کنترل آزمایش پایلوت تصادفی مدیتیشن با تمرکز حواس مبتنی بر کلاس درس در مقایسه با شرایط کنترل فعال در کودکان کلاس ششم

The current study is a pilot trial to examine the effects of a nonelective, classroom-based, teacher-implemented, mindfulness meditation intervention on standard clinical measures of mental health and affect in middle school children. A total of 101 healthy sixth-grade students (55 boys, 46 girls) were randomized to either an Asian history course with daily mindfulness meditation practice (intervention group) or an African history course with a matched experiential activity (active control group). Self-reported measures included the Youth Self Report (YSR), a modified Spielberger State-Trait Anxiety Inventory, and the Cognitive and Affective Mindfulness Measure –Revised. Both groups decreased significantly on clinical syndrome subscales and affect but did not differ in the extent of their improvements. Meditators were significantly less likely to develop suicidal ideation or thoughts of self-harm than controls. These results suggest that mindfulness training may yield both unique and non-specific benefits that are shared by other novel activities.

Children in the United States face myriad psychological challenges, including depression, anxiety, and attention deficits (Bloom, Dey, & Freeman, 2006). It is estimated that the prevalence among American youth of a mental disorder resulting in severe impairment is as high as 22.2% (Merikangas et al., 2010). Not only do many disorders emerge during childhood and adolescence (Costello et al., 1999 and Paus et al., 2008), but also early symptoms of psychological distress can also be predictive of later episodes of minor and major illnesses (Keenan et al., 2008), and subclinical symptoms of depression during adolescence can predict later episodes in adulthood (Pine, Cohen, Cohen, & Brook, 1999). For some, adolescence can be a dangerous period, as unmonitored mood problems and stress can lead to self-harming behaviors and suicide (Beautrais, 2003 and Laye-Gindhu and Schonert-Reichl, 2005). Excessive stress during developmental periods can also lead to serious cognitive consequences in adult life (Davidson and McEwen, 2012 and Hedges and Woon, 2011). Accordingly, pre-adolescence represents a significant window of opportunity during which an intervention can help prevent the development of later life challenges, including a major psychiatric disorder. It has been argued that schools have become the frontline of the mental health system for children and adolescents (Burns et al., 1995). Many American schools offer a variety of mental health services ranging from acute care to more generalized prevention programs, implemented through full-service school-based health centers, school psychologists, or guidance counselors. However, the availability of such services varies depending upon local resources (Weist, 1997), and there is a consensus that the mental health needs of many children in the United States remain largely unmet, especially among minority groups and the uninsured (Broman, 2012, Costello et al., 2005, DeRigne, 2010, Flisher et al., 1997, Kataoka et al., 2002, Kessler et al., 2001, Williams and Chapman, 2011 and Wu et al., 2010). Undoubtedly, schools with limited resources would benefit from low cost interventions that are proven to improve student mental health. Programs that are integrated directly into regular classroom curricula may offer cost-effective alternatives to after-school initiatives, which require additional resources and may not be available to students with competing demands for time, such as jobs or afterschool activities. Programs that are integrated into curricula also present a potential advantage over those offered through health services, which are also not always available to students in impoverished communities. As a result, a variety of classroom-based, teacher-implemented programs have been developed to help prevent the onset of psychological, emotional, behavioral, and social disorders among children (Leaf et al., 1996 and Rones and Hoagwood, 2000). Some school health programs promote health by focusing on general knowledge about care for oneself and others, whereas others teach specific skills to help students lead healthy lifestyles. At least one study (Schlitt et al., 2000) provides evidence that up to around 50% of school-based mental health centers in the United States offer classroom-based behavior modification programs, which suggests popular support for curriculum-integrated intervention strategies. Furthermore, programs that are integrated into existing curricula offer an indirect advantage in the sense that they may reduce the stigma surrounding the procurement of mental health services. Stigma is a common reason that youth do not seek and receive mental health treatment — by incorporating mindfulness interventions directly into the classroom, students and teachers are given an opportunity to raise and discuss mental health concerns. Recently, mindfulness meditation has experienced growing popularity as a form of school-based intervention and has been incorporated into educational curricula throughout the United States, both in K-12 schools (Greenberg and Harris, 2012, Kaiser-Greenland, 2010, Meiklejohn et al., 2012 and Mind and Life Education Research Network (MLERN), et al., 2012) and in higher education (Shapiro, Brown, & Astin, 2011). Mindfulness meditation involves two core activities, the cultivation of attention regulation and emotional equanimity, and has been defined