Online art therapy in elementary schools during COVID-19: results from a randomized cluster pilot and feasibility study and impact on mental health.

BACKGROUND: Emerging literature on the current COVID-19 crisis suggests that children may experience increased anxiety and depression as a result of the pandemic. To prevent such school and mental health-related problems, there is a timely need to develop preventive strategies and interventions to address potential negative impacts of COVID-19 on children's mental health, especially in school settings. Results from previous child clinical research indicate that art-based therapies, including mindfulness-based art therapy, have shown promise to increase children's well-being and reduce psychological distress. OBJECTIVE: The goal of the present pilot and feasibility study was to compare the impact of an emotion-based directed drawing intervention and a mandala drawing intervention, on mental health in elementary school children (N = 22), in the context of the COVID-19 pandemic. Both interventions were group-based and delivered online and remotely. A pilot study using a randomized cluster design was implemented to evaluate and compare both interventions in relation to child anxiety, depression, inattention and hyperactivity symptoms. RESULTS: Analyses of covariance revealed a significant effect of the type of drawing intervention on levels of inattention, after controlling for baseline levels. Participants in the emotion-based directed drawing group showed lower inattention scores at post-test, when compared to participants in the mandala group. Post-hoc sensitivity analyses showed significant decreases in pre-to-post scores for levels of hyperactivity for the complete sample. CONCLUSION: Overall, results from this pilot and feasibility study showed that both an emotion-based directed drawing intervention and a mandala drawing intervention may be beneficial to improve mental health in elementary school children, in the context of the current COVID-19 pandemic. From a feasibility standpoint, results indicate that the implementation of both interventions online and remotely, through a videoconference platform, is feasible and adequate in school-based settings. Further work incorporating larger sample sizes, longitudinal data and ensuring sufficient statistical power is warranted to evaluate the long-term impact of both interventions on children's mental health.

Philosophy for children and mindfulness during COVID-19: Results from a randomized cluster trial and impact on mental health in elementary school students.

BACKGROUND: Preliminary evidence suggests that the COVID-19 pandemic has had a negative impact on children's mental health. Given these problems can have significant impacts throughout the lifespan, preventing the negative repercussions of COVID-19 on children's mental health is essential. Philosophy for children (P4C) and mindfulness-based interventions (MBIs) show promise in this regard. OBJECTIVE: The goal of the present study was to compare the impact of online MBI and P4C interventions on mental health, within the context of the COVID-19 pandemic. We used a randomized cluster trial to assess and compare the impact of both interventions on elementary school students' (N = 37) anxiety and inattention symptoms as well as on their basic psychological need satisfaction (BPN). RESULTS: ANCOVAs revealed a significant effect of the P4C intervention on mental health difficulties, controlling for baseline levels. Participants in the P4C group showed lower scores on the measured symptoms at post-test than participants in the MBI group. Significant effects of the MBI on levels of BPN were also found. Participants in the MBI intervention reported greater BPN satisfaction at post-test than participants in the P4C intervention. CONCLUSION: Results from this study suggest that, in the current context of the COVID-19 pandemic, a P4C intervention centered around COVID-19 related themes may be helpful to reduce mental health difficulties, that a MBI may be useful to satisfy BPN, and that both interventions were easy to offer online to elementary school students. Future work including a larger sample size and follow-up measures is warranted. PUBLIC SIGNIFICANCE: Practice: Philosophy for children (P4C) and mindfulness-based interventions (MBIs) can be used to foster mental health in elementary school students, in the current COVID-19 context. Policy: As we do not anticipate that facilitators will be allowed in schools during the 2020-2021 school year and that children will, most likely, be attending school in the current COVID-19 context, policymakers who want to implement psychological support measures in elementary schools should consider an online modality, which has shown in this study to work well, be feasible, and yield positive results on youth mental health.

Impact of a Combined Philosophy and Mindfulness Intervention on Positive and Negative Indicators of Mental Health Among Pre-kindergarten Children: Results From a Pilot and Feasibility Study.

