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Mindfulness-Based Interventions for Adolescents: Time to Consider Telehealth

2019; Mary Ann Liebert, Inc.; Volume: 26; Issue: 3 Linguagem: Inglês

10.1089/acm.2019.0302

1557-7708

Nicholas Chadi, Elli Weisbaum, Dzung X. Vo, Sara Ahola Kohut,

Educational Methods and Impacts

The Journal of Alternative and Complementary MedicineVol. 26, No. 3 CommentaryFree AccessMindfulness-Based Interventions for Adolescents: Time to Consider TelehealthNicholas Chadi, Elli Weisbaum, Dzung X. Vo, and Sara Ahola KohutNicholas ChadiAddress correspondence to: Nicholas Chadi, MD, MPH, Division of Adolescent Medicine, Department of Pediatrics, Sainte-Justine University Hospital Centre, Sainte-Justine Hospital Pediatric Research Centre, University of Montreal, 3175 Ch de la Cote Sainte-Catherine, Montreal H3T 1C5, Quebec, Canada E-mail Address: nicholas.chadi@umontral.caDivision of Adolescent Medicine, Department of Pediatrics, Sainte-Justine University Hospital Centre, Sainte-Justine Hospital Pediatric Research Centre, University of Montreal, Montreal, Canada.Search for more papers by this author, Elli WeisbaumInstitute of Medical Sciences, University of Toronto, Toronto, Canada.Search for more papers by this author, Dzung X. VoDivision of Adolescent Health and Medicine, Department of Pediatrics, University of British Columbia, British Columbia Children's Hospital, Vancouver, Canada.Search for more papers by this author, and Sara Ahola KohutDivision of Gastro-Enterology, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada.Department of Psychiatry, Institute of Medical Sciences, University of Toronto, Toronto, Canada.Search for more papers by this authorPublished Online:11 Mar 2020https://doi.org/10.1089/acm.2019.0302AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail IntroductionInterest in Mindfulness-based interventions (MBIs) has been growing exponentially within the sectors of health care, business, and education. Taking roots from ancient Eastern spiritual traditions, MBIs are now well established as an approach to enhance well-being and quality of life among adolescents and adults.1 Yet, the rapid increase in popularity of MBIs has led to challenges to meet the growing need for adequately trained providers to deliver these interventions, especially outside large urban centers. Children and adolescents are particularly receptive to MBIs.2 As rates of anxiety and depression steadily increase among children and adolescents, MBIs offer a promising therapeutic avenue to prevent and treat several of the most common mental health concerns in this age group.3 MBIs can also improve adolescents' ability to cope with chronic illness and chronic pain.4 The delivery of structured MBIs facilitated in real time through telehealth can broaden access for youth who live outside of urban centers and who otherwise may not have access to MBIs.Online delivery also comes with several unique challenges and a pressing question: is it possible to reach some or all of the benefits associated with in-person MBIs (often considered the "gold standard") using available technology? In this commentary, this question is addressed, through a discussion of the authors' own experience as pediatric mindfulness providers delivering mindfulness interventions through telehealth using evidence-informed programs tailored specifically for groups of adolescents, such as the Mindful Awareness and Resilience Skills for Adolescents (MARS-A) program. MARS-A is an adaptation of 8-week Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy interventions for adults and has been described elsewhere.5Delivering MBIs OnlineAlthough research about the applications and health benefits of MBIs in youth is rapidly emerging,4,6 evidence on the feasibility and effectiveness of delivering facilitated MBIs online, in real-time, remains limited (note that this differs from MBIs that adolescents can watch or download online, which do not have the benefits of live facilitation and group interactions). In a study conducted in a small sample of adolescents with a wide range of chronic medical illnesses, similar levels of feasibility, acceptability, and reports of benefit between youth who had received an 8-week MBI facilitated in-person, versus online through telehealth were found. In this study, participants were randomly allocated to the in-person or online group and completion rates were seven of nine participants, or 78%, in both groups.7 In a separate study comparing a moderated in-person MBI versus an online MBI for adolescents with inflammatory bowel disease, retention was far superior in the online (67% enrolled) than in the in-person version (41% enrolled) with similar benefits reported in both groups.8,9 In both studies, participants received the intervention from their own home and could see the facilitator as well as all the other participants on their screen. Self-guided and facilitator-guided individual or group-based online MBIs have been the object of a small number of adult studies, yielding promising results, with larger effect sizes noted for guided interventions.10,11This experience facilitating online MBIs has revealed that relatively minimal changes are needed to adapt in-person programs so they can be delivered online. These adaptations tend to be focused on the logistics of setting up the learning space, which is something a facilitator also needs to consider and manage for in-person groups, with slight differences in what needs to be explicitly discussed in terms of privacy and confidentiality (see Table 1 for complete list). In this experience, slightly smaller groups (optimal range: 8–10 participants, compared with 10–15 participants for in-person groups) are preferable for online facilitation, contingent on what is known about group dynamics.Table 1. Suggestions for Online Adaptations of In-Person Mindfulness-Based Interventions In-personOnline adaptations and rationaleOptimal