Mindfulness has been increasing in popularity in mainstream western health care since the introduction of Mindfulness-Based Stress Reduction (MBSR)1 nearly 40 years ago. Although the skills and practices taught in mindfulness-based interventions are secular, one must acknowledge that many of these skills and practices are components of ancient contemplative wisdom from many different traditions. In this era of increasing rates of mental health conditions in children and adolescents, and particularly during the coronavirus disease 2019 (COVID-19) pandemic, primary and specialized health care clinicians are often the first point of contact and identification of mental health issues. In North America, approximately 25% of children and adolescents have a diagnosed mental health disorder, with many more presenting with subclinical symptoms.2,3 These rates are double among children and adolescents living with a chronic disease.4 A recent survey found that 54% of youth rated the impact of the COVID-19 pandemic on their mental health as moderate to severe, and research has shown that 83% of youth (up to age 25 years) reported that the pandemic has made their conditions worse.5 Thus, health care clinicians are frequently looking for ways to provide resources and support for their patients and families. Yet, clinicians themselves are not unscathed by the impact of COVID-19 on mental health. A rapid meta-analysis has found that rates of depression (23.2%), anxiety (22.8%), and insomnia (28.9%) are rising in health care clinicians.6 Due to its versatility in addressing both physical and mental symptoms simultaneously, mindfulness is an approach to support overall well-being and potentially improve physical and mental health outcomes for clinicians and patients alike.
What Is Mindfulness?
Jon Kabat-Zinn, creator of MBSR, describes mindfulness as the “awareness that arises through paying attention, on purpose, in the present moment, nonjudgementally.”7 Although attention and awareness are key components of this definition, nonjudgment is sometimes misunderstood. Mindfulness is not about suspending judgement; rather it is a means of bringing compassionate awareness to the thoughts, feelings, and physical sensations that are inherent in the human experience. Further, Jon Kabat-Zinn also highlighted the essential nature of kindness in non-judgment, “if you're not hearing mindfulness in some deep way as heartfulness, you're not really understanding it. Compassion and kindness towards oneself are intrinsically woven into it. You could think of mindfulness as wise and affectionate attention.”8 Within the literature, three foundational components of practicing mindfulness have been identified that align with Jon Kabat-Zinn's definition: focused attention, open awareness, and kind intent.9 These components map directly onto specific practices; focused attention practice (eg, awareness of breath, body scan), open monitoring practice (eg, observing the five senses, thoughts, emotions), and loving-kindness practice (eg, compassion for self and others). These practices have been shown to be associated with specific and distinguishable physiological and neurological changes as well as reduction in biomarkers of stress.9–12 Currently, both mindfulness research and practice demonstrate that this specific type of attention, awareness, and kindness toward ourself and others is a skill that can be cultivated through training and repetition.
Mindfulness-based interventions are skill-based: teaching formal practices, integrated mindfulness (eg, mindful eating, mindful walking) as well as strategies to maintain practice. Mindfulness focuses on helping people be with and transform unpleasant experiences (eg, stress, pain, anxiety, depression), enjoy and savor pleasant experiences, as well as offer opportunities to make neutral activities more enjoyable. By applying these skills and practices, people learn to accept unwanted experiences that are unavoidable (eg, pain, negative emotions) instead of becoming overwhelmed or trying to escape them. In turn, people are able to actively respond instead of react to their circumstances in ways that are aligned with their values and what is important to them. Mindfulness-based interventions support overall well-being by offering practices and training skills that are adaptable to all moments in life.
The literature on the impact of mindfulness-based interventions and practices in clinical and nonclinical samples of adults has demonstrated it is equal to evidence-based treatments, and provides significant improvements, relative to passive and active controls, in many different physical and mental health outcomes (eg, decreased pain, stress, anxiety, and depression, and improved sleep quality10,13–17) across various populations. Similarly, a recent meta-analysis of mindfulness-based interventions in children and adolescents found improvements, over and above active control conditions, in mindfulness, depression, and anxiety/stress, as well improvements compared to passive control conditions in executive functioning, attention, and negative behaviors.18 Improvements may be even more pronounced in clinical versus nonclinical pediatric populations, in which another meta-analysis found pre- and post-effect sizes were more than twice the size in clinical samples compared to nonclinical samples (delta = 0.50 vs 0.19, respectively).19 The research supports the practice of mindfulness as an approach to support overall well-being as well as supporting physical and mental health outcomes in clinical samples.