Background: Fostering greater resiliency to stress, optimal psychosocial development and promoting better mental health and well-being in youth is an important goal of the Canadian and American elementary school systems (1, 2). Recent research on mindfulness and philosophy for children (P4C) has yielded promising results regarding innovative interventions that may be implemented in elementary school settings to foster greater child resiliency and well-being (3-5). Goal: The goal of this feasibility study was to pilot a new intervention, which combines mindfulness meditation and P4C activities, with the goal of improving mental health in pre-kindergarten children, assessed with positive (i.e., social skills and adaptability) and negative (i.e., internalized symptoms, comprises depression, anxiety, inattention; and hyperactivity) indicators. Methods: A randomized cluster trial with a wait-list control group was employed to evaluate the impact of the combined MBI and P4C intervention on child mental health. Two classrooms of pre-kindergarten children (N = 38, mean age = 4.6 years old) took part in this study and were randomly allocated to the experimental or wait-list control conditions. Teachers completed pre- and post-intervention questionnaires. Results: ANCOVAs did not reveal a significant effect of condition on internalized symptoms, controlling for baseline levels. Sensitivity analyses indicated that for the whole sample, internalized symptom scores were statistically significantly lower at post-intervention, when compared to pre-intervention scores. No impact of group on levels of hyperactivity was found, however, sensitivity analyses indicated that for both the experimental and control groups, hyperactivity scores were statistically significantly lower at post-intervention, when compared to pre-intervention scores. Finally, no impact of group on levels of social skills and adaptability were found. Sensitivity analyses conducted using paired t-tests did not indicate statistically significant pre-to-post changes in scores for both variables. Conclusion: These preliminary results suggest that mindfulness and philosophy for children may not be the most effective intervention to foster short-term resiliency, well-being and better mental health in children. Yet, group differences were often small and past research suggested the effectiveness of this type of intervention. Further research considering the impact of moderators such as age or baseline levels of psychopathology, using longer time frames and comparing the effectiveness of this combined intervention with other types of school-based interventions with similar aims (such as, e.g., P4C or MBI alone) is warranted, to evaluate if mindfulness and P4C interventions have an added value compared to other types of interventions implemented in school settings.

Impact of a Mindfulness-Based Intervention on Basic Psychological Need Satisfaction and Internalized Symptoms in Elementary School Students With Severe Learning Disabilities: Results From a Randomized Cluster Trial.

BACKGROUND: Mindfulness is hypothesized to lead to more realistic appraisals of the three basic psychological needs, which leads people to benefit from high levels of need satisfaction or helps them make the appropriate changes to improve need satisfaction. Mindfulness-based interventions (MBIs) have also shown promise to foster greater basic psychological need satisfaction in students with learning disabilities (LDs). OBJECTIVE: The goal of the present study was to evaluate the impact of a MBI on the satisfaction of the basic psychological needs and on internalized symptoms in students with severe LDs. A randomized cluster trial was implemented to compare the progression of need satisfaction, anxiety, and depression symptoms in participants pre- to post-intervention and at follow-up. METHOD: Elementary school students with severe LDs (N = 23) in two special education classrooms took part in this study and were randomly attributed to either an experimental or an active control group. RESULTS: Mixed ANOVAs first showed that the experimental condition did not moderate change over time such that similar effects were observed in the experimental and active control groups. Looking at main effects of time on participants' scores of autonomy, competence, and relatedness across time, we found a significant within-person effect for the competence need (p = 0.02). Post hoc analyses showed that for both groups, competence scores were significantly higher at post-intervention (p = 0.03) and at follow-up (p = 0.04), when compared to pre-intervention scores. A significant main effect was also found for anxiety levels over time (p = 0.008). Post hoc analyses showed that for both groups, scores were significantly lower at post-intervention (p = 0.01) and at follow-up (p = 0.006), when compared to pre-intervention scores. CONCLUSION: Although the MBI seemed useful in increasing the basic psychological need of competence and decreasing anxiety symptoms in students with severe LDs, it was not more useful than the active control intervention that was used in this project. Future studies should verify that MBIs have an added value compared to other types of interventions that can be more easily implemented in school-based settings.

Can the Mindful Awareness and Resilience Skills for Adolescents (MARS-A) Program Be Provided Online? Voices from the Youth.

