmental theories of resilience, personality theories of resilience, or process

theories of resilience, all agree that interventions can improve resilience.

Resilience and Adolescent

Resilience is a natural ability that all adolescents possess for healthy growth and

learning. It may also be a stress-relieving and health-promoting component that

contributes to one's general well-being, quality of life, and psychological

development.93 The notion of resilience is applied in this research in order to better

understand how adolescents cope with adversity. Catalano et al. (2004)94 argue that all

youth, regardless of age-specific level of risk to their mental health, can benefit from

assistance in developing effective coping strategies and resilience skills through

24
 Introduction

preventive interventions that support a strengths-based approach.95 Thus, protective

variables increase resilience by allowing the teenager to overcome issues while being

exposed to high-risk situations.96 The promotive elements that support an adolescent's

positive growth assist them in overcoming hardship.97 Assets and resources are two

types of promotive elements that have been found. Resources are external elements,

such as having a mentor or a community resource95 whereas assets are internal factors

such as having low or high self-efficacy. The current trend of research has shifted

toward investigating the development of resilience by assessing adolescents' social and

psychological well-being and by finding community-based interventions and

preventative initiatives.98 Thus, with the assistance of mindfulness-based therapies in

the school setting, when an adolescent is exposed to an environment that promotes

growth and provides opportunities, the adolescent is far more likely to expand the

adolescent's assets and resources that can satisfy and promote healthy development.99

The internal resources that predict resilience are psychological flexibility and self-

regulation. In other words, the building blocks of resilience are ego resilience and

emotional resilience. Psychological flexibility, defined as the capacity to accept one's

emotional experience without avoiding it and, depending on situational needs, continue

to pursue one's goals despite a negative experience, is another potential contributor to

perseverance.100 More elaborately, psychological flexibility is described as being

completely aware of the current moment, of emotions, feelings, and ideas, of receiving

them all, including the unwanted ones, and of moving in a pattern of behaviour in

service of selected values.101 In simpler terms, this entails embracing our own thoughts

and emotions and acting on long-term ideals rather than short-term impulses, thoughts,

and feelings, which are frequently associated with experiencing avoidance and a strategy

25
 Introduction

of controlling undesired interior experiences.102 Defusion, acceptance, present moment,

self-as-content, values, and committed action are the six key processes that support

psychological flexibility.101 Psychological flexibility is an important aspect of how

resilient people adjust to changes or adversities.103 Block defined ego-resilience as the

ability to deploy social, cognitive, and emotional resources in a flexible manner to meet

changing environmental demands104 and the inability to do so was a sign of

psychological rigidity. The least typical qualities of ego-resilient adolescents are

inflexible, repeatedly in stress, socially inappropriate emotional expressiveness, and

discomfort in unpredictable and stressful circumstances, and the absence of these

differentiates the psychologically flexible person. The term "emotion regulation" refers

to attempts and methods of influencing and expressing emotions.105,106 According to

Gross's (2008)107 emotion regulation model, techniques for controlling emotions vary

according to the situation in which they must be influenced or modified. The concept

classifies emotion control techniques into five distinct families: context selection,

situation alteration, attentional deployment, cognitive modification, and response

modulation. These can be classified into three types of emotion regulation strategies,

each of which focuses on a different aspect of the emotional experience: the external

situation by altering the environment, the internal situation by altering one's perspective

on the situation, or the outward response of emotional expression. Emotional regulation

could otherwise be understood as a positive strategy to adapt to the emotional

situation.108 They are problems solving, reappraisal, and acceptance. Inversely,

suppression, rumination, and avoidance can be termed as emotional dysregulation.

