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PROTOCOL: Mindfulness‐Based Interventions for Improving Academic Achievement, Behavior and Socio‐Emotional Functioning of Primary and Secondary Students: A Systematic Review

2015; The Campbell Collaboration; Volume: 11; Issue: 1 Linguagem: Inglês

10.1002/cl2.143

1891-1803

Brandy R. Maynard, Michael Solís, Veronica L. Miller,

Youth Development and Social Support

Over the past two decades, increased attention on improving academic outcomes of students to compete in a global environment has led to significant changes in education policy, with greater emphasis placed on academic versus other competencies (i.e., social, emotional, behavioural). An increased focus on improving academic rigor and the use of and emphasis on high stakes testing have been two of the more significant factors affecting education, particularly in the U.S. but also in other countries (Gregor, 2005; Von Der Embse, Barterian, & Segool, 2013). Recent policy initiatives in the U.S. (e.g., No Child Left Behind Act, 2001; Race to the Top, 2009) have emphasized school accountability for educational programming and outcomes to facilitate students developing academic proficiency. In short, present-day U.S. education policy has narrowly focused on ensuring high levels of academic achievement, a departure from a broader mission of schools to support vocational education, physical and mental health, all of which had been promoted in the past (Kataoka, Rowan, & Hoagwood, 2009). Despite increased emphasis on academic rigor and high stakes testing, findings from the National Assessment of Educational Progress (NAEP) continue to indicate poor performance for many children in the U.S. Indeed, the U.S. continues to lag behind most Organization for Economic Co-operation and Development (OECD) countries (National Center for Education Statistics, 2012; OECD, 2008), suggesting that existing educational programming is currently not meeting the needs of many students. In addition to changes in education policy requiring an increased emphasis on academic standards and accountability, schools are increasingly expected to attend to the social, emotional, and behavioral needs and problems of students. Although schools have long functioned as a context for improving youth developmental outcomes, the myriad issues that negatively impact students' social, emotional, and behavioral functioning in schools serve as the impetus to revive schools' focus on non-academic issues (Greenberg Domitrovich, & Bumbarger, 2001; Schonert-Reichl & Lawlor, 2010). Moreover, a substantial body of evidence linking social, emotional, and behavioral factors to learning and academic achievement continues to expand, pointing to the critical need for schools to attend to these factors to enhance academic achievement (Denham & Brown, 2010; Eisenberg et al., 2010). Evidence suggests that students today are experiencing high levels of stress as well as other emotional and developmental challenges that may impede their ability to learn and succeed in school (APA, 2009; Merikangas et al., 2010; Pope, 2010). Approximately 13%-20% of children in the U.S. experience at least one mental disorder, and these rates have been on the rise since 2005 (Centers for Disease Control and Prevention, 2013). The increased prevalence of stress and anxiety, and at earlier ages than prior generations, has been at least partially attributed to school-related stress---particularly, high stakes testing, increased academic pressure, and the overscheduling of students in multiple extracurricular activities (APA, 2009; Gregor, 2005; Pope, 2010; Suldo, Shaunessy, Thalji, Michalowski, & Shaffer, 2009). Indeed, students report school-related stress as being their greatest source of stress (APA, 2009), and teachers rate behaviors associated with anxiety as some of the most common problems that children and adolescents face (Harrison, Vannest, Davis, & Reynolds, 2012). The prevalence and levels of student stress and anxiety have become a concern for schools as emerging evidence suggests strong links between stress and academic performance as well as with emotion regulation, behavioral functioning, and brain and cognitive development, which are also strongly linked to academic performance (Anderson, 2003; Anderson & Teicher, 2009; Sandler, Braver, & Gensheimer, 2000; Shonkoff, Boyce, & McEwen, 2009; Suldo et al., 2009; Teicher, Andersen, Polcari, Anderson, & Navalta, 2002; Wolchik, Coxe, Tein, Sandler, & Ayers, 2006). Social-emotional development and competencies have also been linked to learning and academic achievement and increasingly viewed as a target for school-based interventions (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011; Eisenberg, Spinrad, & Eggum, 2010; Zins & Elias, 2006;). A growing body of evidence has found numerous social and emotional factors, including emotion regulation, effortful control, social and self-awareness, self-management, relationships skills and decision-making, to be directly and indirectly related to academic performance, school engagement, and externalizing and internalizing behaviors (Brackett & Rivers, 2014; Denham & Brown, 2010; Eisenberg et al., 2010; National Center for Educational Statistics, 2002; Wang Haertel, & Walberg, 1997). For example, an inverse relationship between emotion regulation and effortful control has been found with externalizing behavior problems in pre-school age children through adolescence (Eiden, Edwards, & Leonard, 2007, Eisenberg et al., 2010; Gardner, Dishion, & Connell. 