Mindfulness-based interventions (MBIs) have been shown to improve health and well-being in adolescents with chronic illnesses. Because they are most often delivered in person in a group setting, there are several barriers that limit access to MBIs for youth with limited mobility or who cannot access in-person MBIs in their communities. The objective of this study was to determine if eHealth is a viable platform to increase accessibility to MBIs for teens with chronic illnesses. This study reports the qualitative results of a mixed method randomized trial describing the experience of the Mindful Awareness and Resilience Skills for Adolescents (MARS-A) program, an eight-week MBI, delivered either in person or via eHealth. Participants were adolescents between the ages of 13 and 18 with a chronic illness recruited at a tertiary pediatric hospital in Toronto, Canada. Individual semi-structured post-participation audio-video interviews were conducted by a research assistant. A multiple-pass inductive process was used to review interview transcripts and interpret emergent themes from the participants' lived experiences. Fifteen participants (8 online and 7 in person) completed post-participation interviews. Four distinct themes emerged from participants in both groups: Creation of a safe space, fostering peer support and connection, integration of mindfulness skills into daily life, and improved well-being through the application of mindfulness. Direct quotations representative of those four themes are reported. Results from this study suggest that eHealth delivery of an adapted MBI for adolescents with chronic illnesses may be an acceptable and feasible mode of delivery for MBIs in this population. EHealth should be considered in future studies of MBIs for adolescents with chronic illnesses as a promising avenue to increase access to MBIs for youth who might not be able to access in-person programs.

In-Person Versus eHealth Mindfulness-Based Intervention for Adolescents With Chronic Illness: Protocol for a Randomized Controlled Trial.

BACKGROUND: Eight-week mindfulness-based interventions (MBIs) have a beneficial impact on mental health and well-being in adolescents with chronic health conditions. Usually delivered in person in a group setting, these programs are difficult to access for teens with disabilities or who do not have in-person MBIs available in their communities. OBJECTIVE: This paper outlines the rationale, development, and design of a randomized controlled trial comparing the effects of an MBI delivered in person or via eHealth in adolescents with a chronic illness. Quantitative outcomes will include mindfulness skills acquisition (primary outcome), effects of the MBI on self-reported mood, anxiety, self-esteem, illness perception, and physiological stress (via salivary cortisol), and qualitative outcomes will include individual practice, participant appreciation, and adaptation of the MBI for eHealth. METHODS: This is a randomized noninferiority mixed methods study comparing 2 MBI arms: in-person and eHealth. Participants are eligible to participate if they are aged 13 to 18 years, have a diagnosis of chronic medical condition, live close enough to the recruitment hospital to participate in the in-person arm of the study, and are currently followed by a health care provider. Each participant will receive an adapted 8-week MBI delivered either in person at a tertiary pediatric hospital or via a secure audio-visual platform allowing group interactions in real time. Groups will be facilitated by 2 experienced mindfulness providers. Quantitative and qualitative data will be collected through standardized research questionnaires administered via a secure, youth-friendly online platform and through semistructured interviews, participant log books, facilitator log books, and salivary cortisol analysis. Qualitative data will be analyzed using a grounded theory model. RESULTS: Data collection is currently underway. Data analysis, manuscript writing, and additional publications are expected to be completed in the winter and spring of 2018. CONCLUSIONS: Based on previous results from in-person trials conducted in adolescents and eHealth trials conducted in adults, we anticipate that both modes of delivery will significantly improve mindfulness skills acquisition, mood, anxiety, self-esteem, illness perception, and stress and that the magnitude of the effects will be correlated to the level of home practice. We predict that participants in both arms will show similar levels of home practice and that both modes of delivery will have high levels of feasibility and acceptability. If successful, this study could provide evidence for the use of eHealth in the delivery of 8-week MBIs in clinical adolescent populations, potentially increasing availability to MBIs for a large group of youth with mobility issues or living away from large urban centers. TRIAL REGISTRATION: ClinicalTrials.org NCT03067207; https://clinicaltrials.gov/ct2/show/NCT03067207 (archived by WebCite at http://www.webcitation.org/6v4ZK8RBH).

Mindfulness-based Intervention in Elementary School Students With Anxiety and Depression: A Series of n-of-1 Trials on Effects and Feasibility.

Mindfulness-based interventions constitute a promising option to address anxiety and depression in elementary school students. This study evaluated the effect of a mindfulness-based intervention on anxiety and depression in elementary school students with a diagnosis of anxiety or depression disorder. A single-subject experimental A-B-A design was used. Participants were three elementary school students from grades three and four, along with their teacher. Anxiety and depression were measured on 10 occasions at baseline, during the intervention, and at follow-up. Primary hypotheses were tested using a univariate single case multilevel modeling strategy and visual analysis. Following intervention, 2 participants reported improvements on anxiety and depression, while their teachers reported deteriorating scores on these variables. Results from this n-of-1 trial design is consistent with other work suggesting caution with regard to the overall impact and efficacy of mindfulness-based interventions as a universal treatment option for youth. Future research is warranted.

