The Effect of Mindfulness Practice on Adolescents: A Pilot Study

Abstract

Background:

Adolescents experience various emotional, cognitive, and behavioral issues for which there is emerging evidence for mindfulness-based interventions, but these have not been investigated with Indian adolescents.

Objectives:

To study the impact of mindfulness practices on attention, perceived stress, emotional competence, and mental health among high school adolescents.

Method:

A single group theme-based 4-week (12 sessions) mindfulness intervention program was conducted on school-going adolescents with a pre-post scale-based assessment design.

Results:

Thirty-nine out of 45 recruited participants (mean age 15.9 ± 0.56 years; M:F = 2:1) completed the study with high session attendance rates (82.05%–100%). On a paired t-test, there was a significant improvement on the Digit Letter Substitution Test (p < .001), the Perceived Stress Scale (p < .001), and three subscales of the Emotional Competencies Scale-Revised (p < .001–.004). Analysis of non-normal data on the Wilcoxon sign-ranked test revealed significant improvement in the Adequate Depth of Feeling subscale of Emotional Competence (p < .001) and all subscales of the Strengths and Difficulties Questionnaire-Teacher Version (p < .001–.048)

Conclusion:

The results indicate that formal mindfulness-based practices for adolescents have significant psychological benefits. Further randomized controlled effectiveness trials are required to establish effectiveness in the non-clinical adolescent population.

Keywords

Mindfulness adolescence attention perceived stress mental health emotional competence

Introduction

Adolescence is a critical period involving transition in all prominent domains of life. Adolescents face various potential risk factors that can affect their psychological well-being. Epidemiological studies indicate that the lifetime prevalence of psychiatric disorders increases radically from 1% of the population under the age of 12 years to 17%–25% of the population by the end of adolescence, with the maximum rise in cases in the age group of 15–18 years.^1,2 In India, the average prevalence rate of psychiatric disorders is 7% in community-based studies and 23% in school-based studies.³ There is a treatment gap globally, and only one-third of children and adolescents receive the necessary treatment, even in high-income countries like the USA, as per the National Comorbidity Survey Replication: Adolescent.⁴ In such a challenging situation, the need for preventive and promotive school mental health programs has been recognized.

School constitutes a large part of an adolescent’s existence. Promoting mental health and well-being at schools may contribute to better behavior, better health outcomes, and better academic achievements. Hence, schools can be a great location for mental health promotion, early identification, and intervention. However, school-based prevention programs are limited in India. Mental health care in India is mostly institution based with a limited focus on community and school mental health.³ Considering the wide gap between needs and services for mental health in India, school settings provide an ideal platform for providing interventions that can facilitate adolescents’ physical, social, and emotional well-being.⁵

Mindfulness-based interventions (MBIs) have been identified as one of the interventions to promote social and emotional well-being in adolescents and promote self-regulatory control.⁶ Klingbeil et al. defined MBIs as “any treatment that intentionally train mindfulness skills as the core therapeutic component for reducing problem behavior or increasing well-being.”⁷ MBIs have been widely accepted and disseminated in the adult population in both non-clinical and clinical settings. The findings from the past 40 years of research have been shown to be beneficial for a variety of physical and mental health outcomes.^8-11 Given the success of MBIs with adults, MBIs are being developed and implemented around the world for children and adolescents, beginning in the early 2000s.¹² Typically, these programs include age-appropriate mindfulness practices to increase attention regulation, social competency, and emotion regulation.¹³

A recent meta-analysis and systematic review indicate the effectiveness and feasibility of MBIs for improving well-being and reducing problem behavior among adolescents.^7,14 A comprehensive meta-analysis by Klingbeil et al. reported findings from 76 studies, including 6121 participants. The findings suggested that MBIs produced a small overall treatment effect for studies with both controlled designs (g = 0.32) and pre-post designs (g = 0.31). The small treatment effects of MBIs were reported to be consistent across seven main outcome parameters: externalizing problems, school functioning, and scholastic achievement; internalizing problems, positive affect and self-appraisal, subjective distress, and negative affect; prosocial behavior and social competence and physical health.⁷ MBIs were found to be just as effective in school settings as in clinical settings.^15,16 Felver et al. concluded from their review of 28 studies implemented in school settings—16 with experimental group designs, nine with quasi-experimental group designs, and three with single-case designs—that MBIs are acceptable and potentially effective interventions for many target behaviors.¹⁷

