Adolescent Perspectives on a School-Based Mind-Body Intervention

Abstract

Background

Poor mental health among adolescents increased over the last decade prompting recommendations for school-based primary prevention programs that promote mental health. Mind-body modalities offer an evidence-based approach to support well-being, however few studies have evaluated the adolescent experience of participating in these groups.

Objective

To engage high school students in a mind-body skills group (MBSG) to assess acceptability in an afterschool setting, learn about the adolescent experience of participating in a MBSG, and get recommendations to enhance program acceptability. To collect preliminary data on mindfulness, social support, emotional regulation, and quality of life.

Methods

Ten high school students participated in an afterschool MBSG. A focus group was conducted 1-week post-intervention. Surveys were administered at baseline, 1-week post-intervention (T1), and 10-weeks post-intervention (T2). The research team used qualitative thematic analysis with inductive and thematic coding. Descriptive statistics of survey scores were calculated, but the study was not powered to detect statistical significance.

Results

Participants deemed the group to be acceptable. They valued the sense of community derived from the group and enjoyed learning a variety of mind-body skills. Participants recommended adaptations to build connections sooner within the group, offer more interactive experiences with mind-body skills, and prioritize social, emotional, and physical comfort. Mindfulness, emotional regulation, and quality of life scores increased from baseline to T1. All survey scores improved from baseline to T2.

Conclusion

This study offers insights into the adolescent experience and recommendations for program adaptations for a MBSG in an afterschool setting. Understanding the adolescent perspective is essential for the development of an acceptable MBSG, which has implications for program implementation, utilization, and effectiveness.

Introduction

Adolescence is a developmental stage characterized by rapid physical, cognitive, and socioemotional changes that coincide with an increased risk for mental health disorders. Poor mental health among adolescents is an urgent public health concern. ¹ A national survey showed that 42 percent of US high school students report persistent feelings of hopelessness or sadness that impede their ability to engage in day-to-day activities; this is a 14 percent increase from 10 years prior. ² In fact, almost all markers of poor mental health, including considering, planning, and attempting suicide, increased over the last decade. ²

In response to increased rates of poor mental health, the Centers for Disease Control and Prevention (CDC) recommends school-based primary prevention programs that teach stress management and emotional coping skills. ³ Mind-body modalities offer an innovative, evidence-based approach to foster adolescent well-being and enhance stress management and emotional coping skills.^3-5

Mind-body modalities are practices that focus on the interactions between thoughts, feelings, and physiology. ⁶ Specifically, mind-body modalities activate the body’s physiological relaxation response to reduce stress and promote self-regulation. ⁶ Examples include diaphragmatic breathing exercises, mindfulness meditation, autogenic training, biofeedback, guided imagery, movement (yoga, Tai-Chi, shaking and dancing), self-expression, and spirituality. In addition, mind-body modalities center on self-efficacy, where each person has the capacity to cultivate greater well-being through self-care practices and inner guidance. ⁶

The Center for Mind-Body Medicine (CMBM) (https://www.cmbm.org/) developed a group model for teaching mind-body modalities called mind-body skills groups (MBSG). In adults MBSGs demonstrate decreases in stress,^7-9 depressive symptoms, ⁸ and post-traumatic stress disorder (PTSD)^10,11 and increases in personal well-being. ¹² There are fewer studies evaluating the use of MSBGs with adolescents. Yet, existing literature is promising. A MBSG for adolescents with depression was associated with significant improvements in depressive symptoms after 10 weeks and improvements were sustained 3 months after the intervention. ¹³ In addition, 2 studies of adolescents living if areas of political violence reported decreased symptoms of PTSD following participation in MBSGs.^14,15

Despite the promise of MBSGs, little is known about the participant experience, especially for adolescents in an afterschool setting. MBSGs were developed for use in adults without specific consideration for the unique needs and preferences of adolescents. Qualitative data about program acceptability is necessary if mind-body modalities are to be translated to primary prevention programs and scaled for use in school settings.

To address this need, we engaged high school students in an 8-week MBSG and conducted a focus group to gather participant feedback. Our primary objective was to assess MBSG acceptability in an afterschool setting, learn about the adolescent experience of participating in a MBSG, and get recommendations to enhance program acceptability for future implementations. Our secondary objective was to collect preliminary data on mindfulness, social support, emotional regulation, and quality of life.

Methods

Study Design

This was a descriptive, non-controlled study of voluntary participation in an 8-week MBSG. Participants engaged in a focus group one week after the intervention and completed questionnaires at baseline (B), 1-week post-intervention (T1), and 10 weeks post-intervention (T2). (Table 1) Data collection at 10-week post-intervention (T2) corresponded with the final week of the school year. Researchers prioritized completing data collection within the school year rather than selecting a longer follow up period. This study was approved by Indiana University institutional review board.

Table 1.

MBSG Curriculum and Data Collection Timeline.

