Sitting-Meditation Interventions Among Youth: AReview of Treatment Efficacy

abstractOBJECTIVE: Although the efficacy of meditation interventions has beenexamined among adult samples, meditation treatment effects amongyouth are relatively unknown. We systematically reviewed empiricalstudies for the health-related effects of sitting-meditative practicesimplemented among youth aged 6 to 18 years in school, clinic, andcommunity settings.

METHODS: A systematic review of electronic databases (PubMed, Ovid,Web of Science, Cochrane Reviews Database, Google Scholar) was con-ducted from 1982 to 2008, obtaining a sample of 16 empirical studiesrelated to sitting-meditation interventions among youth.

RESULTS: Meditation modalities included mindfulness meditation,transcendental meditation, mindfulness-based stress reduction, andmindfulness-based cognitive therapy. Study samples primarily con-sisted of youth with preexisting conditions such as high-normal bloodpressure, attention-deficit/hyperactivity disorder, and learning dis-abilities. Studies that examined physiologic outcomes were composedalmost entirely of African American/black participants. Median effectsizes were slightly smaller than those obtained from adult samplesand ranged from 0.16 to 0.29 for physiologic outcomes and 0.27 to 0.70for psychosocial/behavioral outcomes.

CONCLUSIONS: Sitting meditation seems to be an effective interven-tion in the treatment of physiologic, psychosocial, and behavioral con-ditions among youth. Because of current limitations, carefully con-structed research is needed to advance our understanding of sittingmeditation and its future use as an effective treatmentmodality amongyounger populations. Pediatrics 2009;124:e532–e541

CONTRIBUTORS: David S. Black, MPH, Joel Milam, PhD,and Steve Sussman, PhD

Institute for Health Promotion and Disease Prevention Research,University of Southern California Keck School of Medicine,Alhambra, California

KEY WORDSliterature review, meditation, mindfulness, children,adolescents, youth, efficacy

ABBREVIATIONSTM—transcendental meditationADHD—attention-deficit/hyperactivity disorderMM—mindfulness meditationMBSR—mindfulness-based stress reductionMBCT—mindfulness-based cognitive therapySBP—systolic blood pressureRCT—randomized, controlled trialDBP—diastolic blood pressureHR—heart rateCO—cardiac outputEDAD—endothelium-dependent vasodilation to reactivehyperemia

www.pediatrics.org/cgi/doi/10.1542/peds.2008-3434

doi:10.1542/peds.2008-3434

Accepted for publication Apr 14, 2009

Address correspondence to David S. Black, MPH, University ofSouthern California, Institute for Health Promotion and DiseasePrevention Research, 1000 S Fremont Ave, Unit 8, Building A-5,Suite 5228, Alhambra, CA 91803-4737. E-mail: davidbla@usc.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2009 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

e532 BLACK et al

Persuasive arguments for meditationinterventions and efficacy researchamong children and adolescents havebeen made on the basis of their di-verse usefulness and beneficial effectsobserved in adults.1 This advocacy forapplying empirical attention tomedita-tion interventions has coincided withincreased public interest in, and ac-ceptance of, these practices. For exam-ple, the Mindful Awareness ResearchCenter at the University of CaliforniaLos Angeles Semel Institute (http://marc.ucla.edu) currently providesworkshops for teachers and other ed-ucators to develop mindfulness ap-proaches for children as young as pre-kindergarten age. Moreover, middleand high schools are increasingly im-plementing meditation interventions,although few empirical studies havebeen conducted in this setting.2,3

Meditation interventions are common-ly implemented among youth in school-,community-, and clinic-based settings.For example, organizations such asthe David Lynch Foundation havereached thousands of students in theUnited States by funding transcen-dental meditation (TM) school-basedprograms (eg, the David Lynch Foun-dation for Consciousness-Based Edu-cation and World Peace [www.davidlynchfoundation.org]). These programsserve students aged 10 years andolder and use TM as a modality totreat attention-deficit/hyperactivity dis-order (ADHD) and emotional problems,enhance learning, and provide stabilityto the nervous system. The US Com-mittee for Stress-Free Schools (www.tmeducation.org), established in 2005,provided TM programs to students andteachers in public, charter, and pro-bate schools throughout the UnitedStates and evaluated the effects of TMon intelligence, learning, academic per-formance, ADHD and learning disorders,anxiety, depression, substance use, eat-ing disorders, and other outcomes.

