Examining the Efficacy of Mindfulness Cognitive Therapy to Reduce Anxiety Symptoms in Children

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2019-11 Examining the Efficacy of Mindfulness Cognitive Therapy to Reduce Anxiety Symptoms in Children

Syeda, Maisha M.

Syeda, M. M. (2019). Examining the Efficacy of Mindfulness Cognitive Therapy to Reduce Anxiety Symptoms in Children (Unpublished doctoral thesis). University of Calgary, Calgary, AB. http://hdl.handle.net/1880/111236 doctoral thesis

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UNIVERSITY OF CALGARY

Examining the Efficacy of Mindfulness Cognitive Therapy to Reduce Anxiety Symptoms in

Children

Maisha Musarrat Syeda

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF DOCTOR OF PHILOSOPHY

GRADUATE PROGRAM IN EDUCATIONAL PSYCHOLOGY

CALGARY, ALBERTA

NOVEMBER, 2019

Abstract

Anxiety disorders are a prevalent childhood psychopathology and can lead to significant distress and interference in children’s daily functioning. Hence, there is a consistent need for empirically supported interventions to alleviate children’s distress associated with anxiety issues. One promising intervention for childhood anxiety that warrant further empirical attention is

Mindfulness-based Cognitive Therapy (MBCT). A randomized controlled trial with waitlist controls was employed to examine the effects of MBCT to reduce anxiety symptoms in children, who were aged 9-12. The study also examined whether participation in MBCT was associated with mindfulness growth and improvements in emotional reactivity in children. Stratified randomization procedure, having participants’ anxiety symptom severity and sex as co-variates, was carried out to assign participants into either the intervention (n = 12) or control (n = 13) group. The intervention group completed a 12-week manualized MBCT program, and self- and parent-reports of child’s anxiety symptoms were collected at baseline screening, post-MBCT, and a one-month follow-up. Intervention participants also reported on their mindfulness and emotional reactivity at pre-, mid-, and post-MBCT, and a one-month follow-up. Self- and parent- reports of anxiety were also collected at baseline screening and post-MBCT for the control group. Intervention parents reported significant decreases in the number and severity of their child’s anxiety symptoms from baseline screening to post-MBCT, and this effect was maintained a month after intervention. There were no significant differences in the number and severity of parent-reported anxiety symptoms in the control group while control participants were waiting to receive MBCT. Both control and intervention participants did not report significant changes in their anxiety symptoms from baseline screening to post-MBCT. However, intervention participants who did report some decreases in their anxiety symptoms from baseline screening to

ii post-MBCT, decreases in their anxiety symptoms significantly correlated with increases in their mindfulness at mid-MBCT. Finally, intervention participants did not report any significant change in their emotional reactivity from before to after intervention. Implications of these findings, along with limitations and future direction for research, are discussed.

iii

Acknowledgements

Firstly, I wish to express my sincere gratitude to my supervisor, Dr. Jac Andrews for his continuous support of my Ph.D. research, for his encouragement, advocacy, and genuine enthusiasm for my work. His guidance has taught me to navigate obstacles and bring creativity to my research, a contribution that I appreciate dearly, and was so important to my growth as a researcher.

Besides my supervisor, I thank the rest of my supervisory committee: Dr. Michelle Drefs and Dr. Sal Mendaglio. I thank them for their continuous encouragement and guidance, but also for asking me the hard questions. Their insightful ideas, questions, and feedback helped me to think more critically about my research.

Undertaking of my Ph.D. research took learning, courage, and aspirations. Along with my supervisor and supervisory committee, I would like to acknowledge the many research mentors that I had the opportunities to learn from in my undergraduate and graduate training.

Their teachings uniquely and collectively have evolved my thinking, skills, and readiness to conduct my research. Additionally, I thank my mindfulness teachers and clinical supervisors in

Canada and Washington, District of Columbia; their teaching and mentorship have deepened my perspectives on the human mind, suffering, and resilience.

The support of the administration team of the Werklund School of Education and community partners was integral to the implementation of my study. Jim Baker and Brenda

McDougall were immensely helpful in finding and booking appropriate space to ensure that my study ran smoothly. The custodial staff of Werklund always checked in with me to make sure the study space was inviting for my study participants. I also thank my research assistant, Ivneet

Brar, who worked so diligently to enter the study data. I appreciate her contribution of time as

iv well as her enthusiastic interest in learning about mindfulness and anxiety. Then, I am grateful for my partnership with Calgary area schools that allowed me to reach out to the community and recruit participants.

Additionally, I gratefully acknowledge the funding sources that made my Ph.D. research possible. I was funded by the Social Sciences and Humanities Research (2-year doctoral fellowship) for the last two years of my Ph.D. studies. My work was also supported by the

University of Calgary-Vice President Research-Doctoral Dissertation Grant, Queen Elizabeth-II

Scholarship, as well as local academic scholarships from the University of Calgary.