Week	Topic	Mind-Body Skill	Data Collection
1	Overview of mind-body medicine and drawings	Draw yourself as you are now	Surveys (B)
		Draw yourself with your biggest challenge or problem
		Draw yourself with your biggest challenge or problem solved
2	Autogenic training and biofeedback	Autogenic experience while measuring changes in body temperature
3	Meditation	Playdoh mindfulness meditation
		Expressive meditation: Shaking and dancing
4	Guided imagery	Lemon guided imagery
		Safe place, wise guide imagery
5	Dialog with a Symptom or emotion	Journal to a symptom or emotion
6	Relationship with food and mindful eating	Draw your relationship with food
		Mindful eating experience
7	Spirituality	Loving kindness meditation
		Forgiveness meditation
8	Closing ritual and drawings	Draw yourself as you are now
		Draw yourself as you would like to be
		Draw how you will get there
1-week post-intervention			Surveys (T1)
			Focus group
10-weeks post-intervention			Surveys (T2)

Study Setting

The study was conducted at a public charter high school located in downtown Indianapolis, Indiana. The school serves approximately 960 students [Asian (1.5%), African American (23.9%), Hispanic (12.7%), Multiracial (7.1%), and White (54.6%)] in grades 9th - 12th (Herron Classical Schools Office of Academic Accountability, unpublished data, 2022). About forty percent of students were eligible for free or reduced school lunches (Herron Classical Schools Office of Academic Accountability, unpublished data, 2022).

Participant Eligibility and Recruitment

Eligible participants were high school students, 14-18 years of age, who attended the charter school and were able to attend the weekly group sessions.

All students received an email with information about the study. Interested students contacted the research team to discuss the study, determine eligibility, and schedule a time to complete the informed consent process with a parent or guardian present. The research team tracked and responded to student text and email inquiries in the order they were received, and the group was filled on a first come basis until the group reached capacity (10 students).

Intervention

The MBSG manualized curriculum offers the option of an 8-, 10-, or 12-week program. The 8-week program was selected because it enabled the research team to complete the intervention and focus group prior to spring break which was in line with the school’s preference for the study timeline. The group size of ten participants was stipulated by the MBSG model.

Group Facilitation

The MBSG met once a week after school for 90 minutes in a private classroom space. The group was facilitated by 2 CMBM-trained facilitators who used the CMBM MBSG manualized curriculum. CMBM training involved attending two 5-day advanced training programs where facilitators participated in the group model, practiced facilitating the skills, and received feedback from CMBM faculty and other program trainees. Additionally, the facilitators were supervised by a CMBM faculty member. Supervision consisted of writing and submitting weekly process notes that reflected the group process and the facilitation experience. Process notes were followed by weekly 1-hour meetings with the CMBM faculty member to discuss the previous week and review the next week’s curriculum.

Prior to the start of the first session, facilitators led a discussion of the group guidelines. This included an explicit agreement to maintain the confidentiality of any information shared by other group members, the right for group members to decline sharing with the group or “pass”, mutual respect, attendance, punctuality, and practicing the skills at home.

The first session took place on January 18th, 2022, during the COVID-19 pandemic. The study adhered to COVID-19 precautions which included social distancing guidelines, masking, and seating charts.

Session Structure

Sessions followed a consistent format which included the following: opening meditation, check-in, mind-body skill instruction, mind-body skill practice, sharing about the experience, and closing meditation. ¹⁶

Every session began with an opening meditation. This was a concentrative breathing exercise, such as soft belly breathing, ocean breathing, or breath awareness.

Next, participants were invited, but not required, to “check-in” meaning to share whatever was on their mind or how their week was going. During the first few sessions facilitators offered participants the option to share a “high” and a “low” of their week. Participants were instructed to “pass” if they preferred not to share with the group. A second round of check-in allowed participants to share anything else on their mind or how they were feeling “in this moment”.

Following the check-in, facilitators introduced the mind-body skill, shared background information about the skill, and provided instructions on how to practice the skill. Each session taught a new skill including diaphragmatic breathing, autogenic training, biofeedback, meditation, movement (shaking and dancing), guided imagery, mindful eating, and self-expression through drawing, journaling and spoken word. (Table 1)

After the introduction of the skill, the facilitator led an all-group practice of the skill. The skill practice followed the scripts in the CMBM manualized curriculum.

Group members shared their experience practicing the skill (What was the experience like for you?). Facilitators then discussed how the skill could be used during home practice and reminded group members of previous skills they could practice on their own.

Finally, the group closed with a meditation.

Data Collection

Participants attended a 60-minute focus group one week after completing the intervention. Participants were invited to share their feedback on the overall group experience as well as specific recommendations for each session. Researchers used an interview guide, but also allowed for topics to emerge organically over the course of conversation. The interview guide asked open-ended questions regarding participants’ overall perceptions of the group, experience as a group member, likes and dislikes, and recommendations for program adaptations. (Appendix A) The focus group was audio recorded and transcribed.

