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Supporting emotional wellbeing in schools: A pilot study into the efficacy of a mindfulness-
based group intervention on anxious and depressive symptoms in children
Catherine Dove
Faculty of Education
Monash University
Shane Costello
Faculty of Education
Monash University
57 Scenic Blvd
Clayton AUSTRALIA 3800
Email: shane.costello@monash.edu
This is a preprint manuscript of the article which was published in Advances in Mental Health. The
final published article can be found at http://dx.doi.org/10.1080/18387357.2016.1275717
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Abstract
Objective: This study examines the efficacy of a six week child mindfulness program (TRIPLE R)
in teaching mindfulness skills and reducing negative emotional symptoms in a school setting.
Method: Using a correlational within-subjects repeated measures design, the relationships between
child self-reported mindfulness skills and negative emotional symptoms were explored.
Mindfulness skills were measured using the Child and Adolescent Mindfulness Measure (CAMM;
Greco, Baer & Smith, 2011), and emotional symptoms were measured using the Revised Children’s
Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000). A
sample of 57 Australian grade 5 children in three primary schools completed the measures pre and
post intervention.
Results: There was a small to moderate increase in mindfulness skills post intervention (Cohen’s d
= 0.32), however negative emotional symptoms did not significantly improve. Increased
mindfulness skills were significantly associated with decreased emotional symptoms, most notably
for symptoms related to social phobia (R = -.61), separation anxiety (R = -.42) and generalised
anxiety (R = -.32).
Discussion: This study provides preliminary support for the TRIPLE R program and the potential
benefits of school-based mindfulness interventions in improving children’s wellbeing. The limited
improvement in negative emotional symptoms is likely related to the non-clinical sampling. The
relationship between increased mindfulness skills and decreased emotional symptoms is discussed,
and recommendations for further research are presented.
Keywords: mindfulness, anxiety, depression, wellbeing, children, school
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Supporting emotional wellbeing in schools: A pilot study into the efficacy of a mindfulness-
based group intervention on anxious and depressive symptoms in children
Introduction
In today’s society, children experience increasing challenges. They are expected to manage
high study demands, social relationships, social media, and navigate their own thoughts and
feelings and associated developmental changes as they hit puberty; all within the backdrop of
varying familial stability, support, and personal and learning capabilities (Thompson & Gauntlett-
Gilbert, 2008). Schools are increasingly searching for ways to foster a capacity for resilience and
wellbeing in children, and to provide early intervention during primary school to teach a range of
skills and techniques that enhance children’s self-awareness, coping and social skills (Huppert &
Johnson, 2010; Napoli et al., 2005). Mindfulness is proving a successful intervention to improve
wellbeing in adults (Kabat-Zinn, 2003; Keng, Smoski, & Robins, 2011), and is being used
increasingly with both adolescents and children (Thompson & Gauntlett-Gilbert). Research into the
effectiveness of schools-based interventions using mindfulness techniques is growing, and initial
studies show promise for improving wellbeing in children (Liehr & Diaz, 2010; Kuyken et al.,
2013).
Mindfulness has been defined as “the awareness that emerges through paying attention on
purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by
moment” (Kabat-Zinn, 2003, p.145). The process and practice of mindfulness has in Buddhist
philosophy long been believed to alleviate suffering that is experienced when the mind is focused
on the past or future. In returning to the present moment, mindfulness helps counter experiential
avoidance strategies (Hofmann, Sawyer, Witt & Oh, 2010), which contribute to the maintenance of
many emotional disorders (Hayes, 2004). Mindfulness can bring alleviation from anxious and
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depressive symptoms, and contribute to general wellbeing (Grossman, Niemann, Schmidt, &
Walach, 2004; Keng et al., 2011). Increased awareness and non-judgmental observation of
thoughts and feelings can positively impact emotional regulation and lead to alternative behavioural
choices that positively impact relationships (Hayes & Feldman, 2004; Huppert & Johnson, 2010;
Thompson & Gauntlett-Gilbert, 2008). Increased mindfulness practice can improve attention and
cognitive functioning (Keng et al.), positively impacting learning, problem solving, and decision-
making (Huppert & Johnson, 2010).