Moreover, the Garrison Institute, anonprofit agency, investigated mind-fulness practices among kindergartento 12th-grade students and found nearly20 school- and community-based or-ganizations with established mindful-ness programs, as well as others thatused elements of mindfulness as partof social and educational programs.To date, none of these centers havepublished peer-reviewed program eval-uations, although qualitative and anec-dotal evidence suggest increased self-awareness, self-reflection, emotionalintelligence, and social skills in re-sponse to these programs.4

MEDITATION AND TECHNIQUE

The term “meditation” has been de-fined in various ways, and in Westernculture can be conceptualized as a dis-tinct psychological practice from itsoriginal religious and cultural rootsand philosophies. Meditation practicecan be explained as the deliberate self-regulation of attention in the presentmoment and typically comprises con-centration, relaxation, altered statesof consciousness, suspension of logi-cal thought, and maintenance of a self-observing attitude.5 Meditation hasalso been defined as a practice thatemphasizes maintaining alertnessand expanding self-awareness with anincreased sense of integration andcohesiveness.6

Meditation also differs in form. Sitting-meditative practices used amongyouth include, but are not limited to,mindfulness meditation (MM) basedon vipassana or “insight” meditation,and TM derived from the Vedic tradi-tion of India. Physical movement formsof meditation used among children(ie, tai chi and Hatha yoga [see ref 7for a systematic review of yoga inter-ventions among youth]) are common-ly based on Hatha yoga techniques,which include muscle relaxation,breath control, and mental focus on

particular body movements and self-manipulated postures.8 Empirical evi-dence supports the notion that someforms ofmeditation such as TMmay bemore effective than others (eg, mantrameditation, relaxation, etc) in reducingailments and promoting health.9

In MM, the meditator sits comfort-ably and silently, “paying attention in aparticular way: on purpose, in the pres-ent moment, and non-judgmentally.”10

The meditator consciously scans per-ception entering the field of aware-ness, welcoming rather than avoidingthoughts, emotions, sensations, anddistractions.11,12 By observing thoughtsand emotions from this detached per-spective, clarity of mental perceptioncan be attained. Thus, the content ofthought is monitored as well as thefeelings and reactions associated withthem. MMwas manualized and termedmindfulness-based stress reduction(MBSR) by Kabat-Zinn.13 MBSR wasoriginally aimed at mindfulness tech-niques to reduce chronic pain andstress but is currently used to treat aspectrum of ailments and unhealthybehaviors and is increasingly used inclinical psychology.14 Therapies havefollowed the MBSR modality, such asmindfulness-based cognitive therapy(MBCT), which are adapted for thedevelopmental needs of school-agedchildren.15

TM, developed by Maharishi MaheshYogi, involves techniques that requireneither concentration nor contempla-tion and allow the body to effortlesslyreach a level of deep calmness whilethe mind achieves a stability of atten-tion through a 15- to 20-minute prac-tice done twice per day while sittingcomfortably.16 TM practice uses thesound value of a mantra to draw atten-tion within the mind, experience qui-eter levels of thinking, and draw fortha restful state of awareness referredto as “clear consciousness”17 (see refs18 and 19). The TM course begins with 7

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simple steps of instruction involving�90 minutes per class, including anintroductory and preparatory lecture,personal interview, and 4 days of in-struction.16 Although the description ofMM and TM may differ regarding theirfocus of attention, overlap does exist.20

Several systematic reviews21–28 andmeta-analyses29–31 have provided em-pirical support regarding the effi-cacy of meditative practices amongadult samples for outcomes includ-ing depression, anxiety, panic dis-orders, binge-eating disorders, sub-stance abuse, hypertension, othercardiovascular disorders, pain syn-dromes, respiratory disorders, der-matologic problems, immunologicdisorders, and symptoms of breastand prostate cancer. Only 1 review ofmeditation interventions includedadult and youth samples, and this ar-ticle focused solely on TM and its ef-fects on cardiovascular functioning.32

THE PSYCHOPHYSIOLOGICALPROCESS OF MEDITATION

The psychophysiological processes at-tributed to meditation practice havebeen documented in adult studies, andalthough it is unknown if these sameprocesses occur in youth, similar pro-cess may exist. Among adults, the im-pact of meditation practice on health-related and cognitive outcomes ispartially mediated through neurophys-iological changes (see the review in ref33). For example, meditation is foundto help control the hypothalamic-pituitary-adreno-cortical axis and as-sociated systems (eg, parasympa-thetic nervous system), which arepathways that control stress-responsemechanisms and regulate variousbodily processes including digestion,immunology, mood, and energy usage.Meditation can also affect neuroen-docrine status, metabolic function,and related inflammatory responses29

and can decrease experienced stress

load.34 Relaxed attention can also per-mit more flexible psychological andbehavioral responses to internal andexternal cues,35 possibly through a re-structuring of frontal brain regions as-sociated with self-regulation.36,37 In ad-dition, actively focusing the mind onnonmotor activities, such as medita-tion, is associated with dopamine re-lease in ventral areas of the brain,38

which is a process that can enhancepositive mood states.