2008). Conversely, students with greater ability to self-regulate are more likely to demonstrate better ability to concentrate and pay attention in school and exhibit better impulse control and fewer externalizing behaviors, leading to improved functioning and success in school (Eigsti et al, 2006; Eisenberg et al., 2010; McClelland et al., 2007; Mischel, Shoda, & Rodriguez, 1989). The increased prevalence of stress, anxiety, mental health problems and other social, emotional, and behavioral risk factors, along with the increase in knowledge of the impact of these factors on learning and achievement, has prompted schools and policy-makers to begin to more explicitly attend to students' social and emotional functioning through both curriculum and ancillary programs (Zins & Elias, 2006). Indeed, for students to succeed in school, it seems ever more apparent that schools need to provide strong social and emotional components and support students' well-being in addition to providing strong academic curriculum and instruction (Zins, Weissberg, Wang, & Walberg, 2004). As schools have struggled to find ways to support students' overall well-being, one approach receiving growing interest is the use of mindfulness practices. Mindfulness, commonly defined as “paying attention in a particular way: on purpose, in the present moment, nonjudgmentally” (Kabat-Zinn, 1994, p. 4), is a popular topic in the public realm and being promoted by high profile stars and athletes as a means of improving health and well-being. The mindfulness practices of awareness, attention, and acceptance are interconnected to mindfulness outcomes, including a state or trait of an individual becoming increasingly aware and attentive in the moment. Many scholars have embraced a two component model of mindfulness, (a) self-regulation of attention, described as bringing awareness to the focus of attention to a point of full attention to the changing thoughts, feelings, and sensations, and (b) orientation to experience, which refers to the attitude or approach one takes in attending to the present moment (Bishop et al., 2004). Research suggests that mindfulness practice improves performance on a variety of measures of self-regulation (Lo & Allen, 2008; Heeren, Van Broek, & Philippot, 2009), stress and mood disturbance (e.g., Speca et al., 2000). Empirically, there is evidence to support a direct link between mindfulness and cognitive, psychological and neurological processes, which in turn may affect behavioral, socio-emotional and achievement outcomes (see Figure 1). As mindfulness seems to be a popular trend adopted by researchers and practitioners, it is also beginning to be considered in various areas of public policy, including education policy. Over the past decade, interest in mindfulness has been growing, and mindfulness-based approaches to improving health and well-being, particularly with adults, have spread across fields, including psychology, healthcare, neuroscience, and business. This burgeoning interest in mindfulness is due, at least in part, to a significant and growing body of evidence pointing to positive effects of mindfulness training for ameliorating a variety of negative problems and outcomes. Numerous studies and meta-analyses have investigated the use of mindfulness-based interventions (MBIs) in medical situations, with mindfulness training and practice being found to help patients with chronic conditions manage or reduce pain (e.g., Cramer, Haller, Lauche, & Dobos, 2012; Veehof, Oskam, Schreurs, & Bohlmeijer, 2011), fibromyalgia symptoms (i.e., Lauche, Holger, Dobos, Langhorst, & Schmidt, 2013), and stress in breast cancer patients (i.e., Zainal, Booth, & Huppert, 2013). Additionally, syntheses and meta-analyses have found positive effects of MBIs in treating individuals with mental health diagnoses, such as anxiety (de Vibe, Bjorndal, Tipton, Hammerstrom, & Kowalski, 2012; Vollestad, B. Nielsen, & H. Nielsen, 2012), psychiatric disorders (i.e., Chiesa, Calati, & Serretti, 2011), psychosis (Khoury, Lecomte, Gaudiano, & Paquin, 2013), personal development and quality of life (de Vibe et al., 2012) as well as stress among normally functioning individuals (i.e., Cheisa & Serretti, 2009) including university students (Regehr, Glancy, & Pitts, 2013). LOGIC MODEL The use of MBIs is on the rise in schools across the United States and United Kingdom as more and more schools have begun implementing various mindfulness-based programs and integrating mindfulness into the curricula (e.g., MindUP, The