Participants completed surveys at baseline (B), 1-week post-intervention (T1), and 10 weeks post-intervention (T2). (Table 1)

Mindful Attention Awareness Scale-Adolescent (MAAS-A)

The MAAS-A is a 14-item tool that assesses levels of attention and awareness, or lack thereof, in day-to-day activities. ¹⁷ Participants rate their level of mindfulness for a variety of activities on a scale from 1 to 6. Higher scores indicate greater levels of mindfulness.

Child and Adolescent Support Scale (CASSS)

The CASSS is a 60-item tool that measures perceived social support and importance across for domains (emotional, informational, appraisal, instrumental). ¹⁸ The questions are divided into five groups including parent, teacher, classmate, close friend, and people at my school. ¹⁸ Higher scores indicate greater social support.

Difficulties in Emotion Regulation Scale (DERS)

The DERS is a 36-item tool that assesses difficulties in emotion regulation. Questions ask participants to assess their feelings and/or emotional experiences.^19,20 Higher scores indicate greater difficulties with emotional regulation.

Pediatric Quality of Life Inventory (PedsQL)

The PedsQL is a 23-item tool that measures general health-related quality of life in physical and psychosocial domains. Higher scores indicate higher quality of life. ²¹

Data Analysis

Three members of the research team (JMP, JEP, KMH) used qualitative thematic analysis with inductive and thematic coding ²² facilitated by ATLAS.ti.9. To maintain data integrity, each member of the research team first coded the transcript independently and then met to create a list of codes. Team members discussed and revised the codes until consensus was reached. The agreed upon codes were kept in a master code list by one team member and shared at the completion of each meeting for continued coding by the team. If new codes emerged, an assigned team member reviewed the prior coded data to ensure that all codes were accurately captured and discussed with the team. This process continued until all data was coded and consensus was reached. Team members then grouped codes into themes independently and met to discuss the themes until consensus was reached.

Two members of the research team who coded the data also facilitated the intervention and the focus group. Therefore, a third coder who was not involved with the intervention or the focus group was recruited to help account for bias. In addition to using multiple coders, the research team attempted to minimize bias by collaboratively creating the master list of codes, revising codes throughout the analysis, discussing discrepancies openly until consensus was reached, utilizing inductive coding, and engaging in self-reflection of personal bias.

Descriptive statistics (mean and standard deviation) of survey scores were calculated using Microsoft Excel 365.

Compensation

Participants were eligible to earn up to $75 in gift cards as compensation for their time. Participants received $10 for data collection sessions 1 and 9, $5 for sessions 2-8, and $20 for the final data collection session. Participants received partial compensation based on their participation as outlined above, and gift cards were distributed one week after the final data collection.

Results

Recruitment and Attendance

Researchers were contacted by 66 students who expressed interest in the group. The study recruited the maximum of 10 participants as stipulated by the CMBM MBSG model. Five participants attended all 8 sessions. Four participants completed seven sessions, and one participant completed five sessions.

Participants

Most participants were female (80%) and white (60%). Participants were 15 years of age (SD = 0.88, 14-17) and in the 10th grade (9th-11th grade).

Focus Group

Nine of ten participants attended the focus group in person; the participant who was unable to attend submitted feedback in writing. Focus group data are categorized into three primary themes; (1) participation in the group; (2) experiences in the group; (3) recommendations to improve the group. (Table 2)

Table 2.

MBSG Focus Group Themes.