THE PRESENT STUDY

Although more than 800 studies haveinvestigated the therapeutic effects ofmeditation practices, the vast majorityof these studies were among adults.25

As meditation interventions becomemore widely implemented amongyouth in schools, hospitals, clinics, andcommunity settings, empirical evi-dence is needed to support and guidethese programming efforts. Thus, wesought to determine if similar benefitsof adult meditation are found amongchildren and adolescents by conduct-ing a systematic literature review ofmeditation interventions used amongthese younger populations. The aim ofthis systematic review was to deter-mine the state of empirical researchrelated to the treatment efficacy ofsitting-meditation interventions imple-mented among youth aged 18 yearsand younger in school, clinic, and com-munity settings.

LITERATURE-SEARCH METHODS

Electronic databases (PubMed, Ovid,Web of Science, Cochrane ReviewsDatabase, and Google Scholar) weresearched to identify empirical articlesrelevant to sitting-meditation interven-tions among youth. For this review,sitting-meditation techniques were de-fined as sitting-meditation practicesthat do not involve physical exertion.Key words, and various combinationsof key words, used in search enginesincluded “meditation,” “mindfulness,”

“transcendental,” “adolescents,” and“children,” and searches producedmore than 150 citations. Searcheswere refined to include articles pub-lished between January 1982 and De-cember 2008. The year 1982 was se-lected as a starting point because itwas the earliest date that an electronicdatabase provided access to a full-textarticle relevant to this study. In addi-tion to computer-assisted searches,bibliographies of acquired articleswere scanned to acquire additionalstudies. Finally, leading authors in thearea of empirical studies ofmeditationwere contacted by e-mail and re-quested to provide additional unpub-lished data or articles in press.Meditation interventions were opera-tionalized as programs using medita-tion techniques that involve (1) abreath, image, sound, or mantra to fo-cus the mind and/or (2) passively ob-serving arising thoughts and sensa-tions to becomemindful of the presentmoment. Inclusion criteria included(1) nonmovement meditation was themain intervention modality, (2) studyparticipants were aged 18 years oryounger, (3) there was a quantitativeoutcome that was health related orpsychosocial in nature (outcomessuch as intelligence measures wereexcluded), (4) interventions were de-livered in schools, community facili-ties, or clinics, and (5) the studyresults were published in a peer-reviewed, English-language journal.Studies were typically excluded be-cause of age criteria and lack of sittingmeditation as a main interventioncomponent. Single-participant casestudies were also excluded. Movementforms of meditation such as progres-sive muscle relaxation, yoga, or tai chiwere not included, because the benefi-cial effects of meditation could not beeasily separated from those derivedfrom physical exertion. Sixteen publi-cations met our final criteria and com-prised the final sample for this review.

e534 BLACK et al

Effect sizes were calculated by usingCohen’s d formulas for all studies thatprovided sufficient data (see ref 39).Cohen’s d derives effect sizes in SDunits. For studies using between-group designs, treatment effect sizeswere calculated with the following for-mula, which accounted for relative dif-ferences between the treatment andcontrol groups: d � [(Mtx1 � Mtx2) �(Mc1 � Mc2)]/SDpooled. The notation(Mtx1 � Mtx2) refers to the differencebetween the treatment group meanson a specific outcome measure frombefore to after the test; the notation(Mc1�Mc2) refers to the difference ofthe control group means from beforeto after the test; and SDpooled is thepooled SD of the 2 groups. A similarcalculation was used for studies thatused within-group designs; however,because there was no control group,posttest means were subtracted frompretest means of the same group, andthis difference was divided by SDpooled.

