- Jon Cunha, LMHC
The Benefits of Mindfulness for Children and Adolescents with Anxiety
With the highest levels of anxiety reported in our schools to date (Bernstein, 2016) we see difficulties with self-regulation, decision making and frustration tolerance among students. This article examines the rise in clinical levels of anxiety among children and adolescents. It describes how mindfulness practices help alleviate anxiety symptoms and increase academic performance. Concrete ideas and lessons designed for elementary aged students are offered in an effort to help combat the rise of anxiety and increase academic performance.
Introduction
For as long as I can remember, helping others came to mind when thinking about the question, “What do you want to be when you grow up?” Counseling may not have been the goal since the beginning, but the idea of helping others was always something I wanted to do. However, my journey took another path when I was reinforced by social concepts and language that, “You can’t make money as an educator or helper” or, “Oh you want to help others? How honorable, but you know you won’t make a living doing that.” Unfortunately, I allowed those voices to shape my career decisions. The idea of combining what I felt was both meaningful with supporting myself and future family was drowned out, and somewhere along the road that voice telling me to follow my passion was lost. However, throughout my working career I continued to find myself in positions where I was helping others. For example, lifeguarding and teaching kids to swim, working in schools as a special education tutor, and coaching track and field. Ultimately these jobs all had the same theme: helping others grow. It was not until much later in life, after college, that I discovered while sitting behind a desk selling life and health insurance that I needed to re-evaluate what was important to me. I reflected on where I found meaning, and where I had found myself working until that point. The once drowned out voice broke back through the negative noise and gave me the courage to pursue counseling. Since that realization, I have found my purpose. Since that moment, I have looked to others in the field, theories, and practical ideas to influence and inspire me to better support those I work with. I draw heavily from client-focused teachings, self-as-instrument, and mindfulness practices. My work and exploration into mindfulness is what I will elaborate upon throughout this article, and how it can bring enormous benefits to students.
The effect of mindfulness on academic performance and social-emotional well-being of adolescents is complicated. However, the topic has moved from a helpful conversation to a necessary one. With the highest levels of anxiety ever recorded nationwide (Bernstein, 2016), the need for intervention has never been higher. Youth are facing enormous pressure and stress from a wide range of domains: school, family, friendships, political climates, socio-economic, and systems that promote racial disparities. In this article, I will discuss the benefits of utilizing mindfulness techniques to alleviate high levels of anxiety in children and adolescents. I will present teacher testimonials and observations, as well as assessment data to show the efficacy of teaching mindfulness to children and adolescents as a coping skill for anxiety.
Defining Anxiety
When talking about stress and anxiety, it is important to define what anxiety means. The term has been widely popularized in recent years, thus making it important to understand how anxiety is actually defined. In the United States, the most commonly diagnosed anxiety disorder is Generalized Anxiety Disorder, or better known as GAD. GAD is defined by the Diagnostic Symptoms Manual-5 (DSM-5) as: Excessive anxiety and worry occurring more days than not, for at least 6 months, about a number of events or activities (such as work or school performance). There are also symptoms to look out for, such as, restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance (difficulty falling or staying asleep). Also, the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
When anxiety disorders are not treated or recognized, research has shown a high comorbidity rate with depression. Brady & Kendall (1992) found that, “15.9% to 61.9% of children identified as anxious or depressed have comorbid anxiety and depressive disorders,” and that, “measures of anxiety and depression are highly correlated… the anxiety symptoms tended to predate the depressive symptoms” (p. 244-245).
There has been a lot of research done on the topic of anxiety, especially in the past decade. Throughout the United States, about 25.1% of children between the ages of 13 and 18 suffer from GAD throughout their lives (Kessler, Chiu, Demler, & Walters, 2005). Furthermore, about 6% of children in the same age range suffer from a severe anxiety disorder throughout their lives. These authors also found that in 2002, of the primary care patients complaining of anxiety, 22% suffered from GAD; however, since 2002 that rate has increased to roughly 44%. This means that, in the last decade, the number of primary care patients, with a GAD diagnosis and receiving treatment, has doubled. It is difficult to know if this increase is because professionals are able to identify symptoms sooner or because dissipating stigma has meant more people receiving help. It is important to note there may be multiple reasons for increased diagnosis numbers and identified patients. However, regardless of the increase, the importance for intervention and treatment remains paramount and critical, especially for youth.