Another meta-analysis of 33 RCTs of MBIs comprising 3,666 children and adolescent participants found that MBIs were effective in improving executive functioning, attention, mindfulness, anxiety/stress, depression, and negative behavior, with small effect sizes.¹⁴

While the current evidence suggests that the application of mindfulness to adolescents is a feasible and acceptable approach, there has been limited research on MBIs in Indian adolescents. Anand and Sharma investigated the acceptance, feasibility, and usefulness of the Mindfulness-Based Stress Reduction (MBSR) program in enhancing well-being and reducing stress in 33 adolescents in an Indian school setting using a single group pre-post design with MBIs delivered through eight weekly sessions of 40 min each. The results indicated a significant reduction in physiological and emotional manifestations of stress, stress due to peer interactions, and academic stress, and a significant improvement in well-being and academic stress. Further qualitative feedback from the participants suggested that the intervention was acceptable and feasible.¹⁸

Given the limited research on the implementation and potential benefit of mindfulness-based programs with Indian adolescents, we decided to examine the effectiveness of mindfulness training practices in students of class 11th Indian adolescents on measures of attention, perceived stress, mental health, and emotional competence in adolescents in the school setting.

Method

Procedure

After receiving approval from the Institutional Ethics Committee, ABVIMS, Dr RML Hospital, New Delhi, and with the permission of the school principal and administration of Navyug School, Mandir Marg, New Delhi, the investigator of the study explained the purpose and objective of the research to all 11th-grade students. Eleventh grade was selected because teachers felt that they were the most vulnerable group of adolescents in terms of demands of career, relationships, social life, etc., and suggested that they would be the most cooperative among the higher grades. It was also felt that once the techniques of mindfulness are learned, students will be able to apply them for the critical board exams and pre-university examinations. The parent/guardian consent forms containing the details of the assessments and the program, along with the contact information of the chief investigator, in regard to discussing any issue or doubt regarding the research, were sent to all the students. It was specifically explained that they could refuse to participate in or withdraw from the research whenever they wanted without any disadvantage or penalty.

After informed assent and consent were obtained in writing, the students completed the baseline paper-pencil assessment. The final assessment was completed the next day after the completion of the program. Before the administration of pre-tests and post-tests, it was ensured that the participants clearly understood the instructions and that their queries were addressed.

The 4-week mindfulness-training program was conducted over 12 sessions, with three sessions per week. Each session was approximately 40-45 min. The sessions of both classes were led by the chief investigator of the study and held in their respective regular classrooms. The instructor was an experienced mindfulness practitioner. Each session opened with a brief objective of the session, an introduction to the mindfulness practice, and how it would help them, followed by two practices. After each practice, a brief group discussion was held to make the session more interactive. Instructors used the written scripts to guide the mindfulness meditation practices and ensure the fidelity of the program. The mindfulness practices were introduced gradually, with a new theme introduced each week. Instructions and practice were delivered in English.

One of the challenges faced in the implementation of the program was ensuring that the participants attended all 12 sessions. A limitation of the program was that the participants were not asked to maintain a journal or record of the mindfulness exercises they were practicing at home, which made it hard to follow up with them on their experience of practicing these exercises at home.

The school administration perceived the program as important because it offered the students the opportunity to improve their emotional, social, and academic functioning. Thereby, strong support from the school principal, school administration, and teachers was received, which helped in the unhindered implementation of the program.

Intervention

The present mindfulness program is designed as a four-week program for students that can be integrated into the school curriculum. The program curriculum is based on the MBSR program developed by Kabat-Zinn. The modifications in the curriculum regarding its content were made with the consultation of three experts.

The intended goal of the program was to teach adolescents mindfulness in their daily lives to facilitate their well-being and enhance their mental and emotional health. It was designed keeping in mind the principles identified as important by various reviews of mindfulness-based programs, like adapting and shortening the exercises according to the age of the students. The program consists of age-appropriate and secular practices to enhance emotional and social skills and improve concentration and well-being in educational and other settings.