Although research has predominantly centred on the impact of mindfulness on
psychological wellbeing in adults, recent attention has focused on studying the effects of
mindfulness in children and adolescents. Evidence has shown that individuals with earlier onset of
anxious or depressive symptoms are at greater risk for anxiety or mood disorders later in life as well
as other psychological issues and disorders (Costello, Egger & Angold, 2005), and increasing
numbers of children and adolescents are being diagnosed with anxiety or depressive disorders
(Farrell & Barrett, 2007; ter Wolbeek, van Doornen, Kavelaars, Tersteeg-Kamperman & Jeijnen,
2011).
As childhood development lays the foundation for wellbeing in adulthood (Costello et al.,
2005), and children are facing increased pressures to perform academically, to navigate social
media and manage relationship issues, as well as function in changing family systems (Napoli et al.,
2005) it is more important than ever to foster mental health from an early age. Early intervention
and preventative programs that enhance wellbeing, coping and social skills in children must be a
priority (Esbjorn, Somhovd, Turnstedt, & Reinholdt-Dunne, 2012). While previous programs
which focused on teaching problem solving and social skills had limited effect, more recent studies
are attempting to replicate effective interventions for adults in child populations (Joyce, Etty-Leal,
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Zazryn, & Hamilton, 2010). Napoli et al. advocated for the growing role schools play in
implementing prevention programs, and incorporating mindfulness practices and training into the
classroom.
Research investigating mindfulness in children is limited although growing (Burke, 2010;
Thompson & Gauntlett-Gilbert, 2008). In a review of the current research on mindfulness-based
approaches for children and adolescents, Burke discussed a small number of existing studies that
show tentative evidence for improvements in anxiety symptoms, attention deficit hyperactive
disorders, attention, and social skills in clinical and non-clinical samples of school children;
although references numerous limitations in the research. In a non-randomised controlled study,
Kuyken et al. (2013) found that a Mindfulness in Schools Program delivered over 9 weeks to 12-16
year olds was effective in teaching mindfulness skills, reducing depressive symptoms and stress,
and in enhancing wellbeing. Huppert and Johnson (2010) found that modified short mindfulness
for adolescent student males failed to provide significant differences between mindfulness and
control groups on measures of mindfulness, resilience and psychological wellbeing, but did produce
positive association in the mindfulness group between amount of practice and improvement in
psychological wellbeing and mindfulness.
In a pilot study with children from minority backgrounds, a Mindful Schools-designed
program of mindfulness delivered in ten 15-minute classes every day for two weeks reduced
anxious and depressive symptoms in 8-11 year olds (Liehr & Diaz, 2010). In a pilot study with
Australian children aged 10-13 years using 45 minute mindfulness program over 10 sessions,
designed to be congruent with principles outlined by Kabat-Zinn (1994), Joyce et al. (2010) found a
decrease in self-reported anxiety and depressive symptoms, and an increase in teacher-reported
improvements in emotional health. While there were no control groups or long term follow up, this
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research provides support for a tailored intervention within schools that successfully teaches
mindfulness skills and reduces anxious and depressive symptoms in Australian 10-13 year olds.
To date, research has been restricted by a lack of quantitative research and substantial
empirical evidence, small samples and lack of control groups (Burke, 2010). In addition none of
the above studies used an empirically validated mindfulness measure specifically designed for
children and/or adolescents to assess mindfulness skills pre and post treatment. Kuyken et al.
(2013) measured mindfulness postintervention by asking questions regarding practice; Joyce et al.,
(2010) asked teachers to provide a one-page reflection on their teaching of mindfulness meditation
and associated barriers; Liehr and Diaz (2010) indicated no mindfulness measurement and Napoli et
al. (2005) used a measure of attention. Huppert and Johnson (2010) measured mindfulness pre and
post intervention using the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R;
Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007), although this measure was designed for
use with clinical adult populations.
While a number of self-reported assessment measures for mindfulness have been developed
for use in adult populations (Bergomi, Tschacher, & Kupper, 2013), few exist for children. The
first measure of mindfulness specifically for children and adolescents, the Child and Adolescent
Mindfulness Measure (CAMM) was developed recently (Greco, Baer & Smith, 2011), and has been
found to be reliable and valid with children as young as nine years (de Bruin, Zijlstra & Bogels,
2014; Greco et al., 2011). The Mindfulness Attention Awareness Scale (MAAS), an adult measure,
has been adapted for use with children (Lawlor, Schonert-Reichl, Gadermann & Zumbo, 2014)
although there are concerns regarding the developmental appropriateness of simply adapting adult
measures for use with children (Watt, Hopkinson, Costello, & Roodenburg, 2016).