Inner Resilience Program, South Burlington Wellness and Resilience Program, Mindful Schools, Learning to Breathe, Mindfulness in Schools Project, Still Quiet Place, Stressed Teens, and Wellness Works in Schools). Moreover, efforts to promote mindfulness practices are being included in public policy initiatives. In the U.K., for example, members of parliament have received training in mindfulness and have heard testimony of the evidence and benefits of mindfulness, including testimonies from thousands of school children who have experienced mindfulness training in school. Also this year, an all-party parliamentary group was launched in the U.K. to conduct a nine-month inquiry into the potential role of mindfulness in areas of public policy, including education (Booth, 2014). The third session of the all-party parliamentary group focused on “mindfulness in health and education,” and members considered possible applications of mindfulness in health and education, with discussion of challenges for scaling up mindfulness programs to be included in teacher training as well as other potential policy actions (http://parliamentarywellbeinggroup.org.uk). Although the use of MBIs appears to be on the rise in schools, and policy makers are calling for more mindfulness in education policy, it is unclear whether mindfulness-based approaches do indeed positively impact academic, emotional, and behavioral outcomes in students. While there is a growing body of studies of MBIs on a range of cognitive, social, and psychological outcomes including working memory, attention, academic skills, social skills, and emotional regulation (Meiklejohn et al., 2012), few studies have synthesized this literature using systematic and quantitative methods and focused specifically on school-based interventions. Rather than being driven by substantial evidence of effects on student outcomes, the seemingly growing acceptance of MBI approaches for use in school settings appears to be largely driven by intervention studies with adult populations or hypotheses based on correlational data or theories that link mindfulness practice to positive outcomes. As schools develop practices and policies to try to more effectively and efficiently improve student outcomes, it is important that researchers, practitioners, policy makers, and other key stakeholders have access to evidence of MBI effects in order to make informed decisions rather than rely on anecdotal evidence and follow current popular trends. This review will focus on mindfulness-based interventions (MBIs) with preschool, primary and secondary students in school settings. Mindfulness is a type of practice derived from the Buddhist traditions of Vipassana and Zen/Chan (Chiesa, Calati, & Serretti, 2011; Eberth & Sedlmeier, 2012), which is characterized by awareness of the current state of the mind and body without judgment, elaboration, or attachment (Burke, 2010; Eberth & Sedlmeier, 2012) through a variety of techniques. Ideally, these strategies would be taught explicitly during the training phase, with students eventually engaging in these cognitive and behavioral processes in a variety of other situations (Hwang & Kearney, 2013; Jha, Krompinger, & Baime, 2007). Typically, MBIs are conducted by a trained implementer through teaching of a combination of the listed elements in a group setting, though sometimes in one-on-one setting with the implementer or therapist (i.e., Singh et al., 2007). The MBI includes the direct, explicit teaching of the principle, opportunity for students to practice the principle during the intervention time, followed by practice of the principle in other situations and daily life activities. Some school-based MBIs used with pre-school, primary or secondary students include, but are not limited to, Mindfulness Based Stress Reduction (MBSR), Mindfulness Based Cognitive Therapy for Children (MBCT-C), Meditation on the Soles of the Feet (SoF), and Learning to BREATHE (LTB). MBSR was developed in 1979 by Jon Kabat-Zinn as a treatment for adults in clinical settings with the goal of reducing stress. MBSR programs are group-administered and composed of weekly 2.5-hour sessions with a daily 45-minute homework assignment (Grossman, Niemann, Schmidt, & Walach, 2004). Participants receive instruction in various aspects of mindfulness, including mindful awareness during meditation, yoga, and daily life activities as a means to alleviate stress. Participants are taught to engage in continuous awareness of physical, mental, and emotional states without judgment or evaluation in a guided group practice with accompanying independent practice. Though typically designed for adults with medical diagnoses, researchers have also adapted and implemented MBSR with children in clinical settings (Bootzin & Stevens, 2005) and community settings (Saltzman & Goldin, 2008). Mindfulness based cognitive therapy (MBCT) was originally developed by Segal, Williams, and Teasdale (2002) as a treatment to reduce relapse of recurrent major depressive episodes in adults (Semple, Lee, Rosa, & Miller, 2010). MBCT was later adapted by Semple, Reid, and Miller (2005) and Semple et al. (2010) for use with children (MBCT-C) to address anxiety. MBCT-C was modified for children by changing the duration of the intervention from 8 weeks to 12 weeks, reducing the amount of time of each seated period, and reducing the group size (Semple et al., 2010). During weekly 45-minute sessions, children were guided through a series of activities that included identifying their present emotional state, identifying worries, engaging in a mindful breathing exercise, learning a mindful technique related to one of the senses, debriefing of previous learning, and reflecting on the previously identified emotional state (Semple et al., 2005). Both MBCT (for adults) and MBCT-C combine mindfulness-based practices such as attention on the breath and awareness of the present moment with cognitive interventions to achieve “affective self-regulation” (p. 222). Another distinction between the adult and child programs is that MBCT-C encourages parental involvement in the form of information sessions, brief mindfulness training exercises, and home practice of meditation with children. Since its development, several studies of MBCT-C in school settings have been conducted (i.e., Semple et al., 2005), as well as in other settings (e.g., Lee, Semple, Rosa, & Miller, 2008; Bogels, Hoogstad, van Dun, DeShutter, & Restifo, 2008). SoF is a MBI designed to cultivate self-control of aggressive behaviors through self-regulation of emotion. Participants who have a history of aggressive behaviors are trained to notice emotional states and redirect attention to a neutral focus; in this case, the sensation of the soles of the feet (Singh et al., 2007). A trained therapist conducts the SoF training with each participant individually. The routine consists of a 10-step process in which participants are taught to notice when they feel angry, assume a sitting or standing meditative position, breathe, and allow the emotion to be present with an attitude of acceptance. Participants then shift attention to the physical sensations on the soles of the feet until the emotion is at a manageable level. Participants complete guided practice sessions and are encouraged to use the technique independently whenever they feel it is needed (Singh et al., 2007). LTB is a MBI that was designed specifically for a classroom setting. The curriculum “tailors mindfulness-based approaches to the developmental needs of adolescents” by helping students be mindful of their present situation through lessons on body, thought, and emotion awareness, reducing self-judgment, and increasing mindfulness in everyday life (Broderick & Metz, 2009). LTB is a brief, six-lesson curriculum conducted in a group setting that has been integrated into school curriculum in health classes (Broderick & Metz, 2009) or choir classes (Metz et al., 2013). Each lesson includes a short overview of the mindfulness principle being studied, group discussion, time to practice mindfulness by applying the principle, and home meditation practice assignments with supporting materials (Broderick & Metz, 2009; Metz et al., 2013). In the descriptions of these approaches, one can discern that there are more similarities between MBI approaches than differences. For example, all of the approaches incorporate a training period of guided meditation techniques focusing on mindful attention and awareness of breath, body, or mind and followed by independent practice. The interventions differ in their intended purposes, such as treatment of anxiety and stress, managing aggressive behaviors, emotional regulation, and overall health promotion Mindfulness interventions have been implemented in “core” content classes (reading and Language Arts, math, science, or social studies), in “elective periods” such as physical education classes (Napoli et al., 2008), choir classes (Metz et al., 2013), enrichment or intervention periods, or out-of-school contexts (e.g., after-school tutoring or summer school). The type of setting is often determined by the purposes or outcomes measured, as well as the practical and systemic constraints and requirements in the school. For example, Broderick & Metz (2009) examined outcomes related to mental health by conducting the intervention in students' health classes. In the growing area of MBI in schools, a review of the literature by Zenner and colleagues (2014) found that a majority of studies (k = 15 out of 24 total) used researchers or individuals hired by researchers to provide the intervention. For example, Napoli, Krech, and Holley (2005) used two implementers who had received professional training in mindfulness and had 10-20 years of experience in teaching mindfulness to deliver the intervention during children's regular physical education classes. Zenner and colleagues (2014) also found evidence of studies (k = 7) that used teachers to implement MBI, and two studies that used a combination of teacher and non-school trainers. For