The program is based on four themes of mindfulness: mindfulness of the body, mindfulness of thoughts, mindfulness of emotions, and mindfulness of loving-kindness. These are considered instrumental aspects of mindfulness, involved in the mechanism of change, with a specific focus on the loving-kindness theme throughout the 4 weeks. The mindfulness practices were introduced gradually, with a new theme introduced each week.

For each theme, three sessions were devoted involving the same set of practices. Each session began with a mindfulness practice based on the theme of the week and concluded with one of the loving-kindness practices. They were not given separate homework exercises and were just asked to practice the practices taught in the session at home. The theme of the first week was mindfulness of the body and loving-kindness, which incorporated two practices: (1) mindful breathing and (2) loving-kindness journal. The second week was inspired by the theme of mindfulness of thoughts, with the goal of cultivating the capacity to observe and examine one’s thoughts with the ability to see thoughts just as thoughts without identifying with them by introducing the practice of thought-naming meditation. To further foster loving-kindness meditation writing letters: loving-kindness practice was introduced.

The theme of the third week was mindfulness of emotions and incorporated two practices: mindfulness of emotions meditation and wishes in the bowl: loving-kindness practice. The objective of the week was to develop emotional fluency, the ability to be aware of feelings without resisting or indulging in them, and the capacity to respond to emotions rather than react to them. The fourth week, based solely on the theme of loving-kindness, aimed to develop the capacity to send and receive love by including loving-kindness practice. Further, to help students apply mindfulness in their daily practices, the session incorporated putting it all together: STAR practice.¹⁹

Overview of 4-Week Mindfulness-based Program for Adolescents

Week	Objective	Group Practice
Week 1	• Introduce the concept of mindfulness • Provide an experience of mindfulness	1. Mindful breathing 2. Loving-kindness journal
Week 2	• Cultivate the capacity to observe one’s thoughts • Examine thoughts	1. Mindfulness of thought 2. Writing letter: loving-kindness practice
Week 3	• Develop emotional fluency, or ability to be aware of feelings without resisting or indulging them • Develop the capacity to respond than react	1. Mindfulness of emotions  2. Wishes in the bowl: Loving-kindness practice
Week 4	• Develop the capacity to send and receive love • Applying mindfulness in daily practice	1. Loving-kindness meditation practice 2. Putting it all together: STAR

Tools

Demographic Information

A socio-demographic proforma was made to record the details of the students who participated in the study, which included participant’s age, gender, grade, and demographic details of the parents.

Attention

Digit Letter Substitution Test (DLST) was used to assess attentional domains of sustained attention, mental flexibility, visual scanning, speed of information processing, and psychomotor speed. The participants were given 90 sec to perform DSLT. Norms for Indian children aged between 9 and 17 years are available.²⁰

Perceived Stress

Perceived Stress Scale (PSS), a 10-item, 5-point Likert scale, was used to evaluate the degree to which events were appraised as stressful over the past 1 month. It has high Cronbach’s α (0.84–0.86) and test–retest reliability (0.85.).²¹

Emotional Competence

We assessed the participant’s emotional competency using the Emotional Competencies Scale-Revised (ECS).²² The inventory consists of 30 items measuring the following five competencies: Adequate Depth of Feeling (EC-ADF), Adequate Expression and Control of Emotions (EC-AEC), Ability to Function with Emotions (EC-AFE), Ability to Cope with Problem Emotions (EC-ACPE), and Enhancement of Positive Emotions (EPE). The test–retest reliability of the scale is 0.74, and the split-half reliability is 0.76.

Mental Health

To assess the mental health of the participants, the teachers completed the Strengths and Difficulties Questionnaire-Teacher Version (SDQ-T) developed by Goodman.²³ It is a 25-item mental health screening tool for children and adolescents of about 4–17 years of age. It has five subscales: Emotional Symptoms (SDQ-ES), Conduct Problems scale (SDQ-CPS), Hyperactivity/inattention scale (SDQ-HS), Peer-relationship Problems scale (SDQ-PPS), and Prosocial scale (SDQ-PS), with higher scores on the first four subscales indicating greater impairment while higher scores on the SDQ-PS indicate more adaptive social behavior. Each subscale has moderate internal reliability (0.42 to 0.62).²⁴

Statistical Analysis

Data were analyzed using the statistical software Statistical Package for Social Sciences (SPSS) version 21.0. The percentage was calculated for categorical variables, and continuous variables were presented as mean and standard deviation (SD). The normality of the data was tested by the Shapiro-Wilk test. The pre-test and post-test scores were assessed using a paired t-test if the assumption of normality was not violated. If normality could not be assumed, then the non-parametric Wilcoxon signed-rank test was used. A p-value of <.05 was considered statistically significant.