Participation
Prior experience	Quote
Like yoga or therapy	For about three, four years, I did yoga, and I stopped maybe like a year or 2 before this year. I Kind of started getting back into it again this year. So, it [the group] lined up pretty well. And then I talked about some meditation stuff that’s kind of similar to some stuff we did in therapy that I’ve done for about 2 years. So it was pretty good timing, and it overlapped with a lot of different things. (P1)
	I used to do yoga on and off but otherwise I’ve done art therapy before, and I guess just drawing normally is art therapy for me. (P7)
	I have done yoga with my mom for the past three years, and I also took yoga classes and stuff like that. (P2)
	I did it in therapy. So, yeah. (P9)
	Meditation was something that my therapist recommended, so I’ve done some before, but I kind of been doing just one or 2 meditations over and over and kind of got stagnant. So, I wasn’t really good at it nor had I done very much in terms of diversity. (P6)
A new experience	It was pretty new for me, too. I’ve done a few meditation things. One with middle school and then one was just kind of like trying out stuff, but nothing ever worked out. So, this is my first actual step of it. (P4)
	I don’t have much experience with it. Some of my family members like to do yoga and things like that so I’ve heard of some things but not really done them myself. (P5)
	I was fairly new to it. We did like mindful moments at my old school but other than that, that’s all. (P8)
	For me, it was all pretty new and just learning about the meditations and stuff. (P3)
Compensation	Quote
Participated regardless of compensation	I feel like I would have still done it [participated in the group] because I didn’t really see the compensation thing until after reading through it. And I was already interested. So, it [compensation] was a cool thing, but it was more of a side note. I do know a few people who wanted to do it but mostly wanted to do it for the compensation. But I feel like after a few sessions, a lot of people who had been there for the money would have been more interested in the actual study itself because it helped a lot. (P4)
	I think I still would have because personally it was a new thing I haven’t tried. I have a lot of friends around me who struggle with things that are mental health related. (P5)
	So, I didn’t know compensation was part of it until I had that meeting with you. And so, I think the compensation might have initially been a motivation a little bit, but as I got into it, I actually kind of forgot about it. (P7)
	I think I also would have done it even without the compensation because it was definitely something I was interested in reading through the email before I got to the bottom where I said there’d be compensation. I do think the compensation was nice because it convinced the part of me that is greedy for my time. I’m sometimes reluctant to do things, extracurricular or otherwise, just cause I like time. But I think I would have done it. It [compensation] was definitely not my primary motivation. (P6)
Timing	Quote
Convenient time	I just needed something to do after school. I just didn’t have much after school anymore and it was a pretty good reason to do something. (P1)
	For me, I was just looking for more extracurricular activities to do after school. Because for me it’s like better cause my ride he’s at work and I kind of live far away, So the later I can stay at school and do extra things and stuff like that, the better. (P2)
Parental encouragement	Quote
Prompted by parents	So, I probably wouldn’t have read the email if it didn’t say that because I don’t read a lot of [school] emails and my mom does. And then she says like, oh, you should probably look into this. And then I click on the link and actually look at it. So, I probably wouldn’t have joined because my parents probably wouldn’t have told me. (P9)
	So, I didn’t actually look at my email about this. My mom works at [work]. And so, when she got the email about coming from [work] she was like oh [P7 name] you should do this after school. It was just something she related to. So that’s how I first heard of it. (P7)
Experience
Interactions	Quote
Nerve wracking	...if you’re doing a first day of anything, it’s just very nerve wracking… (P1)
	...as we got to know each other...it’s less nerve wracking. (P6)
	It [the first group session] was a little nerve-wracking. . . (P10)
	Keeping it small is a lot easier because it’s very nerve wracking to say something in front of a group of 20 people. (P1)
Confidentiality and trust	It [confidentiality] made me feel safe to actually open up more. (P3)
	The check-ins definitely got better the further we went along because it is easier to be more honest and open about how you are doing when you know people better. (P6)
	...after a short while I felt pretty comfortable and trusted the confidentiality of the group. (P10)
Connecting with strangers	I know people in this school since I was a child, and I don’t want to say some of the things to them that I shared with this group. (P5)
	I loved the strangers. I wouldn’t call you strangers when we met. I Knew you around the school. I didn’t know your name. We’ve never talked. But it is just a good fresh start then if I invited my friends because it’s hard to open up to them. As teenagers when you make friends, I don’t think this just...applies to me, but you don’t talk super deep about anything. It’s just kind of surface level things, day to day things, not mental health stuff. It’s full of people who don’t know each other. Then that’s how you start a relationship, and it gets stronger after that, so its good, yeah. (P9)
	...It also helped with us being strangers in the confidentiality thing because I don’t think anyone is going to feel the temptation to go and tell things they’re hearing about here because it’s people that you see mostly here. And like, if it was a group of people that I all knew well, it would be more sticky because it’s people I’ll see every day. If it was people that I knew really well you get that sense of not wanting to say things, say some things, I think that would be trickier. (P6)
	I liked that we came in as strangers just because I don’t know how comfortable, even with my closest friends, I feel like I’m kind of burdening them, if I keep talking about my issues. And so, I think going in as strangers and getting to know around how we met is good. (P8)
Talking about what’s important	We talked about stuff that was important to us and that we found comforting and spiritual...and I liked that...connecting with everyone. (P4)
In-person is better	I also feel like it is better in person because I feel like it gives me more of a chance to kind of talk to people around you. And it makes it more of an involved environment than being on a computer. (P1)
	I’m not sure the group would be as successful if it was virtual because it is much easier to find things to get distracted by and not give your full attention to the group environment. (P10)
	I know the anti-social gremlin instead of me says “yes Zoom” when I started. But I certainly don’t think this would be the same on Zoom. So even if some people might innately want to do it, I don’t think it would be as good. I think, if they had a few sessions in person they wouldn’t want to go back to Zoom either. (P6)