RESULTS

Sample Characteristics

The intervention descriptions, studysamples and designs, outcome mea-sures, effect sizes, and key findings ofthe 16 studies containing a total of 860participants are described in Table 1.Studies included participants from 6to 18 years of age. Studies that exam-ined physiologic outcomes were al-most entirely composed of black par-ticipants,40–44 whereas the remainingstudies that examined psychosocialand behavioral outcomes were com-posed of a more-diverse group of par-ticipants, including white, Hispanic,black, Asian, and “other.” Among thepsychosocial/behavioral study sam-ples, 2 were mainly black,45,46 2 weremainly Hispanic,47,48 1 was completelywhite,49 and 5 were mostly male.45,46,50–52

Studies were primarily conductedin elementary,52,53 middle,42,46,49 andhigh schools,40,41,43–45,50 followed by

clinics48,51,54,55 and community cen-ters.47 All studies that examined physi-ologic outcomes were conducted inschool settings, whereas studies thatexamined psychosocial/behavioral out-comes were conducted across all 3settings. Study participants weremost often recruited on the basis ofadolescents’ preexisting physiologiccondition such as high-normal systolicblood pressure (SBP)40,41,43–45 or psy-chiatric conditions such as ADHD diag-nosis,45,51,52,54,55 learning disability,47,48,50

or conduct problems.49 Only 3 studiesincluded samples that included non-clinical volunteers.42,53,54

Meditation Interventions

Thirty-one percent (n� 5) of the studiesexamined physiologic outcomes, and69% (n � 11) examined psychosocial/behavioral outcomes. The majority ofstudies used MM (n � 6) and TM(N� n), followed by MBSR (n� 2) andMBCT (n � 2). Studies that examinedphysiologic outcomes used TM andMMinterventions, whereas studies that ex-amined psychosocial/behavioral out-comes used TM, MBSR, MBCT, and MMinterventions. The extent of the inter-ventions varied across studies, rang-ing from 4 weeks to 4 months, with in-dividual sessions ranging from 10minutes to more than 2 hours. Therange of studies examining physio-logic outcomes provided meditationsessions that lasted 10 to 15 minutes,twice per day, from 2 to 4 months.Studies that examined psychosocial/behavioral outcomes provided ses-sions that ranged from 5 minutes to2.5 hours, 1 to 2 times per day, span-ning 4 weeks to 4 months.

Study Designs

The majority of intervention designswere randomized, controlled trials(RCTs) (n � 11), and the remainingstudies (n� 5) had a pretest/posttestno-control-group design. Of the RCTs,control groups were provided health

education,40–45 provided treatment asusual,53,54 or given the intervention at alater time (wait-list control).47,48 Only 1study design contained 3 conditions in-cluding a TM, muscle relaxation, andwait-list control arm.51 Nine of the RCTsreported equivalence of participantson key variables across treatmentgroups,40–45,47,48,54 and 2 studies did notprovide data regarding this informa-tion.51,53 Sample sizes for studiesranged from 3 to 194 participants, witha mean sample size of 53.8 for all stud-ies combined. The majority of studiesthat used a comparison group main-tained a relatively proportionate sam-ple size in each treatment arm. How-ever, 1 study hadmore than double theparticipants in the control arm relativeto the treatment arm.44

Intervention Effects onPhysiologic Outcomes

Primary physiologic outcomes in-cluded SBP, diastolic blood pressure(DBP), heart rate (HR), cardiac output(CO), endothelium-dependent vasodila-tion to reactive hyperemia (EDAD), andurinary sodium excretion rate (USER).These studies were almost entirelycomposed of black adolescents.40–45 Inaddition, all of these studies had out-comes solely related to cardiovascularfunctioning. Of the 4 studies that exam-ined SBP, there was consistent evi-dence that meditation decreased SBPrelative to controls.40–42,44 Decreases inDBP were not consistently found. Twostudies identified marginal DBP reduc-tions in the meditation group relativeto controls,40,41 and 2 studies foundno significant difference betweengroups.42,44 A single study found thatmeditation positively affected EDAD,which is an indicator of endothelialdysfunction,43 whereas another studyfound meditation to improve USER (anindicator of sodium handling).44 Of the4 studies that examined differencesin HR, 1 study40 found significant de-creases, 2 studies42,44 found decreases

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TABLE1SummaryofEmpiricalStudiesofMeditationInterventionsAmongYouthAccordingtoMeasurementOutcome

Study

NAgeRange,Mean(SD)

Age(y)andGender

AccordingtoCondition

Participant

Description

Treatment

Length/Setting

StudyDesign

Baseline

Equivalence

%Completion

(%Retention)a

Dependent

Variables

Cohen’sd,Median

(Range)

GeneralFindings

Physiologicaloutcomes

Barnesetal40

3515–18;Tx:16.5(1.1),

53%male;C:16.6

(1.1),66%male

97%AAwithhigh-

normalBP

15min,2timesperday

for2mo/highschoolRCT:TM(n

�17)vs

healtheducation

control(n

�18)