example, Metz et al. (2013) described a high school teacher who attended an eight-week MBSR program and two day in-service to prepare for implementing the LTB intervention. Metz and colleagues reported fidelity data using teacher-completed feedback forms and session logs, though the researchers reported that few of these forms were actually completed. The results of in-person fidelity observations indicated “lesson adherence, teacher enthusiasm and preparedness, and high student engagement” (Metz et al., 2013, p. 260). MBIs may also involve parents or teachers, either as a supplement to student training or as the primary target of the intervention. For example, Semple and colleagues (2010) conducted parent-training sessions in mindfulness, which provided an overview of the program their children would be receiving at school, as well as some opportunities for the parents to engage in mindfulness practice. Parents were also encouraged to participate in their child's home practice sessions; however, no data were collected or analyzed as a result of these parent-training sessions. Other MBIs have been conducted with teachers or parents as the primary or only recipient of the intervention. In these interventions, the intent of providing teacher or parent training is to affect parent or teacher outcomes, with some hypothesizing indirect outcomes on students through changes in parent or teacher behavior from mindfulness practice. For example, Jennings and colleagues (2011) examined the effects of Cultivating Awareness and Resilience in Education (CARE), a mindfulness-based professional development program designed for teachers to reduce stress, improve teachers' performance, and prevent “burnout.” CARE provides teachers with training in a series of mindfulness activities, with periods of silent reflection and opportunities to extend the practices into daily classroom routines. Teachers completed self-report measures in overall well-being, time urgency perceptions, physical symptoms, school perceptions, and mindfulness. Teachers reported high satisfaction with the CARE training, although significant effects were found only for time urgency and measures of mindfulness. There were no measures of student performance. Because MBIs that target teachers or parents as the primary recipient of the MBI focus on different outcomes (teacher and parent outcomes versus student outcomes, with perhaps some secondary student outcomes) and are guided by a different theories of change hypothesized mechanisms in terms of student outcomes, we believe it is most appropriate to separate interventions targeting students from studies targeting teachers or parents as the primary recipient of the intervention. Therefore, we will focus this review on interventions in which students are the primary recipients of the MBI. Mindfulness-based strategies have been increasingly implemented in school settings to enhance and supplement instruction as a means of improving cognitive and academic performance and skills related to the learning process (e.g., attention, self-regulation, management of stress), enhancing social skills, and delivering a more holistic approach to develop the “whole person.” The burgeoning interest in mindfulness-based interventions in school settings has been fueled by shifts in the educational environment, such as increased emphasis on high stakes testing and students with high levels of test anxiety (Gregor, 2005; Von Der Embse, Barterian, & Segool, 2013) and prevalence of behavioral and mental health problems in students. Further, the evidence supporting relationships of emotion regulation and stress with academic, cognitive, and behavioral functioning in school (Zins et al., 2004) has also fueled enthusiasm of MBIs. Moreover, there is emerging evidence that childhood adversity has been found to trigger neurobiological events that may alter brain development (Anderson & Teicher, 2004; Shonkoff, Boyce, & McEwen, 2009; Teicher, Andersen, Polcari, Anderson, & Navalta, 2002), potentially impairing stress response systems that underlie cognitive and emotional regulatory capacities (Anderson & Teicher, 2009). Children who experience chronic stress are potentially at-risk for difficulties with cognitive and emotion regulation, which can lead to maladaptive developmental trajectories (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001). Emotional regulatory capabilities have been shown to mediate the relationship between exposure to stress and youth outcomes in multiple studies (Sandler, Braver, & Gensheimer, 2000; Wolchik, Coxe, Tein, Sandler, & Ayers, 2006). Although the evidence for and theories of the mechanisms of mindfulness training is not well developed, research and theories suggest that mindfulness training affects well-being and development through changing psychological, cognitive, and biological processes (see Grabovac, Lau, & Willett, 2011, Melbourne Academic Mindfulness Interest Group, 2006, and Zelazo & Lyons, 2012 for a review of mechanisms of mindfulness training). For students, mindfulness