Positive aspects of emotion regulation or emotional resilience are directly connected to

psychological flexibility.109 Psychological flexibility can be described in relation to

26
 Introduction

emotions as the capacity or willingness to be in contact with emotions, ideas, or

sensations (private events), both desired and undesirable, while being fully awake and

in perspective and advancing in desired life directions. Otherwise, experiencing

avoidance can occur, which is a persistent tendency in which an individual attempts to

control, alter, or change the frequency of specific private experiences.110 Thus, emotional

resilience is one aspect of psychological flexibility, and therefore it is also a predictor of

resilience. Research suggests that emotion regulation ability is a significant predictor of

adolescents' resilience. Moreover, cognitive regulation strategies, such as positive

reappraisal, predicted perceived resilience among adolescents.111

Resilience and Anxiety

There is an inverse relationship between resilience and anxiety. A low level of

resilience is reported in children with anxiety,112-114 and intervention aimed at resilience

also reduces anxiety.115-123 A decreased level of ego-resilience or psychological

flexibility leads to anxiety because of the experiential avoidance.124 Due to the fear and

experience of bodily arousal that happens in panic disorder, the fear of intense

emotional impulses that occur in GAD, or due to the fear of communicating and

displaying strong emotional experiences, the adolescent tends to avoid such a response

and eventually it becomes a behavioural pattern amounting to anxiety disorder. Four

factors, namely, heightened intensity of emotions, poor understanding of emotions,

negative reactivity to emotions, and maladaptive management of emotions that

contribute to a decreased level of emotional resilience or emotional regulation, are

predictors of GAD, panic attacks, and social anxiety.125 Thus, both emotional

dysregulation and psychological inflexibility have been discovered to be transdiagnostic

27
 Introduction

characteristics that are linked to psychopathology in several studies.126 Maladaptive

emotional regulation strategies, such as rumination, reappraisal, and emotional

suppression, are associated with anxiety and depression.127,128 Whereas psychological

inflexibility is associated with anxiety.124,129

Mindfulness and Resilience

Literature suggests that there is an association between mindfulness and resilience, and it

is also claimed that it can be taught through psychological intervention. Mindfulness is

positively correlated to resilience, and mindfulness is a strong predictor of resilience. A

mindfulness-based intervention proved to be efficacious in increasing resilience. The

research also indicates that mindfulness mediates resilience. Mindfulness helps them to

bounce back from stress, and it also helps them to be aware of the stress or trauma and the

emotional, cognitive, and behavioural reactions triggered by those stress situations.

Furthermore, it helps to accept the situation and face the present relatively with better

psychological flexibility. Mindfulness promotes acceptance and curiosity towards life and

stress, and thus it promotes psychological flexibility, which in turn helps them better

adapt, which is an integral part of resilience.

Operationalized Definitions

The present research is devoted to applying the MBCT module to the anxious early

school going adolescent. The following concepts need to be operationalized for the

purpose of understanding the conceptualised meanings of the terms in this study by

the investigator.

1. School Going Early Adolescent: The teenagers of both gender aged between

10 to14 who are enrolled and regularly attending in a formal and standardized

28
 Introduction

educational institution of, School-age early adolescent: Teenagers of both

genders aged 10–14 who are enrolled and regularly attend a formal and

standardised educational institution (UP) in India and are divided into two

groups: psychological intervention based on mindfulness (PIBM/Experimental

group) and treatment waiting list group (TWL/Control group).

2. Anxiety: As per the study, elevated prospective fear was more than the

normative level in the following domains: generalised anxiety,

panic/agoraphobia, social phobia, separation anxiety, obsessive compulsive

disorder, and physical harm concerns, which have produced trouble in

functional life but not to the clinical range.

3. Resilience: In this investigation it is defined as an adolescent‘s capacity to

cope with stress and adversity, as well as a feature of resistance to subsequent

unfavourable experiences. The major concentration is on seven the aspects of

resilience namely, (1) Time required to regain normalcy, (2) Reaction to

negative events, (3) Response to risk factors (specifically disadvantaged

environment) in life, (4) Perception of the effect of past negative events, (5)

Defining 'Problems, (6) Hope/Confidence in coping with the future, and

(7)Openness to experience and adaptability.

4. Mindfulness: it is a disposition of the adolescent formed out of an intention to

be fully aware of the present moment and to accept all experiences with an

open and curious mind and without any judgement or reaction.