as the process of, “bringing one's complete attention to the present experience on a moment-to-moment basis” (Marlatt & Kristeller, 1999, p. 68). School-based meditation programs implement simple techniques designed to enhance self-awareness and self-regulation of attention, emotions, and behavior in children and adolescents (Greenberg and Harris, 2012 and Mind and Life Education Research Network (MLERN), et al., 2012). Primary practices in school-based meditation programs (particularly mindfulness) include directing attention to a specific “attentional anchor” – a focus of attention, such as the sensations of breathing or environmental sounds, that one returns to whenever the mind wanders – in order to cultivate greater clarity and acceptance of moment-to-moment experience. Such programs often adapt practices from mindfulness programs developed for adults, such as Mindfulness-Based Stress Reduction (MBSR), an 8-week stress reduction program that incorporates stress education, group therapy, and meditations drawn from Buddhist traditions (Carboni et al., 2013 and Kabat-Zinn, 1990). Other school-based programs adopt practices such as yoga (Khalsa, Hickey-Schultz, Cohen, Steiner, & Cope, 2012) and tai chi (Wall, 2005). Interventions can involve daily practice (Beauchemin et al., 2008 and Schonert-Reichl and Lawlor, 2010) or be composed of weekly sessions with additional “homework” meditation sessions. Informal meditation practices are also used, which involve incorporating mindful awareness into common activities such as walking, eating, and talking (Meiklejohn et al., 2012). Empirical studies in adults suggest that meditation practices may have positive impacts on a wide range of conditions that start in adolescence, including anxiety, depression (Grossman et al., 2004 and Hofmann et al., 2010), and suicidal behavior (Williams, Duggan, Crane, & Fennell, 2006). Additionally, studies in adults have also found improvements in sustained attention (Jha et al., 2007, Kaul et al., 2010, MacLean et al., 2010 and Valentine and Sweet, 1999), executive function and self-regulation (Chambers et al., 2008, Heeren et al., 2009, Ortner et al., 2007, Tang et al., 2012, Tang et al., 2007, Zeidan et al., 2010 and Zylowska et al., 2008), which are important markers of risk in children and adolescents. In children and adolescents, poor executive functioning, including self-regulation problems and attention problems, is predictive of a wide range of behavioral and emotional problems, especially depression, anxiety, and suicidality (Moffitt et al., 2011 and Tang et al., 2012). Conversely, better executive functioning is associated with greater emotional, behavioral, and health outcomes (Blair and Peters, 2003, Blair and Razza, 2007, Carlson et al., 2004, Carlson and Moses, 2001, Lefevre et al., 2013 and Moffitt et al., 2011). Because of the widespread popularity, application, and scientific study of meditation in adults, there has been much interest and enthusiasm in applying these practices earlier in life, during childhood and adolescence. A few well-designed randomized control trials (RCTs) suggest that mindfulness-based programs may benefit clinical samples of children and adolescents with anxiety, depression (Beauchemin et al., 2008 and Biegel et al., 2009), and attention problems (Semple et al., 2010 and Zylowska et al., 2008). However, there are serious limitations to the body of mindfulness research on children and adolescent populations (Burke, 2010). In addition to the many pilot trials that suffer from small sample sizes (Bogels et al., 2008 and Singh et al., 2007), previous studies have often involved clinical samples that preclude generalization to normal adolescent populations (Biegel et al., 2009, Singh et al., 2007, Singh et al., 2010 and Zylowska et al., 2008). Such samples include only those children whose symptoms have been severe enough to warrant treatment. Broader interventions for larger, nonclinical groups may help to prevent these behaviors before they reach a clinical severity. Another challenge is that studies involving nonclinical adolescent populations conducted in clinics by licensed therapists and clinicians (Saltzman & Goldin, 2008) run the risk of creating a stigma associated with the treatment's location and may also introduce financial barriers that contribute to substantial selection biases. In an attempt to resolve such problems, several studies to date have incorporated meditation interventions directly into schools. Paralleling the findings in clinical samples above, RCTs of school-based mindfulness programs also suggest that these programs can improve depression and anxiety (i.e. “internalizing symptoms”), behavior and conduct problems (“externalizing symptoms”), attention and executive function, and affective disturbance in nonclinical samples of children and adolescents (Flook et al., 2010, Mendelson et al., 2010, Napoli et al., 2005 and Raes et al., 2013). However, research of school-based programs also suffers from methodological limitations. First, these programs are often presented as electives (Foret et al., 2012) or as pull-out sessions with a specialist (e.g., a counselor or psychologist). Like other forms of pull-out programs (e.g., social skills programs), the outcomes from such self-selected or elective programs may lack the degree of generalizability available to programs that are undertaken by an entire class or school. Mindfulness-based programs have most often been taught by independent instructors who are hired externally and not