Where to Start? Caring for the Caregiver
Pediatric health care clinicians often work under stressful conditions (eg, competing demands, high patient volumes, high patient distress), which are now exacerbated by the COVID-19 pandemic. This puts clinicians at a higher risk for stress, burnout, and mental health disorders.6 Stress and burnout, in turn, are associated with medical errors, decreased work productivity, and lower patient satisfaction.20 To best care for themselves and their patients, it is essential for clinicians to find their own approach to, and practice of, self-care. The literature on mindfulness-based interventions for health care clinicians has shown that mindfulness is beneficial for clinician well-being and decreased stress.21,22 Decreasing stress in health care clinicians may result in positive downstream effects on patients and families under their care.23
If you wish to reap the established benefits of mindfulness in your practice and in your life, begin by establishing a personal mindfulness practice. When choosing resources for establishing your practice it is best to choose those offered by practitioners with their own devoted personal practice, who can support you in navigating the common obstacles to establishing a practice. A useful analogy is establishing an exercise routine. When choosing a coach, you want someone who is both knowledgeable and supportive. Although there a many excellent resources available, the curated resources are listed from most accessible and cost-effective to most comprehensive (Figure 1). Two short practices are included in Figure 2 and Figure 3 to support beginning your mindfulness practice.
Steps to beginning a mindfulness practice. Please note that this is not an exhaustive list, but instead a starting point of free to low-cost options to begin your mindfulness practice. Many helpful books, resources, and programs exist. You are encouraged to explore the different options available to find practices that best fit into your personal and professional lives. MBSR, mindfulness-based stress reduction.
STOP practice. STOP, stop, take a breath, observe, proceed.
Providing Support to Patients and Their Families
Many online resources, podcasts, smartphone applications, and courses currently exist to learn mindfulness skills, and new mindfulness-based resources are currently being developed and investigated. New research supports remote or online mindfulness teaching and practices for youth, increasing access to resources.24 As health care clinicians it can be difficult to remain up to date on existing resources and thus recommend specific practices to families. What is most supportive to communicate to families are the definitions and the specific benefits of mindfulness for them, which take into account their particular circumstances. It is important to emphasize that experiencing the benefits of mindfulness is the result of actually practicing the skills over time. It can be helpful to encourage families to try different types of mindfulness-based practices to determine what is preferred and sustainable for them. Of note, it is by design that mindfulness is often taught in group settings that support establishing practice and building community. Learning and practicing mindfulness as a family, for example, can support long-term practice, yield lasting benefits, and provide a common language for resolving communication difficulties and facing challenges.
Although health care clinicians are encouraged to use their own words and interpretation of mindfulness when speaking with families, a pediatric-friendly definition of mindfulness that can be shared with families is “mindfulness is paying attention here and now, with kindness and curiosity, so that we can choose our behaviors.” As humans we often think and plan for the future or dwell on the past, but mindfulness invites us to pay attention to what is happening in this moment. We also tend to be our own worst critics, treating ourselves more harshly than we would treat a friend. This is where the kind, curious, and a friendly approach to paying attention is essential. It allows us to collect information on what is happening in the moment with our thoughts, our feelings, and our body sensations. We can then take this information and decide how best to care for ourselves and what choices we would like to make. In this way we are responding instead of reacting to everyday life. This often makes it easier to make choices that are aligned with our values and the person we would like to be. Mindfulness can be done in lots of different ways; think of it as a choose-your-own adventure approach. Mindfulness can look like spending time focusing on something specific like your breath or it can be enriching and enhancing any activity you do by focusing on that activity instead of multitasking. Mindfulness can also look like choosing to be kind, curious, and friendly to yourself or others.25
If you wish to share the benefits of mindfulness with the patients and parents in your practice, support them in establishing a personal mindfulness practice. Listed within Figure 1 are simple recommendations. The steps are listed from most accessible and cost-effective to most comprehensive. If you want to personally offer mindfulness to people or groups in your practice you should (1) begin your own personal mindfulness practice, (2) consider the following qualities and qualifications that may support you ( http://www.stillquietplace.com/lets-talk-practice-qualities-qualifications-sharing-mindfulness/), and (3) enroll in a course that supports you in maintaining your personal practice and helps you develop the skills to guide practices and engage in heartfelt inquiry.
Cultivating and training mindfulness skills has been shown to have many physical and mental health benefits across a broad spectrum of populations, including health care clinicians. Maintaining an ongoing practice is key to realizing the benefits of mindfulness. Primary and specialist health care clinicians are in a unique position to introduce and encourage families to explore mindfulness-based skills as a means of promoting well-being and addressing mental and physical health outcomes.
- Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4(1):33–47. doi:10.1016/0163-8343(82)90026-3 [CrossRef] PMID:7042457
- Smetanin P, Briante C, Stiff D, Ahmad S, Khan M. The Life and Economic Impact of Major Mental Illnesses in Canada. Mental Health Commission of Canada; 2015.
- O'Connell ME, Boat T, Warner KE. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. National Academy Press; 2009.
- Harber-Aschan L, Hotopf M, Brown JSL, Henderson M, Hatch SL. Longitudinal patterns of mental health service utilisation by those with mental-physical comorbidity in the community. J Psychosom Res. 2019;117:10–19. doi:10.1016/j.jpsychores.2018.11.005 [CrossRef] PMID:30665590
- YoungMinds. Coronavirus: impact on young people with mental health needs. Accessed January 17, 2021. https://youngminds.org.uk/about-us/reports/coronavirus-impact-on-young-people-with-mental-health-needs
- Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis [published online ahead of print May 8, 2020]. Brain Behav Immun. doi:10.1016/j.bbi.2020.05.026 [CrossRef] PMID:32437915
- Kabat-Zinn J, Hanh TN. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Delta; 2009.
- Szalavitz M. Q&A: Jon Kabat-Zinn talks about bringing mindfulness meditation to medicineFull Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Accessed January 17, 2021. http://healthland.time.com/2012/01/11/mind-reading-jon-kabat-zinn-talks-about-bringing-mindfulness-meditation-to-medicine.
- Villamil A, Vogel T, Weisbaum E, Siegel DJ. Cultivating well-being through the three pillars of mind-training: understanding how training the mind improves physiological and psychological well-being. OBM Integr Compliment Med. 2019;4:11. doi:10.21926/obm.icm.1901003 [CrossRef]
- Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness mediates the physiological markers of stress: systematic review and meta-analysis. J Psychiatr Res. 2017;95:156–178. doi:10.1016/j.jpsychires.2017.08.004 [CrossRef] PMID:28863392
- Lippelt DP, Hommel B, Colzato LS. Focused attention, open monitoring and loving kindness meditation: effects on attention, conflict monitoring, and creativity - a review. Front Psychol. 2014;5:1083. doi:10.3389/fpsyg.2014.01083 [CrossRef] PMID:25295025
- Fox KC, Dixon ML, Nijeboer S, et al. Functional neuroanatomy of meditation: a review and meta-analysis of 78 functional neuroimaging investigations. Neurosci Biobehav Rev. 2016;65:208–228. doi:10.1016/j.neubiorev.2016.03.021 [CrossRef] PMID:27032724
- Goldberg SB, Tucker RP, Greene PA, et al. Mindfulness-based interventions for psychiatric disorders: a systematic review and meta-analysis. Clin Psychol Rev. 2018;59:52–60. doi:10.1016/j.cpr.2017.10.011 [CrossRef] PMID:29126747
- Rusch HL, Rosario M, Levison LM, et al. The effect of mindfulness meditation on sleep quality: a systematic review and meta-analysis of randomized controlled trials. Ann N Y Acad Sci. 2019;1445(1):5–16. doi:10.1111/nyas.13996 [CrossRef] PMID:30575050
- Khoury B, Sharma M, Rush SE, Fournier C. Mindfulness-based stress reduction for healthy individuals: a meta-analysis. J Psychosom Res. 2015;78(6):519–528. doi:10.1016/j.jpsychores.2015.03.009 [CrossRef] PMID:25818837
- Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199–213. doi:10.1007/s12160-016-9844-2 [CrossRef] PMID:27658913
- Zhang M-F, Wen Y-S, Liu W-Y, Peng L-F, Wu X-D, Liu Q-W.Effectiveness of mindfulness-based therapy for reducing anxiety and depression in patients with cancer: a meta-analysis. Medicine (Baltimore). 2015;94(45):e0897. doi:10.1097/MD.0000000000000897 [CrossRef] PMID:26559246
- Dunning DL, Griffiths K, Kuyken W, et al. Research Review: the effects of mindfulness-based interventions on cognition and mental health in children and adolescents - a meta-analysis of randomized controlled trials. J Child Psychol Psychiatry. 2019;60(3):244–258. PMID:30345511
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- Saltzman A. A Still Quiet Place: A Mindfulness Program for Teaching Children and Adolescents to Ease Stress and Difficult Emotions. New Harbinger Publications; 2014.
- Stahl B, Goldstein E. A Mindfulness-Based Stress Reduction Workbook. New Harbinger Publications; 2010.