Then, I thank my family for their unconditional love and support in the pursuit of all my learning. Papa taught me about humility and work ethics; Maa’ji taught me about the importance of advocating for others. My sister, Nashita, reminds me every day how empowering it can be to own one’s individuality. These values guided me in all aspect of my Ph.D. research and heavily influenced my personal development as a researcher and clinician.

I am also very fortunate to have unwavering support from my friends. They celebrated my highs, but they also lifted me during the lows. I thank them for listening, validating, consulting, and be pillars of strength, unity, and inspiration for me. A speciate note of gratitude to the Three Musketeers. Their friendship to support me doing the best I can helped me to cope through and even thrive during the most challenging times of my Ph.D. journey.

Lastly, I express my gratitude to the children and their parents who participated in this study. Their time, interests, and engagement made this study possible. I thank them for joining me in learning about mindfulness.

Dedication

To the seven-year-old girl for whom the thought of attending after-school activities evoked intense separation anxiety, but she struggled to explain to the others the dragons that were growling inside.

Table of Contents

Abstract ...... i

Acknowledgements ...... iii

Dedication ...... v

Table of Contents ...... vi

List of Tables ...... xii

List of Abbreviations ...... xiii

Chapter One: Introduction ...... 1

Interventions for Childhood Anxiety ...... 3

MBCT for Childhood Anxiety ...... 4

Statement of the Problem ...... 6

Purpose of the Study ...... 7

Overview of the Study ...... 7

Overview of the Dissertation ...... 8

Chapter Two: Literature Review ...... 10

Childhood Anxiety ...... 10

Categories and their symptoms...... 11

Developmental course and prognosis ...... 13

Etiology...... 14

Cognitive factors ...... 15

vii

Measurement...... 17

Interventions ...... 21

Empirical supports and limitations of CBT for childhood anxiety...... 23

Mindfulness-based psychotherapies ...... 23

Mindfulness-based Interventions (MBIs) ...... 24

MBCT...... 28

Mindfulness...... 28

Mindfulness and child development ...... 29

Measurement of mindfulness ...... 31

MBCT vs. CBT...... 34

Implementations and evaluations of MBCT with children and adolescents...... 37

MBCT for childhood anxiety ...... 41

Mechanisms of action in MBCT...... 48

Mindfulness as a mechanism of action ...... 51

Emotional reactivity...... 53

Emotional reactivity and childhood anxiety ...... 53

Measurement of emotional reactivity ...... 54

Emotional reactivity and MBCT ...... 56

Gaps and Limitations of the Literature ...... 59

Statement of Problem and Research Questions for the Current Study ...... 60

viii

Chapter Three: Methods ...... 64

Research Design ...... 64

Power Analysis ...... 65

Participants ...... 65

Participants not meeting the eligibility criteria...... 66

Measures ...... 67

Anxiety symptoms ...... 67

Social-emotional and behavioral functioning ...... 68

Mindfulness...... 69

Emotional reactivity ...... 70

Research Intervention ...... 70

Intervention structure and activities...... 72

Parental components ...... 73

Intervention fidelity ...... 74

Procedures ...... 76

Phase one: Baseline screening ...... 76

Eligibility criteria ...... 78

Phase two: Randomization and intervention evaluation ...... 81

Intervention provision ...... 82

Phase three: Follow-up and the waitlist controls receiving MBCT...... 83

Study Objectives...... 84

Data Analyses ...... 85

Ethical Considerations...... 86

Chapter Four: Results ...... 89

Participants ...... 89

Determining eligibility ...... 90

Preliminary Analysis ...... 91

Intervention participants vs. waitlist controls...... 91

Intervention ...... 91

Intervention attendance...... 91

Intervention fidelity...... 92

Data Inspection and Descriptive Analyses ...... 92

Primary Analyses ...... 95

Primary outcomes: Decreases in anxiety symptoms...... 95

Parent-reports of the intervention participants ...... 96

Self-reports of the intervention participants ...... 96

Intervention participants vs. controls ...... 97

Secondary outcomes: Changes in mindfulness and emotional reactivity ...... 99

Changes in mindfulness ...... 99

Changes in emotional reactivity ...... 100

Anxiety, mindfulness, and emotional reactivity ...... 100

Change Analysis ...... 103

Chapter Five: Discussion ...... 105

Self- and Parent-Reports of Anxiety and Determining Eligibility ...... 105

Intervention Attendance ...... 107

Intervention Fidelity ...... 109

Primary Intervention Outcomes: Decreases in Anxiety Symptoms ...... 110

Secondary Intervention Outcomes and Changes ...... 115

Mindfulness...... 115

Mindfulness and self-reports of anxiety ...... 117

Mindfulness and parent-reports of anxiety ...... 121

Emotional reactivity...... 122

Theoretical, Empirical, and Clinical Implications ...... 125

Implications for mindfulness programming in schools ...... 130

Strengths ...... 133

Limitations and their Implications ...... 134

Future Directions for Research ...... 139

Conclusion ...... 140

References ...... 142

Appendix A ...... 172

Appendix B ...... 174

Appendix C ...... 175

Appendix D ...... 179

xii

List of Tables

Table Page

1. Sex and Age Distributions of Twenty-Seven Participants Meeting 82 Eligibility Criteria to participate in MBCT

2. Means, Standard Deviations, and Ranges of T-scores of Anxiety and 83 Social-Emotional and Behavioural Symptoms Reported by the Eligible Participants at Baseline Screening