Yes

School:68%;home:

77%

SBP,DBP,HR,CO,

TPR

0.16(�0.08to0.43)TMgroupdecreasedfrombeforetoafter

testinSBP,HR,andCOduringacute

stresssimulation,andinSBPtoa

socialstressorcomparedtocontrols;

marginaldifferencesinDBP

Barnesetal41

100Tx:16.0(1.3),64%

male;

C:16.3(1.4),62%

male

100%AAwithelevated

SBP

15min,2timesperday

for4mo/highschoolRCT:TM(n

�50)vs

healtheducation

control(n

�50)

Yes

School:63%;home:

76%(64%)

SBP,DBP,HR

0.29(0.05to0.35)TMgroupdecreaseddaytimeSBPand

marginallydecreasedDBPcompared

tocontrols;nosignificantdifferences

inHRbetweenTxgroups

Barnesetal42

73Tx:12.2(0.5),53%

male;

C:12.4(0.6),54%

male

52%AAvolunteersfor

aclassproject

10min,2timesperday

for3mo/middle

school

RCT:MM(n

�34)vs

healtheducation

control(n

�39)

Yes

School:89%;home:

86%(79%)

SBP,DBP,ABP,HR0.22(�0.10to0.72)MBSRgroupdecreasedrestingSBP,

daytimeambulatorySBPafterschool,

anddaytimeambulatoryHRafter

schoolcomparedtocontrols;no

differencesindaytimeambulatory

measureatschoolforSBPorHR

Barnesetal43b

111Tx:16.2(1.3);

C:16.3(1.4),68%

male

100%AAwithhigh-

normalBP

15min,2timesperday

for4mo/highschoolRCT:TM(n

�57)vs

healtheducation

control(n

�54)

Yes

—EDAD

—TMgroupincreasedEDADcomparedto

controls,indicatingimproved

endothelialfunction

Barnesetal44

66Tx:15.0(0.7),45%

male;

C:15.3(0.9),41%

male

100%AAwithhigh-

normalBP

10min,2timesperday

for3mo/highschoolRCT:MM(n

�20)vs

healtheducation

control(n

�46)

Yes

—(85%)

SBP,DBP,HR,

USER

0.26(0.29to0.54)MBSRgroupdecreasedSBPduring

schoolandnighttime,ambulatoryHR

duringschool,andovernightUSERand

sodiumcontentcomparedtocontrols;

noDBPdifferencesbetweenTxgroups;

noHRdifferencesfoundfornighttime

orafterschool

Psychosocialand

behavioral

outcomes

Barnesetal45

4515–18y;Tx:16.2(1.3),

76%male;C:16.0

(1.4),65%male

100%AAwithelevated

SBP

15min,2timesperday

for4mo/highschoolRCT:TM(n

�25)vs

healtheducation

control(n

�20)

Yes

72%(100%)

Suspensions,

tardies,

absentees,rule

infractions

0.66(0.09to0.69)TMgroupdecreasedabsenteeperiods,

ruleinfractions,andsuspensiondays

resultingfrombehaviorproblems

comparedtocontrols;females

performingTMdecreasedanger

comparedtocontrolfemales(notfound

formales);nodifferenceintardiness,

lifestyle,orstressbetweengroups

Beaucheinetal50

3413–18y;Tx:16.6,71%

male

Diagnosedwith

learningdisabilities5–10min,5dperweek

for5wk/highschoolPre/post,nocontrol:

MM

NA—(100%)

SSRS,STAI

0.70(0.49to0.85)Bothtraitandstateanxietyscores

significantlyreducedatposttest

measure;decreasesinteacherratings

ofstudentproblembehaviorsaftertest

Biegeletal54

10214–18y;Tx:15.7(1.1),

30%male;C:15.0

(1.2),23%male

45%white,28%Latino,

and27%other

physician-referred

patientsand

volunteers

2hours,1timeper

weekfor8wk/

outpatientpsychiatric

clinic

RCT:MBSRplusTAU

(n�50)vsTAU

(n�52)

Yes

78%(73%)

DSM-IV,GAF,AxisI

disorders,

PSS-10,STAI,

SCL-90,SES

0.60(0.41to1.09)MBSRgroupreducedanxiety,depressive

symptoms,somatization,increased

self-esteem,andsleepquality

comparedtothosewithTAU;MBSR

groupincreasedGAFandpercentage

ofpositivementalhealthchanges

comparedtothosewithTAU

Grosswaldetal46

1011–14y;90%male

60%AAand40%white

withpreexisting

ADHDdiagnosis

10min,2timesperday

for3mo/schoolfor

studentswith

learningdisability

Pre/post,nocontrol:

TMNA

—(91%)

CBCL,RCMAS,

YSR,BRIEF,CAS,

D-KEFS,TOL

0.40(0.20to0.80)TMgroupreducedsymptomsofanxiety,

depression,affectiveproblems,

attentionproblems,andtotal

problemsaftertest;teachersreported

studentreductionsinanxiety,

depression,andtotalproblemsafter

testandimprovementsinbehavioral

regulation,meta-cognition,and

executivefunctioning

e536 BLACK et al

TABLE1Continued

Study

NAgeRange,Mean(SD)

Age(y)andGender

AccordingtoCondition

Participant

Description

Treatment

Length/Setting

StudyDesign

Baseline

Equivalence

%Completion

(%Retention)a

Dependent

Variables

Cohen’sd,Median

(Range)

GeneralFindings

Leeetal47

259–13y;40%male

60%Latino,28%AA,

and12%whitewith

readingdifficulties

90min,1timeper

weekfor12wk/

communityclinic

RCT:MBCT(n

�13)

vswait-list

control(n

�12)

Yes

78%(68%)

CBCL,MASC,

STAIC,RCDS

0.27(0.11to0.40)MBCTgroupreducedCBCLtotalscore

andCBCLexternalizingproblemsfrom

beforetoaftertest;nodifferencesin

CBCLinternalizingproblems,anxiety,

ordepressionfrombaseline

Napolietal53

194Tx:first-,second-,and

third-graders

Studentvolunteers

45min,bimonthlyfor

24wk/elementary

school

RCT:MM(n

�97)

vsnotreatment

control(n

�97)

——(85%)

ACTeRS,TAS,

TEA-Ch

0.48(0.39to0.60)MMgrouphadfewerproblemsnotedby

teacherforattentionandsocialskills,

decreasedtestanxietyscores,and

increasedselective(visual)attention

scorescomparedtocontrols

KratterandHogan51247–12y;Tx:10.05;100%

male

Psychologistand

teacher-referred

ADHDdiagnosis

20min,2timesper

weekfor4wk/clinicRCT:TMvsmuscle

relaxationvs

waitlistcontrolc

——

MFFT,FDT,LCS,

PTQ

—TMgroupincreasedselectiveattention

andfreedomfromdistractibility;both

theTMandrelaxationgroupsshowed

decreasesinimpulsivitycomparedto

controls;parentsreported

improvementinbehaviorofchildren

inTMandrelaxationgroupscompared

tocontrols;nodifferencesinLCS

scorebetweenTxgroups

Sempleetal49

259–13y;40%male

60%Latino,24%AA,

and16%whitewith

academicproblems

90min,1timeper

weekfor12wk/

universityclinic

RCT:MBCT(n

�13)

vswait-list

control(n

�12)

Yes

90%(80%)

CBCL,MASC,STAIC0.42(0.27to0.46)MBCTgroupshowedfewerattentional

problemsthancontrolswitheffects

maintained3moafterintervention;

significantreductionsinanxietyand

behaviorproblemsfoundinchildren

whoreportedelevatedlevelsof

anxietyatbeforethetest,butfull

sampledidnotreportthese

reductions

Sempleetal52

57–8y;60%male

Teacher-referred

studentsdisplaying

anxietysymptoms

45min,1timeper

weekfor6wk/

elementaryschool

Pre/post,nocontrol:

MBSR

�MBCT

NA—(80%)

CBCL

—Teacherratingsindicatedgainsforall5

childreninadaptivefunctioningand

reductionsintotalinternalizingand

externalizingproblems;trend

indicatedfewerproblembehaviors

reportedbyteachers

Singhetal49

313–14y;Tx:13.3(0.6);

100%white

School-referred

studentsdiagnosed

withconduct

disorder

15min,3timesper

weekfor4wk/

middleschool

Pre/post,nocontrol:

MM

NA—(100%)

Aggression,

bullying,fire

setting,cruelty,

noncompliance

—MMgroupdecreasedaggressive

behaviororbullyingslightlyduringthe

MMtrainingandsubstantiallyduring

the25wkofpracticethatfollowed

training

Zylowskaetal55

815.6(1.1);38%male

Parent-refereedADHD-

diagnosedchildren2.5h,1timeperweek

for8wk/university

clinic

Pre/post,nocontrol:

MM

NA—(88%)