group size range10–158–10: smaller groups allow more frequent interactions between participants and facilitatorsLocationQuiet space in a hospital, school, or community space offering minimal distractions and interruptionsQuiet space that is either in the home or outside and is conducive to quiet meditation. Comes with the additional challenges and responsibility of insuring that the space is private and quiet. Potential benefit of increasing generalizability to everyday lifeSession duration and format90 min, includes a 5-min snack/health break90 min, may include an optional 5-min break during which youth can leave camera viewInstructorsTwo instructors present in personTwo instructors present through webcam, may be in same or separate location(s):Presence of two instructors in the same space allows more flexibility and addressing any technical issues that may emerge without disturbing the flow of the sessionPresence of two instructions in different rooms allows facilitators to be closer to their webcam and be more visible to participants who may be using a smaller screenEquipment or supplies neededSnacksDesktop computer, laptop, tablet, or smartphone with a webcam and a reliable wired (preferred when available), wireless, or roaming function for Internet access: a larger screen is preferred to allow better visibility of other participantsExpenses (beyond facilitation)Parking and transportation costsUsually none: most youth would have access to the electronic equipment/technology requiredPrivacy and distractionsAsk that participants refrain from using mobile devices and taking pictures or recordings during sessionsNeed to ensure that youth stay in view of camera and that there are no other people in the room (including parents or siblings), or if other people must be in the room, the use of headphones (ideally noise cancelling) should be encouragedEncourage turning off any other mobile devices, chat, or messaging programs that may take away from the experienceOther logistical aspects specific to online facilitationN/AMake sure participants cannot join without the host/facilitatorMake sure participants cannot message each other on the program (chat) unless monitored or instructed by a facilitatorAsk participants to use "gallery view" (or equivalent) settings to allow all participants to view facilitators and other group members simultaneouslyAsk participant not to include last names in loginHave participants mute their microphone when not speaking, to reduce background noiseN/A, not applicable.Facilitator ExperienceOur backgrounds in medicine, psychology, education, public health, and mindfulness have allowed us to reflect in different ways on the experience of delivering MBIs online. Although there was some initial skepticism (including from one of the coauthors) about the possibility of embodying mindfulness through an online platform, the authors have been surprised by how positive the experience has been. In fact, it was noticed very quickly that it was not only possible, but also quite natural, to develop the sense of support and community that is integral to the experience of an in-person MBI. An important reflection has been that participants in the online groups reported a different, yet valuable, experience of social connectedness with their peers. The observation as facilitators, which was mirrored by the qualitative analyses of participants' accounts from in-person and online groups,12 revealed that online delivery of MBIs shifts the focus of social connectedness toward feeling a sense of community and support from their peers, rather than an emphasis on trying to make new friends. In fact, participants in the online group mentioned that they had felt connected with the group as a whole, whereas participants in the in-person group reported that they had enjoyed the social aspect of the program and meeting other adolescents who were facing similar challenges (a more detailed discussion can be found elsewhere).12 It was also noted that since participants attend sessions in the comfort of their own home, and make a conscious effort to identify a quiet, private, and restful space to practice mindfulness, they directly use and naturally generalize the practices learned to their everyday lives outside of the group sessions.Online facilitation also comes with a unique set of challenges. While digital interfaces allow the possibility of visualizing all participants at once, nonverbal communication and picking up social cues can feel more limited (this may be felt by participants and facilitators). Poor audio quality can also be an issue if more than one person speaks at once. It was found that these challenges can be managed effectively by eliciting participation through different means, such as using "thumbs up" signs, which all participants can do at once without causing audio issues. This and other active gestures allow to maintain ongoing engagement and contact with all participants. Potential technology issues are another challenge that can distract the facilitator (especially if facilitating alone) and make it more difficult to entertain an atmosphere of calm, introspection, and open sharing conducive to the practice and learning of mindfulness skills. It was found that even more so than in the context of in-person facilitation, having two facilitators to help with potential distractions and technological issues offers facilitators peace of mind and an opportunity to ensure a higher level of depth in practice and inquiry. Specifically, the capacity to maintain eye contact through a digital interface can be enhanced by the presence of two facilitators.In speaking with adolescents who have experienced online MBIs moderated in real time, it was found that participants quickly became comfortable with, or were already familiar to, the online platform the authors used. Participants also reported that participating in MBIs from the comfort of their home is convenient, pleasant, and more