interventions are hypothesized to improve students' capacities for self-regulation of emotions and enhance cognitive functioning, including executive function, working memory and attentional focus, and to affect physiological response which could improve behavior and academic achievement in school (Meiklejohn, 2012; See Figure 1). As such, educators and schools have begun to adopt mindfulness-based interventions as part of educational programming. MBIs hold promise for influencing several important outcomes related to school success and achievement, namely increased learning and grades through increased grit, resiliency, self-regulation, and reading comprehension. Mindfulness training has been shown to positively affect students' emotional resiliency (Semple et al., 2010) and self-regulation (Mendelson et al., 2010). In a study of undergraduate students, Mrazek and colleagues (2013) suggested that mindfulness training had a positive effect on students' scores on the GRE reading comprehension measure by increasing working memory and decreasing thoughts unrelated to the task. While this study was done with older participants, this could potentially generalize to students in primary or secondary schools. We are interested in examining whether and how school-based intervention studies are measuring academic outcomes and the intervention effects on academic outcomes. We hypothesize that during mindfulness practice, the adoption of a non-judgmental attitude will lead to increased emotional awareness and regulation and decreased anxiety. One possible pathway to decrease school-related anxiety is through the reduction of “cognitive interference,” which was defined by Wine (1971, 1982) as an internalizing behavior where an individual experiences difficulties with attentional focus, concerns about competence, and preoccupation with self-oriented negative thoughts. Swanson and Howell (1996) suggested that cognitive interference is the most powerful predictor of academic anxiety. Since one of the fundamental elements of mindfulness is the awareness and acceptance of one's own thoughts and feelings, it is possible that students' cognitive interference can be reduced through mindfulness training (Beauchemin, Hutchins, & Patterson, 2008). Mindfulness training has shown promise in increasing working memory capacity in adults (Jha et al., 2010). Similarly, in a study of mindfulness with adults and adolescents with ADHD, participants reported a decrease in attention-related symptoms (Zylowska et al., 2008). There is also preliminary evidence that MBIs may improve self-regulation outcomes (Meiklejohn et al., 2012). MBIs may decrease externalizing behaviors in children by increasing the child's awareness of present circumstances (Bogels et al., 2008). Additionally, we hypothesize that increased mindful attention to daily activities, including academic activities, can lead to increased self-monitoring and self-regulation of attention, which can lead to an increase in task completion. Further, reviews of mindfulness interventions for individuals with developmental disabilities (Hwang & Kearney, 2013) and intellectual disabilities (Chapman et al., 2013) reported a reduction in aggressive behaviors. MBIs show promise for affecting individuals' physiological functioning. Preliminary investigations found that MBI have been associated with decreased levels of cortisol, a hormone associated with stress, in school-aged children (Sibinga, Perry-Parrish, Chung, Johnson, Smith, & Ellen, 2013). Additionally, mindfulness practices and other practices that can cause relaxation could have positive impacts on participants' heart rates, speed of breathing, and muscle tension (Hooker & Fodor, 2008). While several reviews have been conducted on mindfulness-based interventions with adults for a myriad of problems and outcomes, less attention has been given to reviewing the literature on outcomes of mindfulness-based approaches for children and youth, particularly outcomes relevant to education. To date, we have located nine reviews of mindfulness-based interventions that include studies with children or youth. One of the reviews focused on health-related effects of sitting-meditative practices (Black, Milam, & Sussman, 2009) and two reviews were not specifically focused on children or education, but did include some studies of mindfulness-based approaches with children and/or youth with intellectual disabilities (Chapman, 2013) and developmental disabilities (Hwang & Kearney, 2013). The remaining five reviews examining effects of mindfulness-based interventions with children and youth are more relevant to the proposed review and will be discussed in more depth. Meiklejohn and colleagues (2012), Greenberg and Harris (2012), and Thompson and Gauntlett-Gilbert (2006) published traditional narrative reviews describing mindfulness interventions with children and youth. Meiklejohn and colleagues focused on literature related to integrating mindfulness training in primary and secondary education whereas Greenberg