DSM-IV,SNAP-IV,

CDI,RCMAS

ANT,TMT,DST

0.38(0.03to1.01)MMgroupshowednosignificant

changesindepressionoranxietyat

follow-upcomparedtobaseline

scores;otherdifferencesfor

adolescentscouldnotbeextracted

fromtheadultsample

Txindicatestreatmentgroup;AA,AfricanAmerican/black;C,controlgroup;TPR,totalperipheralresistance;ABP,ambulatorybloodpressure;TAU,treatmentasusual;SSRS,SocialSkillsRatingSystem;STAI,State-TraitAnxietyInventory;DSM-IV,

DiagnosticandStatisticalManualofMentalDisorders,FourthEdition;GAF,GlobalAssessmentofFunctioning;PSS-10,PerceivedStressScale;SCL-90,HopkinsSymptomChecklist90;SES,RosenbergSelf-esteemScale;CBCL,ChildBehaviorChecklist;

RCMAS,RevisedChildren’sManifestAnxietyScale;YSR,YouthSelf-report;BRIEF,BehaviorRatingInventoryofExecutiveFunction;CAS,CognitiveAssessmentSystem;D-KEFS,Delis-KaplanExecutiveFunctionSystem;TOL,TowerofLondon;MASC,

MultidimensionalAnxietyScaleforChildren;STAIC,State-TraitAnxietyInventoryforChildren;RCDS,ReynoldsChildDepressionScale;ACTeRS,ADD-HComprehensiveTeacherRatingScale;TAS,TestAnxietyScale;TEA-Ch,TestofEverydayAttentionfor

Children;MFFT,MatchingFamiliarFiguresTest;FDT,FruitDistractionTest;LCS,LocusofControlScale;PTQ,AbbreviatedParent-TeacherQuestionnaire;SNAP-IV,Swanson,Nolan,andPelhamscale;CDI,ChildDepressionInventory;ANT,AttentionNetwork

Test;TMT,Trail-MakingTest;DST,DigitSpanTest;—,valuesnotpresentedbecauseofinsufficientdata;NA,notapplicable.

aPercentagesareroundedtothenearestwholenumber.

bPeer-reviewedabstractonly.

cThemeditationpracticeusedwasdevelopedbyBenson,63whichisalmostidenticaltotheTMmethod.

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with significance dependent on thetime of measurement, and 1 studyfound null results.41 Median effectsizes for dependent variables acrossstudies with physiologic outcomesranged from 0.16 to 0.29 (observedrange:�0.10 to 0.72).

Intervention Effects onPsychosocial and BehavioralOutcomes

Primary psychosocial/behavioral out-comes included anxiety (eg, State-TraitAnxiety Index, Revised Children’s Man-ifest Anxiety Scale), social behavior(eg, Child Behavior Check List), andpsychological disorders (eg, ADHD,depressive symptoms). Of the 7 stud-ies that examined changes in anxi-ety,46–48,50,53–55 5 revealed significantdecreases in anxiety attributed to medi-tation.46,48,50,53,54 Of the 9 studies thatmeasured changes in social/behavioralproblems, 7 showed meditation to sig-nificantly improve absentee periods,45

rule infractions,45 externalizing prob-lems,47,50–54 attentional problems,48,51,53

self-esteem,54 and suspension days45

that result from behavioral problems.Two studies with small sample sizesthat ranged from 3 to 5 participantsindicated trends toward improved so-cial/behavioral functioning.49,52 Theseimprovements were noted in levels ofaggression, bullying, adaptive func-tioning, and externalizing behavior. Ofthe 3 studies that examined changes indepression, 1 study54 revealed signifi-cant reductions, whereas 2 studies re-ported nonsignificant reductions in de-pression scores.47,55 Participants in the2 studies that showed null results re-ported low baseline depression scoresthat did not reach clinically significantcutoff points. In a study of males diag-nosedwith ADHD, themeditation groupincreased selective attention, reducedimpulsivity, and decreased distracti-bility relative to controls.51 A secondstudy of children with ADHD was incon-clusive in that it could not determine

the differential effects of the medita-tion intervention for the child samplebecause adults were included in thestatistical analysis.55 Median effectsizes for dependent outcomes vari-ables across psychosocial/behavioralstudies ranged from 0.27 to 0.70 (ob-served range: 0.03 to 1.09).

Compliance and Retention Rates

Compliance in the reviewed studieswas defined as attendance to treat-ment sessions at the study site and/orat home. Retention was defined as thepercentage of participants who com-pleted survey measures, follow-up vis-its, and procedures as specified in thestudy protocol. Treatment compliancepercentages ranged from 68% to 90%,and study retention rates ranged from64% to 100% for the studies providingthese data. Mean compliance and re-tention rates for all the studies com-bined were 77% and 84%, respectively.Of the 3 studies with 100% retentionrates,45,49,50 none had total sample sizeslarger than 45 participants.