Spiritualty and connection	I liked more towards the end of doing the meditations and the activity, we just kind of talked about stuff that was more important to us and that we found comforting and spiritual to us, and I really liked that aspect cause it was more of a conversation of like oh yeah, you like that, I like that too, and like connecting with everyone. I feel like maybe doing that as one of the first ones would be kind of cool because that would be a good way to connect with everyone else. (P4)
Facilitators as participants	You were doing it with us, and it made me feel more comfortable I think. (P9)
	…adults are better because they have a more mature outlook, and they could even learn some things from teens who are experiencing whole new things and needing to learn how to cope from people who have been through similar things. (P10)
Activities	Quote
Interactive experiences	I just love the interactive stuff where you get something, and you have to eat it or play with it or describe it. (P9)
	I also like interactive things, but I think the thing for me was I had to eat the grape and it was in your mouth for so long that it got really gross. (P3)
	I like the interactive stuff, but I think specifically for me, food is a hard topic to discuss… (P8)
Preferences	I love that one [mindful eating]. (P9)
	This one [mindful eating] was hard for me because I was scared of showing my relationship with food to other people because it kind of made the reality of it much more apparent and I struggled a lot… (P10)
	That one [autogenic training] was my favorite honestly… (P7)
	I think that [autogenic training] was one that people either really enjoyed it, or it just wasn’t for them at all. And that was the first example of that for me. (P1)
New skills	...I liked having something new every week…, if I didn’t like one thing than I had a chance to do something new the next week, so it gave me always like a fresh start of here’s a new thing to do, here’s a new thing to try out and see how it works for you. (P4)
	I like new things cause if I didn’t feel like the same thing last week, then I always knew that I could learn something new and maybe I would like that better than the old one. (P9)
Benefits
Understanding feelings	They [opening and closing meditations] really helped you understand your feelings more and think about them during the day. (P3)
	It [dialog with an emotion] helped me work through something I was going through at the moment and helped me clear my mind and find what I was really feeling. (P10)
	I feel like if you are really angry at something or you had a big issue with someone, definitely in a moment, it [dialog with an emotion] could help kind of understand more about what’s going on before it gets the best of you. So really knowing what it is and being able to resolve it within yourself before you actually act on it could definitely help not have a really huge conflict with someone. (P1)
Sleep	It [autogenic training] was something that I can use at night to help me fall asleep because I have trouble with that. (P7)
Get mind off things	I actually really like the playdoh one too. Because to me it was really interesting to just sit and just think about one specific thing and it really got your mind off of things at home. (P3)
Feel like I would like to feel	I liked the loving kindness meditation. It’s one of my favorites and I think, I know this is kind of a weird phrasing but when I finished the loving kindness meditation, I feel like I would like to feel after a meditation. It’s very, you know. (P6)
Other students would benefit	I have a lot of friends around me who struggle with things that are mental health related. (P5)
	There are lots of people at [school] who struggle with anxiety and could likely use a group like this, and I think a decent amount of them would take the opportunity to learn new coping mechanisms and ideas of how to reduce stress. (P10)
Recommendations
Interactions	Quote
In-person groups	I also feel like it is better in person because I feel like it gives me more of a chance to kind of talk to people around you. And it makes it more of an involved environment than being on a computer. (P1)
Build community	… but a session zero or something where you could play games or talk and get to know each other so that you are familiar not just with names and faces but also little bit of the personalities before we begin. (P6)
Students felt it was important to choose icebreakers that do not cause anxiety	Some of them give me anxiety cause I feel like I forget. So, I felt like saying everyone’s name before we did it was helpful… (P9)
	I feel like the general reason why a lot of icebreakers are also ineffective, just like question icebreakers, is because it feels kind of awkward and tense to ask really niche questions to people you’ve never met before. (6)
Activities	Quote
Interactive experiences	I like the interactive stuff…(P8)
	I also like interactive things…(P3)
Alternate activity to shaking and dancing	Despite not liking it all that much I did like the idea of the more movement-based meditation, especially with the playdoh because I like to do it with my hands a lot. So, it gave me something to do and to focus on. (P4)
	You should do just dance, and we would move and it would be kind of fun. The wii and move that wii remote thing. That would be fun movement. (P9)
Warning before difficult topics	…I think specifically for me food is a hard topic to discuss. And so, warning beforehand or something like that. (P8)
Physical comfort	…I actually like the opportunity to lay down. Because honestly, after an entire day of sitting in these hard chairs, sitting in these hard chairs more, it’s pretty uncomfortable. So, I think the opportunities to lay down helped me to be comfortable but it also makes sense that it may not be the best thing for everybody. (P6)
Home practice	Maybe just more suggestions of ways you can practice them (P10)
	This is something that I could make, that I could compile a list of all the skills we learned plus the things like extra breaths we learned, that we touched briefly on. A list of all the things we could do if you’re feeling stuck that you could practice. (P6)
Format	Quote
Offering the group in person is better than virtually	…I know the anti-social gremlin instead of me says “yes Zoom” when I started. But I certainly don’t think this would be the same on Zoom. So even if some people might innately want to do it, I don’t think it would be as good, I think, if they had a few sessions in person they wouldn’t want to go back to Zoom either. (P6)
Students had differing thoughts on time of day and day of week to offer the group	It might be hard coming back to school only for an hour and for only for 90 minutes, but maybe finding somewhere else…. I Know the weekend wouldn’t be ideal…(P7)
	I feel like before school would be really nice, but I also feel like having it after school is good, to destress from being at school. And then I also feel like if it was on saturdays, that’d be kind of hard…(P4)
Shorter duration	I liked that it was after school, but I think it was a little long. Maybe an hour or an hour and 15 minutes instead. (P8)