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The aim of the current study was to investigate the efficacy of a mindfulness-based
intervention for children, delivered in a school setting. It was expected that children’s self-reported
mindfulness skills would be higher postintervention (Time 2) than preintervention (Time 1). It was
also expected that children’s self-reported negative emotional symptoms would be lower
postintervention (Time 2) compared to preintervention (Time 1). Finally, it was expected that there
would be an inverse relationship between the change in children’s self-reported mindfulness skills
and emotional symptoms across time.
Method
Participants
Three government primary schools in Melbourne, Australia elected to be involved in the
program, which was supported by local government funding. A fourth school commenced the
program however was excluded from the study as no post program data was available. The
program was delivered to 72 children enrolled in grade 5 (typically aged nine to 10 years). Pre and
post measures were unable to be matched for 15 children due to either being absent at either data
collection time (six children) or incorrect use of codes (nine children), and were therefore omitted
from analysis. The data provided by 57 children (37 males) are included in this study.
Sampling across the schools varied. One school chose to deliver the program to an entire
class, while two schools chose to screen children for inclusion according to a range of criteria:
identified by parents or teachers as having difficulties with anxious or depressive symptoms
manifested through school nonattendance, limited peer friendships, social isolation/withdrawal,
non-participation in class activities, and/or repeated attendance at sick bay. Participation was
voluntary and children were considered eligible if parents consented to their attendance, and
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counselling for ongoing support after the completion of the program was made available if desired.
Participants were free to withdraw from the program at any time if parents wished to do so.
Procedures
Program intervention
The six week intervention program (TRIPLE R: Robust, Resilient, Ready to Go) was
developed by a non-government organisation and the delivery was supported by provisionally
registered psychologists enrolled in Master of Psychology (Counselling) and Master of Psychology
(Educational and Developmental) courses. At least one school teacher was present at each session.
Ethics approval was granted for evaluation of the TRIPLE R program by the Monash University
Human Research Ethics Committee (project no: CF14/2118 – 2014001119). The program was
delivered during the school term.
The program was developed based on a range of mindfulness principles and
developmentally appropriate exercises for children as outlined by Snel (2013). Each one hour
weekly session provided a combination of psycho-education, activities and mindfulness practice
centred on a particular theme, such as the body, feelings, mind, and relationships. Each session
consisted of whole-group activities and also included activities for groups of three to five children,
which were then discussed in plenary. Allocation to smaller groups was random.
Session one provided an outline of the program, an understanding of mindfulness, and the
opportunity for children and facilitators to get to know each other. Session two focused on naming
and understanding feelings, and practicing observing different feelings in the body. Session three
focused on understanding how and where different sensations and feelings manifest in the body.
Session four focused on the mind, observing thoughts, and discussing how they relate to feelings
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and sensations. Session five focused on mindful relationships, understanding elements of healthy
and unhealthy friendships and how behaviour impacts others. Session six focused on reviewing
learning over the six week program and engages children in a feedback process. Each session
started with a brief mindfulness practice and ended with an audio guided mindfulness exercise
written by Snel (2013). The program was delivered at the same time each week during term time.
Measures
Mindfulness was measured using the Child and Adolescent Mindfulness Measure (CAMM).
The CAMM was developed to be used with children from nine years old (Greco et al., 2011), and
was adapted from the Kentucky Inventory of Mindfulness Skills (Baer, Smith & Allen, 2004). The
CAMM is a 10 item scale that assesses present-moment awareness and nonjudgmental, non-
avoidant responses to thoughts and feelings. Respondents are asked to rate how often each item is
true for them using a five point scale from 0 (never) to 4 (always). Greco et al. found that the
CAMM scale demonstrated strong internal consistency with a sample of American children aged 10
to 16 years (α = .81). In a Dutch translation, De Bruin et al. (2014) also reported high levels of
internal consistency for children aged 10 to 12 years (α = .71), and adolescents aged 13 to 16 years
(α = .80). In the current study, the CAMM demonstrated good reliability at both preintervention (α
= .64) and postintervention (α = .72).