Anxiety and Academic Achievement
When discussing educational attainment and academic performance, a student’s ability to be present in the classroom and stay attuned to learning is essential. It is partly the responsibility of schools to find ways in which they can support, not only the academic demands and achievement of their students, but the mental health of their students as well. For decades, education has been about producing top academic achievers. A student’s success was viewed and judged by their overall GPA. Education should not just be about producing the highest GPAs; rather, it must be committed to the holistic development of a child, which includes their mental health as well.
Academic achievement and ability become irrelevant if a student is unable to navigate him or herself through day-to-day life. Which is why, unfortunately, we have seen the increase in suicide, both in attempts and completions, over the last 15 years (National Institute of Mental Health, 2015). It would appear that academic achievement and excellence are not the best indicators for success or personal well-being. There is something else that is missing for these students and I suggest that what is missing is a gap in students’ abilities to be aware enough to support themselves earlier so that they never reach the level of depression or hopelessness where the only plausible solution is to take their own lives. Along with an awareness gap, I also suggest a lack of acknowledgment in the academic system to notice these precursors and act appropriately to support those students in need.
Student Stress and Neurological Changes
In terms of academics, a fact that typically catches the attention of parents in my community is that prolonged levels of stress, or heightened moments of stress, can cause neurological changes within the brain (Bergland, 2014). Jessica Minahan, a board-certified behavior analyst and special educator who serves as Director of Behavioral Services at the Neuropsychology and Education Services for Children and Adolescents group practice in Newton, Massachusetts, states:
Some students with anxiety can have an overactive response to stress, which causes them to demonstrate inflexible, irrational, impulsive, shutting down, and emotionally intense behavior when they are in the classroom. Because of this, they can have a harder time regulating their mood and social interactions and acting and thinking rationally when under pressure (Minahan & Rappaport, 2012, pg. 49).
That jarring fact typically leads to one of the most common conversations I have with parents. Are their children suffering from some of these symptoms and/or do they need counseling? We may continue to see an increase in suicide among our children as the national numbers for anxiety increase. As a therapist in a predominantly privileged white community, much of the dialogue around mental health is about issues related to anxiety, more specifically, how it interferes with learning.
Demographic and Socioeconomic Variability
There is variability in levels of anxiety and in the way anxiety is expressed across demographics. In poor, minority, and underprivileged communities, there are many contributing factors that may cause higher levels of anxiety: inequalities in access to good healthcare providers, insurance coverage disparities, and discrimination from clinical providers, to name a few (McGuire & Miranda, 2008). Stress related illnesses cost the United States nearly $300 billion dollars a year (Brondolo, et al., 2017). In that same study, these authors go on to explain that
People with lower incomes report more severe (but not more frequent) stress and having had more traumatic events in their childhood...African-Americans and U.S.-born Hispanics also report more stress than their non-Hispanic white counterparts, stemming in part from exposure to discrimination and a tendency to experience more violent traumatic events (pp. 11-14)
The next needed development in practice is finding more efficient ways in which we can support these populations. Mindfulness work can help to address certain aspects of stress; however, more needs to be done to address the unequal systems in health care, housing, employment, transportation, etc., that lead to continual oppression of marginalized populations.
Students struggling with anxiety is an issue in privileged, affluent communities as well. The precipitating causes for stress in various populations may be different, but there is an urgent need for more effective support across all communities. For example, in less advantaged areas, financial stress, unstable housing, and food insecurity may cause anxiety. While in more affluent communities, the drive toward status and perfection increases students desire to always be right and fear of making a mistake (Brondolo et al., 2017).
The root causes for anxiety may differ, but anxiety often shows up in similar ways. In my experience, it typically presents in student’s inability to maintain body regulation, difficulty with decision-making and problem solving, low frustration tolerance levels, and overwhelming levels of anxiety related to academic achievement. The struggles from the youth in the Lexington School district and community match the levels seen across the country. Every two years, our school participates in the Youth Risk Behavior Survey (YRBS). The data collected from 2015 matched the national averages for most categories related to anxiety, suicide, and depression (Center for Disease Control, 2018). This is telling that, even in an affluent community, with high socio-economic privileges, the students are not immune to the stressors that are antecedents for the increases in anxiety nationwide.
The biggest difference in levels of anxiety was gender. When asked, “Since you began attending school, has your level of stress…increased dramatically, increased slightly, stayed the same, decreased slightly, decreased dramatically,” over 50% of students reported that their stress levels had “increased dramatically.” Of that 50% who reported, over 61% were female, indicating that females are feeling a higher level of anxiety and stress when reaching the high school level (Rothenbach Research and Consulting, 2015).