Participation in the Group

Participation was grouped into prior experience, compensation, timing, and parental encouragement.

Prior experience. Some participants shared that mind-body skills were either recommended by their therapist or “Similar to some stuff we did in therapy” (P1). Other participants reported having little experience with meditation, it was “fairly new” (P8) or “I’ve heard of some things but not really done them myself” (P5).

Compensation. One participant felt that some students would be initially motivated by the compensation, but would stay engaged in the group because it was helpful, “I do know a few people who wanted to do it but mostly wanted to do it for the compensation, but I feel like after a few sessions, a lot of people who had been there for the money would have been more interested in the actual study itself because it helped a lot” (P4). Other participants said they would have joined the group regardless of the compensation because “it was a new thing I hadn’t tried” (P5) while another participant wasn’t aware of the compensation until the intake interview, “I didn’t know compensation was part of it until I had that meeting with you. And so, I think the compensation might have initially been a motivation a little bit, but as I got into it, I actually kind of forgot about it” (P7). One participant appreciated the compensation but acknowledged that it was not their main reason for joining: “I think I also would have done it even without the compensation because it was definitely something I was interested in before I got to the bottom [of the email] where it said there’d be compensation. I do think the compensation was nice because it convinced the part of me that is greedy for my time. I’m sometimes reluctant to do things, extracurricular or otherwise, just cause I like time. But I think I would have done it. It was definitely not my primary motivation” (P6).

Timing. For some participants, the timing was a motivation to participate. One participant thought it seemed interesting, “I just needed something to do after school…and it was a pretty good reason to do something” (P1).

Parental Encouragement. A couple of participants indicated that they would not have been aware of the group, if their parent had not drawn their attention to the initial recruitment email and encouraged participation, “…you should probably look into this. And then I click on the link and actually look at it. So, I probably wouldn’t have joined because my parents probably wouldn’t have told me” (P9).

Experiences in the Group

Participant experiences in the group are categorized into interactions with others, group activities, and group format.

Interactions. Confidentiality, trust, and connecting came up as interconnected themes throughout the experience. Participants described communication with strangers as nerve-wracking at first. However, the vow of confidentiality helped to build trust in the group and made participants “feel safe to actually open up more” (P3). Participants verbalized that relative anonymity also made it easier to share, “I know people in this school since I was a child, and I don’t want to say some of the things to them that I shared with this group” (P5).

The participants felt that these social mores are typical of peers, “As teenagers when you make friends, I don’t think this just applies to me, but you don’t talk super deep about anything. It’s just kind of surface level things, day to day things, not mental health stuff. It’s full of people who don’t know each other. Then that’s how you start a relationship, and it gets stronger after that” (P9). Time also helped to build trust “because it is easier to be more honest and open about how you are doing when you know people better” (P6).

Participants felt that meeting in person contributed to what they felt was a connected “involved” group because they could give it their full attention with fewer distractions. One participant described Zoom sessions as initially appealing but felt the benefits of in-person were better: “I know the anti-social gremlin instead of me says “yes Zoom” when I started. But I certainly don’t think this would be the same on Zoom. So even if some people might innately want to do it, I don’t think it would be as good. I think, if they had a few sessions in person they wouldn’t want to go back to Zoom either” (P6).

Connection was brought up when more discussion took place during the spirituality session in week 7: “I liked more towards the end of doing the meditations and the activity, we just kind of talked about stuff that was more important to us and that we found comforting and spiritual to us, and I really liked that aspect cause it was more of a conversation of like, ‘Oh yeah, you like that, I like that too’, and like connecting with everyone. I feel like maybe doing that as one of the first ones would be kind of cool because that would be a good way to connect with everyone else” (P4).

Having the facilitators participate as group members helped with group interactions because “you were doing it with us, and it made me feel more comfortable” (P9) and also fostered mutual learning between adults and teens because “…adults have a more mature outlook, and they could even learn some things from teens…” (P10).

Activities. Interactive experiences, preferences for specific activities, learning new skills, and the benefits of mind-body skills were discussed by participants.

Participants liked interactive experiences which one participant defined as “stuff where you get something, and you have to eat it or play with it or describe it” (P9). Examples include journaling, mindfully manipulating playdoh, drawing, and mindful eating.

However, not all interactive experiences were universally liked. When discussing mindful eating one student stated, “I love that one” (P9). While other participants found the experience hard, “this one was hard for me because I was scared of showing my relationship with food to other people because it kind of made the reality of it much more apparent and I struggled a lot…” (P10).

Participants verbalized differing preferences for other mind-body skills. One participant stated, “That one [autogenic training] was my favorite honestly…” (P7). While another participant explained, “I think that [autogenic training] was one that people either really enjoyed it, or it just wasn’t for them at all. And that was the first example of that for me” (P1).

Participants liked learning a new mind-body skill each week and related learning new skills as an opportunity to try another skill and “see how it works for you” (P4).