Results

Forty-five students in the 11th grade of a senior secondary school in Delhi participated in the study, all belonging to urban backgrounds. Thirty-nine participants completed the program. The mean age of the participants was 15.9 years (SD = 0.56; 15–17 years), with a male preponderance (M:F = 2:1) (Table 1). All participants were fluent in the English language. The majority of the students attended all the sessions. There were high session attendance rates, ranging from 82.05% to 100%. The reasons for missing sessions could not be formally collected.

Table 1.

Socio-demographics Characteristics of the Participants.

Variables	No. of Participants (n = 39)	Percentage (%)
Gender Male Female	26 13	66.67 33.33
Age (years) 15 16 17	7 27 5	17.95 69.23 12.82

Mental Health Outcomes

Using a paired t-test, it was found that there was a significant post-intervention improvement in attention on DSLT scores (p < .001) and a significant post-intervention reduction in Perceived Stress (p ≤ .001) (Table 2). The improvement in emotional competency was noted in most of its dimensions. Paired samples t-test indicated significant increases in post-intervention scores on the EC-AEC subscale (p = .004), the EC-AFE subscale (p = .003), and the EC-ACPE subscale (p < .001). No significant difference was observed in pre-post scores on the EPE subscale (p = .537) (Table 2).

Since the analysis of the normality of the EC-ADF subscale suggested that normality could not be assumed, the Wilcoxon signed-ranked test was employed. The results indicated a significant post-intervention increase in EC-ADF (p < .001) (Table 3).

The data for the SDQ-T were non-normally distributed, and hence the Wilcoxon signed-ranked test was used to analyze the results. There was a significant post-intervention improvement in the SDQ-ES subscale (p = .002), SDQ-CPS (p = .004), SDQ-HS (p ≤ .001), SDQ-PPS (p = .048), and SDQ-PS; (p ≤ .001), as can be seen in Table 3.

Table 2.

Comparison of Pre- and Post-mindfulness Intervention Scores of Participants on Measures of Attention, Perceived Stress and Emotional Competence.

Outcome Variables	Pre Mean (SD)	Post Mean (SD)	t score	p-Value
DLST	54.28 (10.32)	66.56 (15.69)	–7.04	< .001***
PSS	23.74 (6.26)	18.85 (6.43)	3.85	< .001***
EC-AEC	18.15 (3.7)	20.9 (6.85)	–3.10	.004**
EC-AFE	16.31 (4.17)	18.69 (4.39)	–3.24	.003**
EC-ACPE	15.15 (4.82)	19.79 (6.86)	–4.38	< .001*
EC-EPE	23.49 (9.05)	22.87 (4.58)	–0.62	.537

*p < .05; **p < .01; ***p < .001.

Abbreviations: DLST, Digit Letter Substitution Test; PSS, Perceived Stress Scale; EC-AEC, Emotional Competency-Adequate expression and control of emotions; EC-AFE, Emotional Competency-Ability to function with emotions; EC-ACPE, Emotional Competency-Ability to cope with problem emotions; EC-EPE, Emotional Competency-Enhancement of positive emotions.

Table 3.

Comparison of Pre- and Post-mindfulness Intervention Scores of Participants on the Measures of EC-ADF and Strengths and Difficulties Questionnaire (Teacher Version).

Sub scales	Pre Mean (SD)	Post Mean (SD)	V	Z	p-Value
EC-ADF	16.41 (5.05)	25.77 (15.2)	79	–4.12	< .001***
SDQ-Total	22.92 (5.29)	21.59 (5)	274	–2.51	.012**
SDQ-EPS	3.77 (2.23)	2.95 (2.19)	170	–3.06	.002**
SDQ-CPS	3.1 (1.76)	2.69 (1.61)	116.5	–2.61	.009**
SDQ-HS	5.33 (1.78)	4.36 (1.72)	136	–3.55	< .001***
SDQ-PPS	4.08 (2.12)	3.72 (2.06)	32.00	–1.97	.048*
SDQ-PS	6.72 (1.9)	7.82 (1.79)	0.00	–3.86	< .001***

*p < .05; **p < .01; ***p < .001.