Symptoms were measured using the Revised Children’s Anxiety and Depression Scale
(RCADS; Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000). The RCADS was designed to
measure symptoms specific to the DSM-IV (APA, 1994) anxious and depressive disorders for
children aged 8 to 18 years (Chorpita et al., 2000, de Ross, Gullone, & Chorpita, 2002). The
RCADS is a 47 item self-report questionnaire consisting of five scales related to anxiety symptoms;
Separation Anxiety Disorder (SAD), Social Phobia (SP), Generalised Anxiety Disorder (GAD),
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Panic Disorder (PD) and Obsessive Compulsive Disorder (OCD); and one scale related to
depression symptoms, Major Depressive Disorder (MDD).
Respondents are asked to rate how often each item is true for them on a 4-point scale from 0
(never) to 3 (always). Chorpita et al. (2000) demonstrated good validity and internal reliability with
an American sample, with Cronbach’s alpha coefficients ranging from .71 to .85 for the subscales.
De Ross et al. (2002) extended this work with Australian samples of 8 to 12 year olds and 13 to 18
year olds, demonstrating good internal consistency (subscale Cronbach’s alpha coefficients ranging
from .79 and .88). Chorpita, Moffitt and Gray (2005) demonstrated support for the RCADS in a
further clinical American sample, and Esbjorn et al., (2012) in a Danish national sample recruited
through community schools. In the current study the RCADS was found to be reliable for each
subscale both pre and postintervention (SP: α = .87 and α = .91 respectively; PD: α = .86 and α
= .83; MDD: α = .81 and α = .80; SAD: α = .80 and α = .73; GAD: α = .89 and α = .86; OCD: α
= .70 and α = .70.
Data preparation
Prior to any analysis, the data was screened for missing and extreme values. Missing values
were replaced using the SPSS expectation-maximisation (EM) technique, which uses a maximum
likelihood approach to iteratively generate values using a normal distribution (Little & Rubin, 2002;
Pigott, 2001). No significant difference was obtained between variable means both before and after
implementing EM at Time 1 (Little’s MCAR χ2= 2123.70, df = 2153, p = .67) or Time 2 (Little’s
MCAR χ2= 1533.99, df = 1606, p = .90) and therefore it was concluded that there was no pattern for
the missing data. Data was screened for outliers by converting to z-scores, and no responses
exceeded an absolute score of 3.29.
Results
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Self-reported mindfulness skills
A two-tailed repeated measure t-test was conducted to evaluate the impact of the
intervention on children’s mindfulness skills scores. There was a statistically significant increase in
mindfulness skills from preintervention (M = 29.14, SD = 4.11) to postintervention (M = 30.49, SD
= 4.36), t (56) = 2.20, p = .03. The mean increase in mindfulness scores was 1.35 with a 95%
confidence interval ranging from 0.12 to .2.58. Because effect size calculations in repeated-
measures testing are inflated, Dunlop, Cortina, Vaslow and Burke (1996) suggest correcting for the
intra-individual correlation between measures across time. The corrected Cohen’s d was calculated
to be 0.32, which is a small to moderate effect size (Cohen, 1992).
Self-reported negative emotional symptoms
Two-tailed repeated measures t-tests were conducted to evaluate the impact of the
mindfulness-based intervention on emotional symptoms, as measured by the RCADS; namely
Social Phobia (SP), Panic Disorder (PD), Major Depressive Disorder (MDD), Separation Anxiety
Disorder (SAD), Generalised Anxiety Disorder (GAD) and Obsessive Compulsive Disorder (OCD).
While the results were not significant, there was a decline in all negative emotional symptoms
postintervention. The results of the analyses are presented in table 1.
<Insert table 1 around here>
Relationship between mindfulness skills and negative emotional symptoms
The relationship between the change in mindfulness skills (as measured by the CAMM) and
the change in emotional symptoms (as measured by the RCADS scales) across time were
investigated using Pearson correlations. The derived scores used in the correlations were calculated
by taking the difference between postintervention and preintervention (Time 1), which preserved
the intraindividual change across time. The correlation represents the relationship between the
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change in mindfulness and the change in emotional symptoms across time, with a negative
relationship indicating that increased mindfulness skills was associated with reduced negative
emotional symptoms. The relationships between mindfulness skills and emotional symptoms is
detailed in table 2.