Methodology
Collecting data to prove efficacy of the work was important to me. I used multiple methods to collect data including teacher reporting, SEARS assessment scores, and disciplinary referrals. What I found through teacher reporting was a decrease in need for redirections to on-task activities. SEARS assessment data showed a decrease in students who scored in the “At Risk” category (3) to the “Average” range. I collaborated with the school Assistant Principal and recorded disciplinary referrals pre and post mindfulness implementation and found a decrease in the classrooms, and students that I was targeting.
School-based Mindfulness Practice
As an elementary school social worker, it is part of my role to understand these statistics and findings. These students were once in elementary school in our district and they were either not given, or had not learned, proper coping skills in order to manage their heightened levels of anxiety. Another part of my role is to work with individual students, helping them with various difficulties, and accessing local resources if necessary. However, I am also responsible for overseeing the general needs of the entire population of the school. What do all students need, not just the individual students I see? What are the general areas of need school-, district-, and community-wide? My scope of practice extends beyond the doors of the school to the broader community as well. My approach to addressing these issues has been mindfulness and adapting practices from Jon Kabat-Zinn who founded the Mindfulness Based Stress Reduction (MBSR) clinic in 1979 (https://www.umassmed.edu/cfm/).
Mindfulness and Brain Benefits
Kabat-Zinn took chronically ill patients not responding to conventional treatment and began practicing mindfulness with them. He adopted many practices from Eastern Buddhist meditation, but mostly focused on the concept of the present moment. Kabat-Zinn discusses the importance of mindfulness and offers his own operational definition, saying that mindfulness is “the awareness that arises when paying attention, on purpose, in the present moment, non-judgmentally, in the service of self-understanding and wisdom (Kabat-Zinn, 1994). This definition is what I try to use when discussing the concept with my students and the community at large. Mindfulness techniques have been around for decades but only within the last ten years has the research finally shown neurological benefits. Harvard Professor of Psychology, Sara Lazar, writes in the Harvard Business review
Neuroscientists have shown that practicing mindfulness affects brain areas related to perception, body awareness, pain tolerance, emotion regulation, introspection, complex thinking, and sense of self…Mindfulness should no longer be considered a “nice-to-have.” It’s a “must-have”: a way to keep our brains healthy, to support self-regulation and effective decision-making capabilities, and to protect ourselves from toxic stress (Congleton, Hölzel, & Lazar, 2015, p. 11-17).
Reading this resonated with me, because all of the areas of functioning that she found to be affected by stress are what I see in my students’ struggles every day.
Implementing Mindfulness in Schools
When I first began implementing mindfulness in the schools, I had a set of goals that I wanted to accomplish. These goals included:
Schoolwide implementation including both staff and students; Development of age appropriate lesson plans across a kindergarten-5th grade age span; Reduction of the reported amount of stress from students and staff.
The first goal of reaching all students and staff was partly fulfilled by lessons across the entire school. However, after collaborating with my school principal she agreed to have myself and other staff members perform “Mindful Minutes” during morning announcements twice a week. At first, it was a difficult task because the mornings were busy with teachers assigning work, reviewing the schedule, taking attendance, counting lunch meals, etc. However, with consistency, teachers began reporting that the morning’s transition to work became easier. Students were more engaged and focused on the days in which Mindful Minutes were performed. Teachers began to implement Mindful Minutes into their daily schedules, because more and more reports of it being an effective transition tool were being discussed across the school.
We thought it would be difficult for 5-year-olds to grasp concepts of the “present moment” and “returning to our breathe.” However, quite the opposite occurred. Not only were the students able to understand, they enjoyed the lessons. Students were able to engage in single-focused planned activities. For example, the K-2 lesson plan developed for these students used a Tibetan Singing bowl. The objective was simple: have students practice being still and focusing their attention to a singular sound resonating from the bowl. In doing so, this could increase their ability to gain an awareness of a single focus, and give their brains a break from constant, numerous free-flowing thoughts. In addition, the repetition of bringing attention back to the present trains the brain to become aware of wandering thoughts, and what it feels like to bring attention back to the “now.”
Here’s how it is done: Invite students to sit up in their chairs with their backs straight and away from the back of the chair, close their eyes, and raise their hand. Explain to them to keep their hands raised for as long as they can hear the sound of the bowl. As the sound starts to disappear, ask students to lower their hands to their side. When the sound is gone, ask them to take one big deep breath and try to follow their air through their body. Do this three times all the way through. Before beginning, tell the students that their thoughts are going to race and wander, and that is supposed to happen. Encourage them to try to notice when their thoughts have wandered and bring their attention back to the sound of the bowl. With repeated practice students begin to learn how to stop free associating thoughts and focus their attention on the present moment.