Abbreviations: EC-ADF, Emotional Competency-Adequate depth of feelings; SDQ-Total, Strengths and Difficulties Questionnaire Total; SDQ-EPS, Strengths and Difficulties Questionnaire-Emotional problem scale; SDQ-CPS, Strengths and Difficulties Questionnaire-Conduct problem scale; SDQ-HS, Strengths and Difficulties Questionnaire-Hyperactivity scale; SDQ-PPS, Strengths and Difficulties Questionnaire-Peer problem scale; SDQ-PS, Strengths and Difficulties Questionnaire-Prosocial Scale.

Other Findings

As not all participants could attend all the sessions of a month-long mindfulness intervention program, secondary data analysis was done to determine the relationship between sessions attended and the outcome measures using the Pearson correlation coefficient. There was no significant correlation between the number of sessions missed and any outcome variables due to high session attendance rates (Table 4) (DLST, p = .116; PSS, p = .163; EC-ADF, p = .602; EC-AEC, p = .965; EC-AFE, p = .251; EC-ACPE, p = .627; EC-EPE, p = .391; SDQ-Total, p = .052; SDQ-EPS, p = .142; SDQ-CPS, p = .716; SDQ-HS, p = .061; SDQ-PPS, p = .603; and SDQ-PS, p = .465).

Table 4.

Correlation Between Outcome Variables and the No. of Sessions Attended.

Outcome Variables	Session
Outcome Variables	r	p-Value
DLST	0.256	.116
PSS	0.228	.163
EC-ADF	0.086	.602
EC-AEC	0.007	.965
EC-AFE	–0.188	.251
EC-ACPE	–0.027	.627
EC-EPE	–0.141	.391
SDQ-Total	0.314	.052
SDQ-EPS	0.246	.142
SDQ-CPS	–0.062	.716
SDQ-HS	0.303	.061
SDQ-PPS	0.087	.603
SDQ-PS	0.12	.465

Note: Same key for abbreviations as in Tables 2 and 3.

Discussion

Mindfulness, as an emerging intervention globally, has been found to be beneficial for all populations, including the adolescent population.¹⁵ The present study was designed to understand the impact of formal mindfulness practices on attention, perceived stress, mental health, and emotional competence in adolescents.

The study findings yielded encouraging evidence in support of the beneficial effect of mindfulness training in adolescents. The findings are consistent with previous studies showing that mindfulness helps in the reduction of stress among adolescents.^6,18,25,26

Mindfulness reduces stress by changing the quality of awareness, making it more clear, non-discriminatory, and flexible, which results in greater insight, a positive reappraisal of the event, and decentering.^27-30 It is possible that mindfulness allowed the participants to look at things more objectively and appraise situations more realistically and less stressfully.

The study also shows promising results in enhancing emotional competency by improving adequate depth/experience of feeling, expression, and control of emotions (EC-AFE and EC-ACPE). These results are also consistent with previous studies showing improvements in emotion regulation, greater awareness of feelings, and a reduction in negative affect.^6,31-35 As conceptualized by Brown et al., the disentanglement of consciousness from the cognitive content allows the viewing of emotions merely as reactions to this cognitive content and helps in noticing their transitory nature, thereby improving affective regulatory self-control.²⁷ However, the intervention did not show any significant effect on enhancing positive emotions, which is similar to previous studies that reported no increase in positive affect after mindfulness intervention in the adolescent population.^31,33

It is postulated that mindfulness practices emphasize relating to pleasant experiences without the desire to have them persist and understanding the passing nature of all kinds of emotions. Further, Mindfulness practitioners emphasized that the desire for the continuation of pleasant feelings is the cause of unhappiness, and thus the aim of mindfulness is not to increase positive affect but to overcome the desire for the persistence of pleasant feelings and reduce aversion to unpleasant feelings.³⁶ This is in line with Buddhist teachings on mindfulness, which stress the experience of equanimity rather than pleasure.