<Insert table 2 around here>
Discussion
This study aimed to investigate the effectiveness of a school mindfulness-based intervention
program. The program was found to increase mindfulness skills, and there was a general decrease
in negative emotional symptoms, albeit not significant. There was a significant inverse relationship
between the change in mindfulness skills and negative emotional symptoms across time.
The result of the current study provided some support for the first hypothesis that children’s
self-reported mindfulness skills would be higher postintervention than preintervention. There was a
significant increase in self-reported mindfulness skills postintervention. Given the links in the
literature between increased mindfulness and improved wellbeing (Huppert & Johnson 2010), the
comparatively small investment in time and resources needed to conduct a six week program in a
school setting shows much promise.
The current study found little evidence to support a brief mindfulness-based program for
children suffering difficult emotions. While there was a notable downward trend in emotional
symptoms for each of the RCADS scales across time, these were small and not significant. This
was expected given that the sample consisted of children in a school setting rather than a clinical
setting, although some schools indicated that some participating children were known to experience
anxious and depressive symptoms. In addition, the decision of one of the schools to provide the
intervention for a whole class would likely have resulted in a sample with more moderate negative
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emotional symptoms. Additional reasons may include the relatively small sample size, and the
design of the intervention, which although encompassing education regarding anxious and
depressive symptoms, focused more holistically on a number of aspects of wellbeing.
The lack of significant improvements in emotional symptoms in the current study is also
partly consistent with previous research. A meta-analysis by Zoogman et al. (2015) found that there
was evidence for a small yet significant decrease in psychological symptoms following
mindfulness-based interventions in youth. Mindfulness-based interventions have also been found to
be more efficacious for reducing symptoms of anxiety and depression in clinical populations
compared to general populations (Hofmann et al., 2010).
The finding that increases in mindfulness-skills was associated with a significant decrease in
emotional symptoms is consistent with past research. A significant inverse relationship was found
between self-reported mindfulness skills and emotional symptoms related to Social Phobia (SP),
Generalised Anxiety Disorder (GAD), and Separation Anxiety Disorder (SAD). The relationship
between mindfulness skills and SP was by far the strongest, followed in size by the relationship
between mindfulness skills and GAD and SAD respectively.
SAD, GAD and SP are considered the three most common anxiety disorders among youth
and are known as the “child and adolescent anxiety triad” (Jablonka, Sarubbi, Rapp & Albano
(2012, p. 543). Higher prevalence rates may somewhat explain the degree of association between
increased mindfulness skills and decreased symptoms, simply due to the greater scope for
improvement over time. Alternatively, mindfulness may be more effective at addressing these
particular emotional symptoms in children, however further research is needed to confirm this.
A similar association between mindfulness skills and the Major Depressive Disorder
(MDD), Obsessive Compulsive Disorder (OCD) and Panic Disorder (PD) scales was found.
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However, the relationships were not significant, indicating that as mindfulness skills increased
symptoms on these scales decreased only marginally. Again, this result could have been related to
the sample size, sampling characteristics, or even a differential impact of mindfulness across the
range of negative emotional symptoms.
The intervention was uniquely designed and its efficacy has not previously been tested. The
TRIPLE R intervention program successfully improved children’s awareness and understanding of
mindfulness, and taught mindfulness skills that can be employed in everyday situations. This
intervention was designed using developmentally appropriate tools based on the work of Snel
(2013) and employed a variety of different delivery methods to cater for different learning styles.
Critically, the intervention focused on experiential learning, linking learnt concepts to practical
experience to improve mindfulness skills.