Children can understand this activity. It is simple and easy for teachers to replicate. Teachers were encouraged to use this exercise during parts of the day that were more difficult for their students to concentrate, such as after recess and lunch. Teachers reported better engagement after the exercise; they transitioned from activities easier; and began the next activity faster and with less resistance.
An activity to do with grades 3-5 is an adaptation of a body scan. It is an exercise that asks students to pay attention to certain parts of the body, and simply try to notice them. For example, asking them, “Can you feel your stomach? Does it feel tight? Hungry? Rumbling?” The stomach is an area of the body where anxiety commonly manifests. It is one of the most common areas of the body to display psychosomatic symptoms, and a lot of children complain of “stomach-aches.” The exercise gives students, some for the first time, an opportunity to turn their attention inwards and start to learn to listen to their bodies. (Also see the Appendix for a useful list of resources.)
The human body is great at alerting to potential danger. However, our brains, if too distracted by past or future thoughts, have a difficult time being aware of those helpful body signs in the present moment. Throughout a typical day, the majority of our thoughts are either ruminating on past events or worrying about the future. However, the present is the only time we have to live in. Seneca, a Greek philosopher, once said, “We suffer more in imagination, than we do in reality.”
Case Example
When students learn to listen to their bodies they are better equipped to handle everyday worries, whatever they may be. Through my tenure in schools, I have had a few examples of success stories of children who were not coming to school because of anxiety or visiting the nurse’s office everyday with stomach and headaches.
However, one example using mindfulness especially comes to mind. I was working with a student to help overcome anxiety in order to access academics. This student had been absent from school for a while. When this student returned, the anxiety was so impactful that the student was either in my office or the nurse’s office for about 90% of the day. The student was having panic attacks in my office that were so severe that, on numerous occasions, fear of dying was a concern for the student. When the student did try to return to class, there was an inability to access any academics and was completely overwhelmed with worry and fear.
We began our time together with simply sitting and learning breathing techniques. The goal was to rewire the brain’s response to anxiety, to go from panic and fear to calm and resilience. When the student felt anxious, triggered by being at school, the student interpreted that anxiety as a life or death threat, and went into “fight, flight, or freeze response.” In order to help this student, the first step was to re-train the body’s reaction to feelings of anxiety.
We worked on deep breathing skills and positive self-talk during moments when panic and fear were subsided. As stated before, when the brain is in that “fight, flight or freeze” mode, learning cannot occur (Minahan & Rappaport, 2012). It was important to teach these skills when the student was in a calm state. The hope was that if this student could learn the skills, while in a calm state, the student would have prior knowledge of what to do and could access those skills more readily in times of severe anxiety.
Combining this practice with mindfulness meditation, body scans, and other deep breathing techniques can prove beneficial for increasing academic performance. This combination was practiced for a little over two weeks. Progress was slow and, at times, frustrating. However, after about two weeks the ability to remain in class increased. When anxiety spiked it could be met with self-talk: “It is just anxiety, I am safe, I am OK,” followed with breathing exercises to calm the misfiring neurons in the brain. Eventually, the student was able to remain in class for the entire day and only see me for 30-minutes once a week to review and practice skills.
Involving Parents and Teachers
The counseling department initiated a parent’s group where some of these techniques were taught to parents. The reception was overwhelming. Parents were eager to learn more and were fully engaged in the work and ideas. Later in the year, reports from families that had consistently done mindfulness practice found that the typical problem routines (bedtime, dinner, morning routines) were all much easier and their children were better able to move through those routines with less resistance.
When talking about the impacts of mindfulness in academics, I believe the potential is enormous. I have seen first-hand the response from children and staff surrounding the issue and its impacts. Teachers frequently come to me asking if I can come in and teach more lessons. Students tell me they are doing mindful minutes and body scans at home to help them sleep and focus. As Sara Lazar said, “mindfulness practice has moved from a “nice to have” to a “must have.” I believe that mindfulness practice should be, and can be, in every school to help benefit our students.
A Social Justice Perspective on Mindfulness
This work has helped students to better access their academics and it has allowed me to consider the impact this work can have through a social justice lens. During the summer, I work for a non-profit organization serving low-income inner-city students with the ultimate goal of helping them get into college. I have taken mindfulness practices to students from low-income families to address the issue of stress in their lives. According to a study conducted by the American Psychological Association titled, Stress and Health Disparities, men in the top 1 percent of income lived, on average, 15 years longer than low-income men. For women, the disparity was closer to 10 years. This study states, “Disparities in both stress and health may not be visible to those who have more advantages or who have relatively limited direct contact with those affected. A well-informed community is critical to improving the health of racial/ethnic and poor communities” (Brondolo et al., 2017, p. 49). I believe that the work I do as an advantaged individual is to bring visibility to the issue while offering support to minimize the levels of stress.