DISCUSSION

Our review of 16 studies provides ini-tial evidence that sitting meditationcan be an effective intervention for thetreatment of physiologic, psychoso-cial, and behavioral problems amongchildren and adolescents. Observed ef-fect sizes ranged from null to 1.09,with median effect sizes across stud-ies ranging from 0.16 to 0.29 for phys-iologic outcomes and 0.27 to 0.70 forpsychosocial/behavioral outcomes. Al-though there have been too few stud-ies to make strong inferences, the ef-fects sizes are slightly smaller thanfindings reported among adults.29,56

Baer56 found MM interventions amongadults to yield effect sizes rangingfrom 0.08 to 1.35 with a mean effectsize of 0.59 (SD: 0.41). Moreover, Gross-man et al29 reviewed 20 meditation-intervention studies among adults and

found mental health mean effect sizesranging from 0.30 to 0.67 and physicalhealth mean effect sizes ranging from0.25 to 1.01. Thus, meditation interven-tions among both youth and adults typi-cally yield small-to-medium effect sizesacross a variety of health outcomes.

There are several limitations to thesestudies. Only 16 studies among youthhave been conducted, in relation tomore than 800meditation-interventionstudies published among adults, indi-cating a great need for researchamong younger populations. The re-sults of the 16 studies reviewed havelimited generalizability. Seven studiescontained samples with a majority ofblack adolescents, and all 5 studiesthat examined physiologic outcomeswere mainly composed of black sub-jects at risk for cardiovascular prob-lems. In addition, almost all the studiesreviewed were completed with clinicalpopulations that were recruited forparticipation on the basis of a pre-existing condition such as high-normalblood pressure, ADHD, learning dis-abilities, and/or conduct problems.In addition, meditation treatmentsthat focused on physiologic outcomeswere conducted primarily in schoolsettings. Thus, future meditation-intervention studies are needed withdiverse samples of youth in a variety oftreatment settings. Studies amongyouth are also needed to measure theimpact of meditation on aspects ofpositive functioning including well-being, mood enhancement, social in-telligence, and self-regulation, particu-larly in universal settings (see ref 57).

The current state of evidence is alsolimited by study-design factors, lack ofdata regarding mediating variables,and incomplete data reporting. Stud-ies examining physiologic outcomeshave all been RCTs; however,�50% ofstudies that examined psychosocial/behavioral outcomes lacked a compar-ison group. Moreover, sample sizes in

e538 BLACK et al

some of the studies reviewed werevery small,46–49,52,55 which may influ-ence the power to detect a treatmenteffect. Seven of the 16 studies in thisreview did not demonstrate sufficientstatistical power (1-� � .80; see ref58). Thus, more RCTs are needed to en-roll an adequate number of youth. Interms of measurement, future studiesneed to measure possible mediatorsof meditation to determine how theseinterventions function to produce en-hanced health status. Valid scales havebeendeveloped tomeasurepossibleme-diators such asmindfulness.59–61 In addi-tion, because some studies did not pro-vide complete information required forcritical appraisal and interpretation,future studies should use the Consoli-dated Standards of Reporting Trials

(CONSORT)62 guidelines to report theirfindings.

CONCLUSIONS

Meditation interventions have been in-creasingly implemented among youthdespite a paucity of empirical supportamong younger age groups. This sys-tematic review of the literature de-scribes the current state of researchpertaining to sitting-meditation inter-ventions among youth and finds medi-tation to have beneficial effects acrossphysiologic, psychosocial, and behav-ioral outcomes. Because the majorityof these studies contained relativelysmall, clinical samples, larger-scaleempirical research efforts among de-mographically diverse samples in var-ious settings are needed to clarify the

treatment efficacy of this approach,particularly in universal health promo-tion and primary prevention efforts. Al-though much remains to be discov-ered about the effects of meditation onhealth, carefully constructed researchwill advance our understanding of sit-tingmeditation and its future use as aneffective treatment modality amongyounger populations.

ACKNOWLEDGMENTSThe National Institute of Drug Abusegrant R01 DA020138 and National Can-cer Institute grant T32 CA09492 sup-ported the preparation of this article.

We thank some of the authors of thestudies cited in this article for theirhelp in responding to our inquiries andproviding us with unpublished data.

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