Participants discussed benefits of experiencing the skills such as better understanding of feelings, “I liked this [dialog with an emotion] a lot, it helped me work through something I was going through at the moment and helped me clear my mind and find what I was really feeling” (P10). One spoke to the use of the skills for de-escalation of angry feelings to avoid conflict: “I feel like if you are really angry at something or you had a big issue with someone, definitely in a moment, it could help kind of understand more about what’s going on before it gets the best of you. So really knowing what it is and being able to kind of resolve it within yourself before you actually act on it could definitely help not have a really huge conflict with someone.” (P1) One participant extended the benefits of the experience to the needs of other students, “There are lots of people at [school] who struggle with anxiety and could likely use a group like this, and I think a decent amount of them would take the opportunity to learn new coping mechanisms and ideas of how to reduce stress” (P10).

Format. Participants also discussed the structure of MBSGs; repetition and rounding out came up as themes. Some participants disliked activities that felt repetitive, especially icebreakers. Others enjoyed the consistent structure of opening and closing meditations. Participants liked exercises that rounded out the structure, such as the opening and closing meditations and the 2 sets of drawings at the first and last sessions. One compared this rounding out to a journey, “…having the end connecting to the beginning made it feel more like we were completing a journey than just finishing” (P6).

Suggesting ways to practice at home is a component of the MBSG model. One student discussed the benefits of home practice, “I think the home practice is a very necessary part of this. It’s kind of like the whole practice makes perfect. If you learn it once in class it’s nice at that moment, but it’s not going to affect you in the long run, and you have to keep up with it. So, completing that home practice really made me feel like I’m achieving something” (P7).

Recommendations for MBSG Adaptations

Participants were asked specifically about recommendations for improvement; those are organized as interactions, activities, and format.

Interactions. Participants recommended more activities to get to know each other better in the beginning, such as memory games to learn each other’s names sooner or interviewing each other and introducing them to the group. One participant suggested a session zero to build connections sooner: “I don’t know if this is something there would be time for, but a session zero or something where you could play games or talk and get to know each other so that you are familiar not just with names and faces but also little bit of the personalities before we begin” (P6). Another participant thought that the spirituality session should be moved closer to the beginning of the group to foster connections between group members.

Activities. Participants suggested ideas to include more interactive experiences including kinetic sand, Legos, and painting with finger paints or watercolors, “I just love the interactive stuff” (P9).

Participants recommended alternatives to shaking and dancing such as yoga or Just Dance. One participant suggested, “a video of how to do it [shaking and dancing] and you can do it at home and then talk about it” (P8).

Participants felt that it would be helpful to have a warning prior to potentially difficult topics such as mindful eating, “I think specifically for me food is a hard topic to discuss. And so, warning beforehand or something like that” (P8).

Participants liked having the option to lie down or feel more comfortable during mind-body activities. “I actually like the opportunity to lay down. Because honestly, after an entire day of sitting in these hard chairs, sitting in these hard chairs more, it’s pretty uncomfortable. So, I think the opportunities to lay down helped me to be comfortable but it also makes sense that it may not be the best thing for everybody” (P6).

Format. Participants recommended offering the group in-person rather than virtually. Due to the COVID-19 surge in January 2022, we discussed pivoting to a virtual meeting. After the sessions ended, students said virtual meetings would not have been as successful, “I’m not sure the group would be as successful if it was virtual because it is much easier to find things to get distracted by and not give your full attention to the group environment” (P10).

Participants discussed the pros and cons of various times of day and days of the week to hold the group. Students thought that it might work better to offer the group before the start of the school day on Fridays (a later start day). One participant explained, “. . . [meeting in the morning] might actually make your day better going into school and having a kind of more positive outlook vs coming to it after when school is already done” (P7). One participant recommended shortening the length of the group to 60-75 minutes.

Participants recommended a variety of tools to aid in home practice. Ideas included planners, lists of skills, new skills, and post-it notes, “It would have been cool if we would have gotten little post-its or something sticky on the back that we could stick on our mirrors to remind us to practice it at home” (P3). One participant thought it would also be helpful to have more advice on ways to create routines by using the skills at home. Another suggested offering other breathing options to try at home, “I feel like we could do a home practice or something that was not what we did in class. You could give out a paper of different breathing techniques that we didn’t do” (P5). When asked about tracking daily practice, one participant verbalized that this expectation would only cause more stress.

Surveys

Descriptive statistics for participants’ mindfulness, social support, emotional regulation, and quality of life were calculated. (Table 3)

Table 3.

Descriptive Statistics for Mindfulness, Social Support, Emotional Regulation, and Quality of Life Surveys.

	B		T1		T2
Survey	M	SD	M	SD	M	SD
MAAS-A	3.14	0.78	3.37	0.65	3.24	0.79
CASSS	240.8	38.4	240.1	40.6	246.2	43.5
DERS	98.2	24.6	88.8	18.3	87.9	24.5
PedsQL	58.8	15.5	64.3	12	68.5	10

M (Mean), SD (Standard Deviation). Mindful Attention Awareness-Adolescent (MAAS-A), Child and Adolescent Social Support Scale (CASSS), Difficulties in Emotional Regulation Scale (DERS), Pediatric Quality of Life Inventory (PedsQL).