5. MBCT-C : mindfulness based cognitive therapy for children, is a manualized

intervention for the treatment of anxious children above the age of 11 with the

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 Introduction

following goals (1) Increasing resilience on a social-emotional level, (2)

Promotion of positive changes in the child's relationship with their own

thoughts and emotions, (3)Learning to distinguish judgmental thoughts from

those that simply describe or observe one's own experiences, (4) Recognizing

the judgments frequently that exacerbates mood disturbances, which can then

trigger maladaptive behaviours. (5) Developing self-acceptance and acceptance

of the unchangeable, (6) improving awareness of one's emotional and

behavioural choices. This is the module used as an intervention in the study.

Rationale of the study

School environment is a strong predictor for anxiety and one of the prominent mental

health issues found in the early adolescent. It is found to be predictive factor for

many mental health issues. Intervention for this disorder at an early age as it

manifests which is age above 12 would help in treating, improving and preventing

mental health issues of adolescents. Anxiety can cause depression and stress

therefore in this research we have taken all those who have identified with anxiety

and all those identified with anxiety co morbid with depression or stress.

The Mindfulness based cognitive intervention for children with anxiety was used by

Semple and Lee (2005). The intervention group were aged between 7 and 8 who

underwent six week intervention apparently showed improved but later review showed

that the intervention group could not adequately comprehend and translate it into daily

routine because they approached it as game rather life skill practice.131 Therefore they

found that certain cognitive abilities are necessary to comprehend mindfulness concept

and to engage in this practice meaningfully. The hypothesized essential cognitive

30
 Introduction

abilities were an ability to comprehend multiple perspectives, attentional orientation to

the experience of others, an ability to distinguish past, present and future thinking and

being able to make causal inferences. Thus they developed the intervention for the

children aged above 11 who would be entering the formal operational stage of

development as mentioned by Piaget.132 This is the reason to select age above 11 in

this intervention. However, there are two more additional reasons for the particular age

group. The mean age of anxiety is reported to eleven and above.10 The childhood

anxiety is the primary predictor of depression and anxiety in later adolescence and in

early adulthood.133 Therefore intervention targeting early adolescent can be beneficial

in preventing or becoming more pronounced to impair the life significantly. A third

reason is that the adolescence is termed as an age of storm and stress. G. Stanley Hall8

regarded Adolescence as an age of ‗storm and stress.134 It is a period when all young

people go through some degree of emotional and Behavioural upheaval before

marching towards a more stable equilibrium in adulthood. 'Storm' refers to a reduced

level of self-control, and 'stress' refers to an increased level of sensitivity. Hall's

perception of adolescence continues to influence our view of this period of

development. Therefore intervention at this age intend to reach children before they

face intense storm and stress so that they may develop resiliency and coping skills and

emotional equanimity to face the challenges unique to the adolescent age. The

aforementioned information was challenging to the researcher as a school mentor of

the adolescent. The researcher was forced to carry out something substantial to help

the adolescent manage the anxiety. MBCT was the preferred option as it is tailored for

adolescents with strong empirical evidence and it not only treats the anxiety but also

enhances the protective factors like resilience to cope with anxiety provoking school

31
 Introduction

and home situations. It also helps in improving the academic performance as well as

the overall well-being of adolescents.

Scope of the study

The scope of the study is directly connected to the enhancement of school mental

health, which is needed at the hour but at the same time is in its infancy stage in India

due to the sustained neglected outlook of policy makers, both in government and non-

government agencies. The study will help in the prevention, improvement, and

treatment of anxiety in early adolescents, which can cause other mental health co-

morbidities like stress and depression. Untreated or unattended anxiety can cause
59
mental health issues in late adolescents as well as in adulthood. The intervention is

daily activity based and has less complexity; therefore it can be easily applied to

children as a curriculum practise in the school. Thus, it prevents anxiety and related

co morbidities. This also helps in improving academic performance, self-esteem, and

quality of life.71 This as a treatment is a self-managed, simple and effective technique,

and therefore it plays a key role not only in reducing anxiety but also in growth and

development. Such types of studies are reflection of important contribution for the

researches on adolescent behaviour and problems. There are many sub disciplines like

developmental science, educational sciences, criminology, public health, medicine,

and many more psychosocial researches can seek facilitation from the findings of the

research. This is an innocent population that needs to be protected, and if we

incorporate the training of mindfulness from the tender age of adolescence, it will be a

great protective, preventive psychological disturbance and promoting psychological

capitals and well-being.

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