delivered by the children's regular teachers or the school counselor, so there is a lack of evidence suggesting the effectiveness of interventions delivered by class-room teachers during school hours (Fernando and Keller, 2012, Foret et al., 2012 and Napoli et al., 2005). It is possible that interventions not delivered by the regular classroom teacher carry with them an additional potential barrier to delivery, as students may not be as receptive to an outsider as to a teacher they are familiar with and may be unmotivated to participate in extracurricular mindfulness training. A number of reviews of the effects of mindfulness, meditation (Black et al., 2009, Burke, 2010 and Waters et al., 2014), and yoga (Birdee et al., 2009) among children offer a high level of enthusiasm tempered by similar conclusions about the poor quality of research. The most recent reports on the state of contemplative education research (Greenberg and Harris, 2012, Mind and Life Education Research Network (MLERN), et al., 2012 and Waters et al., 2014) emphasize a paucity of methodologically rigorous research. For example, out of the 14 studies of school-based meditation interventions covered in a recent review (Meiklejohn et al., 2012), only 2 were RCTs based in nonclinical school classrooms (Flook et al., 2010 and Napoli et al., 2005). The current pilot study was designed so that the interventions could be delivered by classroom teachers and offered during regular school lessons. In addition, this study's design is one of the few to date where the course containing the intervention was required for all students (avoiding self-selection bias). Additionally, the intervention was delivered in a nonclinical setting and taught by the regular classroom teacher during normal lessons and was not introduced for therapeutic reasons (thus, fewer demand characteristics were evident). When such interventions are embedded into the regular curriculum they become a part of the school's ethos, and any effects gained from the intervention become more generalizable to the entire school. Recent reports and reviews have also recommended the use of active comparison groups (Flook et al., 2010 and Meiklejohn et al., 2012), which we included in the current study's design. In response to a recent meta-analysis of school-based self-regulation programs (including mindfulness-based programs; Diamond & Lee, 2011), one critic (Mercer, 2011) pointed out that when control groups do not experience any new and exciting activity, improvements on some scales that occur for the treatment group cannot be attributed to mechanisms beyond nonspecific effects of novelty. In the Flook et al. (2010) study, for example, controls did quiet reading in a regular classroom, whereas meditators moved tables and chairs to prepare for the activity and were allowed to sit on special cushions. Not controlling for these additional environmental variables makes it difficult to ascertain the source of an intervention's effectiveness. The present study attempts to control for such effects by giving the control group an enjoyable, nondidactic, experiential, and novel activity matched to course content (i.e., building a life-size Egyptian sarcophagus). The current study examines the effects of 6 weeks of classroom-based, teacher-taught mindfulness meditation instruction on Internalizing, Externalizing, and Attention Problems, and affect in sixth-grade school children, as compared to a matched, active control group. Other programs often integrate mindfulness techniques as one component of a multicomponent curriculum that includes things such as social and emotional learning, nutritional information, and health and safety information. Thus, although many of these programs have shown positive effects, it is difficult to disentangle which components contributed to observed benefits and whether mindfulness training had any effects on its own. In order to determine the effects of mindfulness practices alone, students in this study received mindfulness meditation training as the sole component, with no other additions. We predicted that those in the meditating condition would show improvements on the Internalizing Problems scale relative to controls, due to greater reductions in anxiety- and depression-related symptoms, and would improve relative to controls on the Externalizing Problems scale, due to reduced problematic behavior and acting out. In addition, as mindfulness training has been shown to improve attention and executive function, we predicted greater decreases in the Attention Problems subscale of the YSR in meditators compared to control students. Regarding YSR items addressing suicidality, we hypothesized that as mindfulness training has been shown to reduce feelings of depression and stress, endorsement of such items would be lower in the meditation condition compared to the control condition following the intervention. Because higher scores on the mindfulness scale (CAMS-R) should indicate improvements on the mental traits that mindfulness meditation is expected to train (i.e., attention, present-focus, awareness, and acceptance), we expected that those in the meditation condition would show greater improvements than controls. In addition, in the same way that others have hypothesized that higher scores on the mindfulness scale would be linked to more flexible coping styles (Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007), we also expected improvements on the CAMS-R to be correlated with reductions in clinical symptoms and affect disturbance.