Conclusion
Since our school has begun this practice the number of counseling referrals pertaining to anxious children, in our department, has dropped by almost 20%. My goal would be to continue the work in my building and to expand the practice to continue to teach parents and community members these techniques. It will help the community-at-large to see the benefits of this practice and the impact it can have on their student’s ability to be the best learners they can be. As my practice grows, and I learn more about how to use mindfulness in the most effective way, I hope to increase the reach of this useful practice outside my community and take what I have learned to other schools and communities that would benefit from the practice. This article represents a step in that direction.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-V-TR. Washington, DC: American Psychiatric Association.
American Psychological Association. (2018). Higher Stress Among Minority and Low-Income Populations Can Lead to Health Disparities. Washington DC.
Brondolo, E., Byer, K., Gianaros, P., Liu, C., Prather, A., Thomas, K., & Woods-Giscombé, C. (2017). Stress and Health Disparities. Washington, DC: American Psychological Association. http://www.apa.org/pi/health-disparities/resources/stress-report.pdf
Bergland, C. (February 2014). Chronic stress can damage brain structure and connectivity. https://www.psychologytoday.com/blog/the-athletes-way/201402/chronic-stress-can-damage-brain-structure-and-connectivity.
Bernstein, J. (January 2016). The rising epidemic of anxiety in children and teens. Retrieved February 26, 2018, from https://www.psychologytoday.com/blog/liking-the-child-you-love/201601/the-rising-epidemic-anxiety-in-children-and-teens.
Brady, E. U., & Kendall, P. C. (1992). Comorbidity of anxiety and depression in children and adolescents. Psychological Bulletin, 111(2), 244-255.
Congleton, C., Hölzel, B. K., Lazar, S. W. (December 2017). Mindfulness can literally change your brain. https://hbr.org/2015/01/mindfulness-can-literally-change-your-brain.
Kabat-Zinn, Jon. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York, NY: Hyperion, 1994.
Kessler R. C., Chiu W. T., Demler O., Walters E. E. (June 2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6), 617-27.
McGuire, T. G., & Miranda, J. (2008). Racial and ethnic disparities in mental health care: Evidence and policy implications. Health Affairs (Project Hope), 27(2), 393–403.
http://doi.org/10.1377/hlthaff.27.2.393
Minahan, J., & Rappaport, N. (2012). The behavior code: A practical guide to understanding and teaching the most challenging students. Cambridge, MA: Harvard Education Press.
Reuters Staff. (2018). U.S. suicide rates see sharp increase from 1999 to 2016: CDC. [online] U.S. Available at: https://www.reuters.com/article/us-usa-health-suicide/u-s-suicide-rates-see-sharp-increase-from-1999-to-2016-cdc-idUSKCN1J32PJ
Rothenbach Research and Consulting. (2015). Youth Risk Behavior Survey. Retrieved March 18, 2018, from http://www.rothenbach-research.com/youth_risk_behavior_survey.htm
U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health. (2015). NIMH Strategic Plan for Research (NIH Publication No. 02-2650). http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml
Appendix
Resources
Books/Websites:
Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life - Jon Kabat-Zinn. Hyperion. 1994
Fully Present: The Science, Art, and Practice of Mindfulness by Susan L. Smalley, PhD and Diana Winston. Da Capo Press. 2010
The Mindful Athlete by George Mumford
The Power of Mindfulness: Mindfulness Meditation Training in Sport by Amy Baltzell
Mindsight by Dan Siegel
https://www.mindfulschools.org/
News and Research:
“Mindfulness Can Literally Change Your Brain.” Christina Congleton, Britta K. Hölzel, Sara W. Lazar https://hbr.org/2015/01/mindfulness-can-literally-change-your-brain“The Power Behind Mindfulness-Based Fitness Training for Soldiers.” Victoria Tilney McDonough, BrainLine https://www.brainline.org/article/beyond-chanting-om-power-behind-mindfulness-based-mind-fitness-training-soldiers“20 Scientific Reasons to Start Meditating Today.” Emma M. Seppälä Ph.D. https://www.psychologytoday.com/us/blog/feeling-it/201309/20-scientific-reasons-start-meditating-todayMindfulness Based Stress Reduction Clinic, UMass Medical School https://www.umassmed.edu/cfm/