personable, as being surrounded by familiar objects can be helpful in encouraging self-expression. Considering that the majority of adolescents now create and maintain friendships through social media and that more than half of 14–17-year-olds in North America report playing online video games, often in social forums, it may be that the level of comfort with online MBIs is a reflection of how current day adolescents interact with their peers.13Future DirectionsThe online delivery of MBIs facilitated in real time is bound to become easier in the years to come. The authors recognize that certain obstacles still exist, and that experiencing sound or connectivity issues during sessions can have an impact on the experience. However, newer technologies such as virtual reality may soon help make online MBIs even more engaging and accessible than they are now.There is a clear need for more research, including larger scale studies to determine the role that online MBIs can play as a first- or second-line treatment modality for youth with different mental and physical health conditions.14 Another question that remains unanswered is whether online MBIs moderated in real time can be optimized with the use of other adjunct modalities such as mobile mindfulness apps. It is also unknown whether new or modified practices such as mindful social media browsing or mindful online communication could take a more central role in future online MBI programs.Although mindfulness training is experienced in a different way through an electronic platform, fundamental principles key to the delivery of in-person MBIs can be honored. Mindfulness remains a highly experiential approach, and for participants, just like providers, quality and benefits of MBIs, whether delivered in-person or online, will be optimized with the cultivation of a committed personal mindfulness practice.Increasing the offer of online MBIs requires training and developing new skill sets and sensitivities for facilitators who are only familiar with in-person settings. However, this training can easily be delivered through telehealth, offering a first-person experience for facilitators in training that can be translated and later shared with participants. Our experience suggests that online delivery of MBIs has a high potential to expand the accessibility of MBIs, moving the field of mindfulness forward: the time has come to consider it as a promising alternative for delivery of MBIs.Author Disclosure StatementNo competing financial interests exist.Funding InformationThere was no funding associated with this publication.References1. Long J, Briggs M, Astin F. Overview of systematic reviews of mindfulness meditation-based interventions for people with long-term conditions. Adv Mind Body Med 31:26–36. Medline, Google Scholar2. Vo DX, Doyle J, Christie D. Mindfulness and adolescence: A clinical review of recent mindfulness-based studies in clinical and nonclinical adolescent populations. Adolesc Med State Art Rev 2014;25:455–472. Medline, Google Scholar3. Lin J, Chadi N, Shrier L. Mindfulness-based interventions for adolescent health. Curr Opin Pediatr 2019;31:469–475. Crossref, Medline, Google Scholar4. Ahola Kohut S, Stinson J, Davies-Chalmers C, et al. Mindfulness-based interventions in clinical samples of adolescents with chronic illness: A systematic review. J Altern Complement Med 2017;23:581–589. Link, Google Scholar5. Chadi N, Kaufman M, Weisbaum E, et al. In-person versus ehealth mindfulness-based intervention for adolescents with chronic illness: Protocol for a randomized controlled trial. JMIR Res Protoc 2017;6:e241. Crossref, Medline, Google Scholar6. Tan LB. A critical review of adolescent mindfulness-based programmes. Clin Child Psychol Psychiatry 2015;21:193–207. Crossref, Medline, Google Scholar7. Chadi N, Kaufman M, Weisbaum E, et al. Comparison of an in-person vs. ehealth mindfulness meditation-based intervention for adolescents with chronic medical conditions: A mixed methods study. J Adolesc Heal 2018;62:S12. Crossref, Google Scholar8. Ahola Kohut S, Stinson J, Jelen A, Ruskin D. Feasibility and acceptability of a mindfulness-based group intervention for adolescents with inflammatory bowel disease. J Clin Psychol Med Settings 2019 [Epub ahead of print]; DOI: 10.1007/s10880-019-09622-6. Crossref, Medline, Google Scholar9. Ahola Kohut S. The nuts and bolts of online mindfulness and ACT based treatment for youth with inflammatory bowel disease. Association for Contextual Behavioral Science World Conference, Montreal, QC, 2018. Google Scholar10. Spijkerman MPJ, Pots WTM, Bohlmeijer ET. Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clin Psychol Rev 2016;45:102–114. Crossref, Medline, Google Scholar11. Ma Y, She Z, Siu AF-Y, et al. Effectiveness of online mindfulness-based interventions on psychological distress and the mediating role of emotion regulation. Front Psychol 2018;9:2090. Crossref, Medline, Google Scholar12. Chadi N, Weisbaum E, Malboeuf-Hurtubise C, et al. Can the Mindful Awareness and Resilience Skills for Adolescents (MARS-A) program be provided online? Voices from the youth. Child (Basel, Switzerland) 2018;5:115. Google Scholar13. Nesi J, Choukas-Bradley S, Prinstein MJ. Transformation of adolescent peer relations in the social media context: Part 1—A theoretical framework and application to dyadic peer relationships. Clin Child Fam Psychol Rev 2018;21:267–294. Crossref, Medline, Google Scholar14. Kelson J, Rollin A, Ridout B, Campbell A. Internet-delivered acceptance and commitment therapy for anxiety treatment: Systematic review. J Med Internet Res 2019;21:e12530. 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Vo, and Sara Ahola Kohut.Mindfulness-Based Interventions for Adolescents: Time to Consider Telehealth.The Journal of Alternative and Complementary Medicine.Mar 2020.172-175.http://doi.org/10.1089/acm.2019.0302Published in Volume: 26 Issue 3: March 11, 2020Online Ahead of Print:November 25, 2019PDF download