A Mindfulness-Based Intervention Pilot Feasibility Study for Elementary School Students With Severe Learning Difficulties: Effects on Internalized and Externalized Symptoms From an Emotional Regulation Perspective.

OBJECTIVE: Students with severe learning disabilities often show signs of anxiety, depression, and problem behaviors such as inattention and conduct problems. Mindfulness-based interventions (MBIs) in school settings constitute a promising option to alleviate these co-occurring symptoms. This pilot study aimed to evaluate the impact of an MBI on symptoms and behaviors of elementary school students with severe learning disabilities. METHOD: A one-group pretest-posttest design was used. The sample comprised 14 students aged 9 to 12 years with special education needs. Both student-report and teacher-report of the Behavior Assessment System for Children, Second Edition were used. RESULTS: Repeated-measures analyses of variance revealed a significant impact of the MBI on symptoms and behaviors such as anxiety, depression, inattention, aggression, and conduct problems. Effect sizes for all variables were considered large (partial η2 = .31-.61). CONCLUSION: These preliminary results indicate that MBIs can reduce the frequency of symptoms and problem behaviors often found in children with learning disabilities in elementary schools. Further multiple baseline experimental trials with a long-term follow-up are warranted to establish more robustly the effect of MBIs for children with learning disabilities.

Mindfulness-based Intervention for Female Adolescents with Chronic Pain: A Pilot Randomized Trial.

OBJECTIVE: To test the feasibility of a randomized-controlled trial measuring the impact of an adapted mindfulness-based intervention (MBI) in female adolescents with chronic pain. METHODS: This was a single center, single-blind, prospective, experimental, longitudinal trial conducted in a pediatric tertiary care center. Participants had a history of chronic pain during at least three months. They were randomized into an intervention group or a wait-list control group. Both groups successively followed an adapted eight-week MBI designed specifically for adolescents with chronic pain. Pre-determined criteria were established to assess the feasibility, validity and acceptability of the study model. Data evaluating changes in quality of life, depression, anxiety, pain perception, psychological distress and salivary cortisol were collected throughout the 4-month study period. RESULTS: Nineteen female participants completed the study and had a mean age of 15.8 years (range 13.9 -17.8). Attrition rate was low (17%). Attendance to mindfulness sessions (84%) and compliance to study protocol (100%) were high. All participants reported a positive change in the way they coped with pain. No changes in quality of life, depression, anxiety, pain perception, and psychological distress were detected. Significant reductions in pre-and post-mindfulness session salivary cortisol levels were observed (p<0.001). CONCLUSIONS: Mindfulness is a promising therapeutic approach for which limited data exist in adolescents with chronic pain. Our study indicates the feasibility of conducting such interventions in teenage girls. A large trial is needed to demonstrate the efficacy and bio-physiological impacts of MBIs in teenagers with chronic pain.

OBJECTIF: Vérifier la faisabilité d'un essai randomisé contrôlé qui mesure l'effet d'une intervention de pleine conscience (IPC) adaptée chez des adolescentes souffrant de douleur chronique. MÉTHODES: Il s'agissait d'un essai monocentrique, à l'insu, prospectif, expérimental, longitudinal mené dans un centre soins tertiaires pédiatriques. Les participantes avaient des antécédents de douleur chronique durant au moins trois mois. Elles ont été randomisées soit dans un groupe d'intervention, soit dans un groupe témoin placé sur une liste d'attente. Les deux groupes ont suivi successivement une IPC adaptée de 8 semaines, conçue spécifiquement pour les adolescentes souffrant de douleur chronique. Des critères prédéterminés ont été établis pour évaluer la faisabilité, la validité et l'acceptabilité du modèle d'étude. Les données évaluant les changements touchant la qualité de vie, la dépression, l'anxiété, la perception de la douleur, la détresse psychologique et le cortisol salivaire ont été recueillies durant la période de 4 mois de l'étude. RÉSULTATS: Dix-neuf participantes ont participé à l'étude et leur âge moyen était de 15,8 ans (écart de 13,9 à 17,8). Le taux d'attrition était faible (17 %). L'assistance aux séances de pleine conscience (84 %) et l'observance du protocole de l'étude (100 %) étaient élevées. Toutes les participantes ont déclaré un changement positif de la façon dont elles traitaient avec la douleur. Aucun changement n'a été détecté en ce qui concerne la qualité de vie, la dépression, l'anxiété, la perception de la douleur, et la détresse psychologique. Des réductions significatives des taux de cortisol salivaire avant et après les séances de pleine conscience ont été observées (p < 0,001). CONCLUSIONS: La pleine conscience est une approche thérapeutique prometteuse pour laquelle il n'existe que des données limitées pour les adolescentes souffrant de douleur chronique. Notre étude indique la faisabilité de mener ces interventions auprès d'adolescentes. Il faut un vaste essai pour démontrer l'efficacité et les effets biophysiologiques des IPC chez les adolescentes souffrant de douleur chronique.

Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies.

BACKGROUND: Emotional competencies are extremely important for healthcare providers exposed to patients' suffering. The effect of mindfulness-based stress reduction (MBSR) has been studied in this population. However, it is unclear whether capacities identified as core for care are modified favourably by this intervention. OBJECTIVES: (1) To identify outcomes in studies on the effect of MBSR in healthcare providers. (2) To evaluate the impact of MBSR on these outcomes. (3) To assess current knowledge on whether capacities central to care are positively impacted by MBSR: empathy, identification of one's own emotions, identification of other's emotions and emotional acceptance. METHODS: We performed a systematic review on interventional studies published up to 2015 evaluating the effect of MBSR in healthcare professionals. A subset of studies including empathy and emotional competencies was assessed for bias following current methodological standards. RESULTS: Thirty nine studies were identified. 14/39 studies measured empathy or some form of emotional competence in healthcare providers. Evidence regarding the effects of MBSR in professionals suggests this intervention is associated with improvements in burnout, stress, anxiety and depression. Improvements in empathy are also suggested but no clear evidence is currently available on emotional competencies. CONCLUSIONS: High quality evidence is available on the effect of MBSR on professionals' mental health. However, while some emotional competencies have been identified as being of major importance for high quality care, they are still scarcely studied. Studying these outcomes is important, as it may help explain how mindfulness contributes to professionals' mental health and thus help develop targeted interventions.

Mindfulness-based intervention for teenagers with cancer: study protocol for a randomized controlled trial.

BACKGROUND: Individuals living with cancer must learn to face not only the physical symptoms of their condition, but also the anxiety and uncertainty related to the progression of the disease, the anticipation of physical and emotional pain related to illness and treatment, the significant changes implied in living with cancer, as well as the fear of recurrence after remission. Mindfulness-based meditation constitutes a promising option to alleviate these manifestations. METHODS/DESIGN: This article presents the rationale and protocol development for a research project aimed at evaluating the effects of a mindfulness-based meditation intervention on quality of life, sleep, and mood in adolescents with cancer compared to a control group. A prospective, longitudinal, experimental design involving three time points (baseline, post-intervention, and follow-up) and two groups (experimental and control) was developed for this project. Participants will be assigned randomly to either group. Eligible participants are adolescents aged 11 to 18 years with a diagnosis of cancer, with no specific selection/exclusion based on type, stage, or trajectory of cancer. A final sample size of 28 participants is targeted. Adolescents in the experimental group will be completing the mindfulness meditation intervention, taught by two trained therapists. The intervention will comprise of eight weekly sessions, lasting 90 min each. Once the follow-up assessment is completed by the experimental group, wait-list controls will be offered to complete the mindfulness-based program. Intra-group analyses will serve to evaluate the impact of the mindfulness-based meditation intervention on quality of life, sleep, and mood pre-post intervention, as well as follow-up. Analyses will also be used to carry out inter-group comparisons between the experimental group and the wait-list controls. Voluntary participation, risk of attrition, and the small sample size are potential limitations of this project. In spite of possible limitations, this project will be one among very few aimed at improving quality of life, sleep, and mood in adolescents living with cancer, will evaluate the potential benefits of such a practice on both psychological and physical health of youth with cancer, and help in creating mindfulness-based intervention programs, in order to provide the necessary psychological help to adolescents living with cancer. TRIAL REGISTRATION NUMBER: NCT01783418.