The study also demonstrated improvement in attentional domains with mindfulness intervention, similar to the available literature.^37-41 It is theorized that the encouragement of systematically bringing the focus back to the present moment using sensory anchors with open awareness during mindfulness training improves sustained attention capacity.^42,43

The teachers reported significant improvement in internalizing and externalizing problem behaviors as well as an increase in pro-social behavior post-intervention. The finding is consistent with the previous literature demonstrating a decrease in hyperactivity, disruptiveness, and emotional and behavioral problems after MBI.^33,44 Brown et al. explained that mindfulness promotes behavioral regulation that enhances well-being. Mindfulness optimizes the regulation of behavior through the provision of choice with consideration of abiding values, needs, and feelings and their fit with situational demands and options.²⁷ Thus, by facilitating mindfulness awareness, more adaptive and flexible responses to situations are fostered, which helps in reducing impulsive, habitual, and automatic responses.^27,45 As Siegel suggested, mindfulness may change the adolescent’s baseline state from withdrawal to approach and may influence responding to events rather than merely reacting to them.⁴⁶ The current findings have significant implications considering that learning takes place optimally in a non-disruptive environment, where even teachers feel more in control and not distressed.⁴⁷

Most of the students attended more than 80% of the session, indicating that overall participation was high in the program. Further analysis suggested that there was no significant correlation between the number of sessions missed and the resultant outcomes on all the variables. The finding is consistent with the previous review conducted by Carmody and Baer, who reported no significant correlation between mean, effect size, and the number of class hours with both clinical and non-clinical samples. They emphasized that even adaptations that comprise less time are significant for the population for whom improvement in psychological distress is the primary goal and for whom a longer time commitment may not be possible.⁴⁸ A significant improvement after the 4-week intensive intervention is an encouraging finding, highlighting the effect of even a short mindfulness-based intervention. The factors that could have resulted in such findings may include less spacing between classes, the 40–45 min of a session; the repetition of the same practices thrice a week, the inclusion of loving-kindness practice every week, and the quality of the delivery of the session.

Strengths, Limitations, and Future Directions

Speaking of strengths pertaining to this research, it is the first attempt to study the feasibility and effect of a mindfulness intervention on adolescents in India measured on the variables of attention, perceived stress, emotional competency, and mental health. The mindfulness interventions were spread over 4 weeks, with three weekly theme-based sessions, and included both subjective and objective assessment measures.

The results of the study must be viewed in light of methodological limitations. Since there was no control group in the study and the sample size was small, it limits our ability to generalize the findings of the study. Pre- and post-test practice effects could also account for some improvement in test scores. Secondly, the person administering the assessments and conducting the intervention was the same, which could have introduced participant or researcher bias. The timing of the intervention, too, could have presented a source of error. The intervention was presented near the end of the academic term. Adolescents could have experienced a general improvement in mental and emotional health outcomes as they approached winter break. Lastly, the absence of a follow-up assessment limits the ability to answer the question of whether the gains of such a short program persist or weaken. Exploration of the potential moderating effect of school variables such as urban background, average achievement levels, and socioeconomic status on outcomes and implementation quality of the program is need to be explored in the future.

The understanding of mindfulness practices among adolescents in India is in an emerging phase. There is a huge gap to fill in to address the feasibility of such intervention in our settings. The current study is exploratory research that lays the foundation of the evidence base for MBIs in India and adds to the rising empirical literature on MBIs in schools. Even though there are several limitations, the study offers an opportunity for future studies to advance our understanding of the effect of mindfulness on adolescents. Randomized clinical trials are required in the future to examine the effectiveness of mindfulness interventions in the adolescent population. Future studies should also consider developing school-based programs delivered by classroom teachers within school hours.

Footnotes

Acknowledgements

The authors would like to thank Dr Dinesh Madan, Principal, Navyug School, Mandir Marg, New Delhi for his help and cooperation throughout the study. The authors also express appreciation to all teachers of the same school for facilitating the study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Statement of Informed Consent and Ethical Approval

Ethical Approval was approved by The institutional Ethics Committee, PGMIER, Dr RML Hospital, New Delhi. Informed consent were received and obtained respectively before initiating the study from allparticipants.

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