Mean participant scores for mindfulness increased from B (M = 3.14, SD = 0.78) to T1 (M = 3.37, SD = 0.65) and from B to T2 (3.24, SD = 0.79). Social support scores were stable from B (M = 240.8, SD = 38.4) to T1 (M = 240.1, SD = 40.6) and increased from B to T2 (M = 246.2, SD = 43.5). Scores for emotional regulation improved from baseline (M = 98.2, SD = 24.6) to T1 (M = 88.8, SD = 18.3) and from B to T2 (M = 87.9, SD = 24.5). Quality of life scores improved from B (M = 58.8, SD = 15.5), to T1 (M = 64.3, SD = 12), and T2 (M = 68.5, SD = 10). The study was not powered to detect significant differences between study time points.

Discussion

School-based mind-body programs are an accessible, evidenced-based approach for primary prevention of mental health disorders in adolescents. ³ Yet, little is known about the adolescent perspective of mind-body modalities in an after-school group setting. The primary objectives of our study were to evaluate MBSG acceptability, collect information about the adolescent experience in an after-school MSBG, and ascertain recommendations for a manualized intervention that was originally designed for use in adult populations. We found that MBSGs are acceptable and enjoyable in the population studied, and while the study was not powered to detect significant differences between time points, there were increases in mindfulness, emotional regulation, and quality of life from baseline to 1-week post-intervention and improvements in all survey scores from baseline to 10-week post-intervention.

The MBSG had excellent retention and participation. All participants remained in the group for 8 weeks, and all but one completed at least seven of the 8 sessions. The high level of engagement indicates good acceptability as an after-school program. There is a lack of data about voluntary participation in school-based mind-body groups. However, the after-school setting may have facilitated greater attendance when compared to a clinic based MBSG, in which in which 86 percent of adolescents attended six or more MBSG sessions, and 25 percent attended all sessions. ¹³

Additional factors may have influenced MBSG engagement. First, study compensation potentially motivated session attendance for some participants. However, when asked about compensation as a motivator, participants stated that they would have attended the group regardless of the payment. Others were not aware of the compensation when deciding to participate in the group. Second, the group took place during a local surge of COVID-19 which may have exacerbated feelings of stress and increased the relevancy of the group. Last, passive recruitment methods likely attracted participants with an interest in or previous knowledge of mind-body skills. However, this also seems to vary. Some participants shared that mind-body skills were recommended to them by a mental health professional while others had little previous experience.

Participants experienced the MBSG as a safe environment for social support and sharing. This is meaningful as social connection is a protective factor for mental health ²³ and the lack thereof is significant source of stress among adolescents. ²⁴ Participants valued uninterrupted time during the check-in to talk about what was going on in their lives. Relative anonymity and the agreement of confidentiality fostered a sense of trust among group members. Trust-building took time but was important when talking about deeper things such as “mental health stuff” which participants did not always feel like they could talk about with their friends. Participants preferred meeting in-person and related the in-person group as feeling more involved. The desire for connection with others may have been heightened by the isolation felt during the concurrent COVID-19 pandemic.

Participants enjoyed learning a new skill each week, particularly skills that felt interactive (eating, touching, describing). However, they had varied experiences with specific mind-body skills. For instance, some participants enjoyed mindful eating while others found it stressful. This is consistent with previous findings where adolescents had different preferences for mind-body skills. ²⁵ Programs that teach a variety of skills may be especially beneficial because they allow participants to gain exposure to many different skills and find practices that work for them. In fact, the notion of choice may enhance program acceptability ²⁵ and promote self-efficacy. ⁶

Participants offered recommendations for program adaptations which can be used to adapt the curriculum for use in larger, more definitive trials. Future MBSGs should include intentional opportunities to build connections sooner within the group, offer more interactive experiences with mind-body skills, prioritize social, emotional, and physical comfort.

Limitations

This study has limitations. First, this was an uncontrolled, pre-post study with a small sample size that took place during the COVID-19 pandemic. Most participants were white and female. Future efforts should be made to recruit more diverse participants to understand a wider variety of perspectives. The timing of the group during the COVID-19 pandemic likely affected participant feedback regarding the group. Second, the passive recruitment methods attracted participants with an interest in mind-body skills. While this sampling bias has implications for generalizability, it was a helpful strategy for engagement in the program and the focus group. In addition, mind-body skills must be routinely practiced for optimal benefit. We did not collect information about students’ practice of the skills outside of the group.

Conclusion

This study offers new insights to understand the adolescent experience in a MBSG and adapt the program for adolescents in an after-school setting. Adolescents found the MBSG curriculum to be acceptable, valued the social connection within the group and enjoyed the opportunity to learn a variety of mind-body skills. Future research design should include a control group with a larger more diverse sample to evaluate participation in an after-school or during school setting, as well as mental health outcomes.

Supplemental Material

Supplemental Material - Adolescent Perspectives on a School-Based Mind-Body Intervention

Supplemental Material for Adolescent Perspectives on a School-Based Mind-Body Intervention by Julie M. Pike, Janet E. Panoch, Kathryn M. Haberlin-Pittz, and Tamara S. Hannon in Global Advances in Integrative Medicine and Health.