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Mindfulness and Urban Youth Erica M S Sibinga, MD, MHS General Pediatrics & Adolescent Medicine Johns Hopkins School of Medicine December 4, 2009
Learning objectives • Improve understanding of mindfulness • Review effects of mindfulness in adults • Learn about mindfulness for youth • No conflicts of interest to disclose
What is mindfulness? Mindfulness is a conscious, moment-to-moment awareness, cultivated by systematically paying attention on purpose in a particular way. —Jon Kabat-Zinn
Mindfulness qualities • Non-judging • Patience • Beginner’s Mind • Trust • Non-striving • Acceptance • Letting Go
Popular interest Oprah—“Missing the Moment” (Oprah.com) Trying to live fully in the present—or, said another way, "being in the moment"—is a challenging proposition. We frequently get caught up in our routines, habits and thoughts, and find ourselves feeling disconnected from what is happening around us…or even within our own bodies. Instead, we spend our time and energy creating to-do lists and dwelling in the past.These thought patterns—wishing, hoping, planning, missing and regretting—prevent us from truly being present and from completely engaging in what is happening in our lives right now…in the present moment. Instead, we often find ourselves running on "autopilot"—without conscious awareness—because we have literally become lost in our thoughts.
Mindfulness-based stress reduction (MBSR) program • Developed by Jon Kabat-Zinn, 1979 • MBSR core elements Grossman 2004; Kabat-Zinn 1990 • Structured 8-10 week program • Groups typically 10-40 participants • Approximately 2 hours per session • Content: • mindfulness meditation practice • mindful awareness during yoga postures • mindfulness during stressful situations • MBSR instructor training (UMass)
MBSR evidence—adults • MBSR is beneficial in heterogeneous populations of adults (including healthcare providers) Kabat-Zinn, Carlson, Davidson, Antoni, Robinson, Grossman, Baer, Krasner, etc. • Improved mental health • Improved quality of life • Improved immune parameters • Enhanced response to flu vaccine
MBSR evidence—emerging for children and youth • Few published studies on MBSR for youth • Case studies, multi-modal studiesOtt, Wall, Bootzin • HIV-infected youth Sibinga • Outpatient psychiatric patients Biegel
Possible MBSR mechanism(s) • Likely multiple pathways and/or synchrony of brain waves Goldin, Singer • “Re-perceiving” (shift in perspective) Shapiro • Decrease in rumination • Rumination mediates MBSR’s effect on psychological distress & depression Jain, Ramel • Decrease self-centerednessHutcherson, Farb • fMRI shows less activity in self-focused region of brain • Decrease negative automatic responses Hutcherson • Brief meditation interrupts automatic negative responses
The Three Breaths Break Stop and Pause • When you are stressing or busy or on automatic pilot, just stop. Stop everything. Put everything down a minute. Turn off the music or the TV, or leave the room. Close your eyes. • Take three mindful breaths. Just drop into the breath, this breath. Nothing to do, nowhere to go in this moment. Say to yourself “in” with the in-breath and “out” with the out-breath.
Preliminary studies • Uncontrolled study of MBSR program • Mixed methods (survey & interview) • IRB approved • N=33; 26 (79%) completers • Post-program improvement in: • Hostility (p = 0.02) • Overall discomfort (p = 0.01) • Emotional discomfort (p = 0.02)
Results—qualitative data (N= 15) • Interview data—5 themes emerged • Decreased anger • Fewer conflicts • Improved relationships • Improved coping skills • Improved physical well-being
Improved coping skills • “Breathing meditation—use it everyday at work. Helps me calm myself, prepare for my day.” • “Learning that I control my stress. It’s up to you whether you allow yourself to be stressed or not.”
Fewer conflicts • “I’ve actually practiced it the other day. I was about to get in an argument. I just sat there and I took three breaths and did my own little counting in my head and took three more breaths. And I was actually calm and left the argument—just let it be.” • “Before I would say ‘I’m gonna smack you’ and actually hit people. Now I be more calm. I say ‘Can you please stop’.”
Conceptual framework for MBSR effects PSYCHOLOGICAL & INTERPERSONAL FUNCTIONING Psychological symptoms Mood states Interpersonal functioning APPRAISAL & COPING PROCESSES Threat appraisal Perceived stress Coping mechanisms HEALTH- RELATED BEHAVIORS MBSR Mindfulness
Pilot RCT—MBSR vs. active control • Harriet Lane Clinic patients • 13-21 years old • Mixed methods • Quantitative—mental health, quality of life, stress • Qualitative—individual structured interview • IRB approved
Active control—Healthy Topics (HT) • Age-appropriate health education curriculum (e.g., nutrition, physical activity, etc.) • positive adult instructor • effects of peer group participation • learning new information • matched for session frequency and length, time of day, group size • Does NOT include instruction in meditation
Results: Quantitative • MBSR vs. HT participation • Increased coping self-efficacy (p=0.26) • No differences seen in other mental health, physical health, stress measures
Results: Qualitative • Qualitative—individual interviews • In-person semi-structured interview re: experience with MBSR & HT programs, techniques, skill acquisition, etc. • Interviews continued until themes saturated • 20 interviews • HT—8 • MBSR—12
MBSR—Change w/ stressor • I was a little embarrassed because I really never got fussed out in front of friends or anything like that. So I took a minute and breathed in and out. And that's that. Because at that point in time, I would sometimes maybe fuss back at him. Or something like that. So I just stopped altogether and started through. And I went to the kitchen. I sat down on the floor and I said, "Dad, she is having a funeral in two days and I need to do her hair because she couldn't go out and get her hair done. Now, is it okay that I do it? I know that it wasn't right for me not to ask you before I brought someone over." And then I stopped and looked at him. So I believe that thinking things through with the mindful-thinking, I was able to solve this situation. Because that situation would have blown up and she would have got put out, and I would have been punished. That's what I think would have happened if I didn't think. Which I usually didn't do, but I do now.
Small RCT—thoughts so far • MBSR participants showed increased coping self-efficacy, as well as expressing more self-awareness and self-regulation • HT seems to function as an effective control group for MBSR in this population
Mindfulness Mindfulness is a conscious, moment-to-moment awareness, cultivated by systematically paying attention on purpose in a particular way. —Jon Kabat-Zinn
APPRECIATIONS • Study participants • Collaborators • Katie Thorpe • Carisa Perry-Parrish, PhD • Deanna Kerrigan, PhD • Miriam Stewart • Melissa Heuer • Trish Magyari, MS • Cora Welsh, CCLS • Nancy Hutton, MD • Shana Millstein, PhD • Jonathan Ellen, MD • Funded in part by: • Thomas Wilson Sanitarium for the Children of Baltimore City • The Hawn Foundation
Resources • Wherever You Go, There You Are (Kabat-Zinn, 2005) • Coming to Our Senses: Healing Ourselves and the World Through Mindfulness (Kabat-Zinn, 2005) • Everyday Blessings: The Inner Work of Mindful Parenting (Kabat-Zinn, 1998) • National Center for Complementary & Alternative Medicine (nccam.nih.gov) • Mayo Clinic website (mayoclinic.com) • Culbert, Timothy (mind-body approaches for children) • Be the Boss of Your Pain; …Stress; …Sleep