This study has some limitations. Firstly, it must be noted that the results do not guarantee
that the significant increase in mindfulness skills can be wholly subscribed to the mindfulness
intervention. It could be argued that a range of additional factors caused the increase in mindfulness
skills, such as independent learning and practice. It is also possible that children answered
positively in the postintervention questionnaire due to response bias, a desire to present themselves
as ‘performing’, or simply because they were more familiar with the terms. While some individual
responses indicated little change in mindfulness skills, overall observation throughout the program,
and children’s reflections and feedback in Session 6 indicate there was indeed an increase in
understanding and practice of skills at the end of the program. These observations and data
corroborate the finding that mindfulness skills increased considerably at the end of the program.
The lack of significant findings across all RCADS scales also warrants discussion. While
statistical analysis indicated a 95% probability of detecting a moderate effect size, the small sample
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size and associated lack of power suggested that it was unlikely that small effect sizes would be
detected. Although previous research indicates that larger effect sizes are more likely found in
clinical than non-clinical samples (Zoogman et al., 2015), a larger sample size would enable small
effect sizes to be detected at the significant level with greater reliability. The sampling method in
the current study also had the potential to introduce effects between schools, which was not
controlled in the current study. A mixed effects approach to the analysis of subject-specific change
may be warranted for future studies.
Limitations notwithstanding, this research has significant implications for the field. It
extends limited existing research and provides support for the role of a school-based mindfulness
intervention program. Most importantly, it demonstrated that increased mindfulness skills are
associated with decreased negative emotional symptoms, in particular for symptoms associated with
social, generalised, and separation anxiety. By selecting the CAMM (Greco, Baer, & Smith, 2011),
the current study also partially addressed a known limitation in the field with regards to the lack of
developmentally appropriate mindfulness outcome measures being used to investigate program
effectiveness. However the CAMM is not without psychometric criticism, with a lack of reversed
items preventing investigation into possible response bias (Costello & Roodenburg, 2015).
Further research into the TRIPLE R program would benefit from addressing methodological
issues by increasing the sample size, and addressing sampling procedures so that they are consistent
(or investigating the difference in results across subsamples). As this first study into the TRIPLE R
program was correlational, further studies using a randomised control group is warranted. Other
wellbeing factors which are worthy of exploration using the TRIPLE R include attention, sleep,
emotional awareness and regulation, subjective happiness, and resilience.
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The results of the current study have demonstrated the efficacy of a developmentally
appropriate mindfulness-based program that both increases mindfulness skills and decreases
anxious symptoms in non-clinical primary school aged children. The transition into adolescence is a
key developmental window for self-regulation and a period when young people are negotiating
complex school and social stressors (Kuyken et al., 2013). Given the high prevalence of negative
emotional symptoms in children, and the long term ramifications, providing early preventative
intervention is crucial. Mindfulness has been shown to help individuals cope with everyday
stressors and to cultivate and promote wellbeing and mental health (Huppert, 2009). Teaching
mindfulness skills to children before or around the onset of puberty and adolescence may act as a
protective factor later in life. Further research into the TRIPLE R program and the role of
mindfulness in enhancing areas of wellbeing in children is warranted and will add considerably to
this field.
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Table 1.
Changes in RCADS emotional symptoms across time (N = 57)
Time 1
Time 2
Cohen’s
Mean
SD
Mean
SD
t
df
p
d
Social Phobia
10.65
6.31
9.51
6.87
1.51
56
.14
0.17
Panic Disorder
6.93
5.46
5.68
4.74
1.95
56
.06
0.24
Major Depressive Disorder
9.37
5.37
8.61
5.24
1.12
56
.27
0.14
Separation Anxiety Disorder
5.21
4.72
4.72
4.17
1.27
56
.21
0.12
Generalised Anxiety Disorder
7.58
4.67
6.81
4.37
1.48
56
.15
0.17
Obsessive Compulsive Disorder
5.82
3.62
5.33
3.64
1.09
56
.28
0.14
Table 2
Correlations between derived CAMM and RCADS scores across time (N = 57)
RCADS scale
R
p
R2 (%)
Effect size
Social Phobia
-.61
<.001
37.33
Large
Panic Disorder
-.21
.12
4.37
Small
Major Depressive Disorder
-.26
.05
6.67
Small
Separation Anxiety Disorder
-.32
.01
10.43
Moderate
Generalised Anxiety Disorder
-.42
<.001
17.56
Moderate
Obsessive Compulsive Disorder
-.26
.06
6.56
Small
Note. Effect sizes according to Cohen (1992).