3. Age and Sex Distributions of Intervention Participants and Waitlist 84 Controls after Randomization

4. Descriptive Information of the Primary Study Variable: Anxiety 86 Symptoms Measured at Different Time Intervals

5. Descriptive Information of the Secondary Study Variables: 87 Mindfulness and Emotional Reactivity Measured at Different Time Intervals

6. Correlations before MBCT 94

7. Correlations at mid-MBCT 95

8. Correlations at post-MBCT 95

9. Correlations after one-month following MBCT completion 96

xiii

List of Abbreviations

Symbol Definition

ANOVA Analysis of Variance APA American Psychiatric Association CBT Cognitive behavioural therapy CMHO Children’s Mental Health Ontario DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision DSM-5 Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition GAD Generalized anxiety disorder MAAS Mindfulness Attention Awareness Scale MAAS-C Mindfulness Attention Awareness Scale for Children MAAS-A Mindfulness Attention Awareness Scale for Adolescents MASC Multidimensional Anxiety Scales for Children MASC-2 Multidimensional Anxiety Scales for Children-Second Edition MBCT Mindfulness-based cognitive therapy MBCT-C Mindfulness-based Cognitive Therapy for Children MBSR Mindfulness-based stress reduction RCMAS-2 Revised Children’s Manifest Anxiety Scale, Second Edition RCT Randomized controlled trial REA Emotional Reactivity Scale RSCA Resiliency Scales for Children and Adolescents RUPP Research Units on Pediatric Psychopharmacology Anxiety Study Group SCARED-R Screen for Child Anxiety Related Emotional Disorders- Revised SES Socioeconomic status SCAS Spence Children’s Anxiety Scale for Children SPSS IBM-SPSS Statistics 26.0 STAIC State-Trait Anxiety Inventory

Chapter One: Introduction

Anxiety is a common mental health issue in children (Beesdo, Knappe, & Pine, 2009). In fact, childhood anxiety disorders are one of the most common types of psychiatric disorders in childhood (Curry, March, & Harvey, 2004), with a cumulative prevalence of 10% by 16 years of age (Costello, Mustillo, Erkanli, Keeper, & Angold, 2003), and with lifetime prevalence of about

29% (Kessler et al., 2005). The rates of anxiety disorders can be higher in children and adolescents referred for psychological or psychiatric services. For example, out of the 1375 children referred to a major pediatric psychopharmacology program in the United States between

1991 and 2002, 46% of them had at least one anxiety disorder, and 28% of them had two anxiety disorders (Hammerness et al., 2008). While the age of onset varies between the subtypes of anxiety disorders, epidemiological research suggests that the development of anxiety disorders typically begin in childhood (Gregory et al., 2007; Kessler et al., 2005), and once diagnosed, anxiety disorders can persist throughout life if they remain untreated (Esbjorn, Hoeyer, Dyrborg,

Leth, & Kendall, 2010). Taken together, the reported high prevalence and early onset of anxiety disorders substantiate the need to continue evaluations of child-focused interventions and treatments to determine further the robust effectiveness of these interventions and treatments in alleviating symptoms, distress, and impairments associated with anxiety disorders in children.

Anxiety disorders are usually characterized by displays of excessive levels of fear, worry, physical complaints, and avoidant behaviours (American Psychiatric Association [APA], 2013).

Anxiety is the anticipation of a future threat. The experience of anxiety can evoke muscle tension and vigilance in individuals in their anticipation of future danger, and thus, often lead individuals to be cautious, if not avoidant of an object or situation associated with the threat (APA, 2013).

Individuals with clinically diagnosed anxiety usually overestimate the future threat or danger in

2 situations they fear or avoid, and often their fear is out of proportion to what the situation or the object warrants.

In children, anxiety disorders can lead to significant distress and interference in their day- to-day functioning. In the short-term, anxiety disorders can impair children’s school, occupational, and psychosocial functioning (Albano, Chorpita, & Barlow, 2003). With respect to school functioning, anxiety disorders can interfere with children’s school attendance, academic performance, and participation in extra-curricular activities. Socially, children with anxiety disorders may have challenges with developing and maintaining friendships, possibly leading to social isolation (Greco & Morris, 2005). The long-term consequences of anxiety disorders in children can be more concerning and distressing. As children with anxiety disorders get older, they are at increased risk of developing more serious psychiatric disorders, such as co-morbid anxiety disorders, mood disorders, suicidal ideations, and substance abuse (Stein & Stein, 2008;

Woodward & Ferguson, 2001). Untreated childhood anxiety disorders are also a major concern for our society. The cost to families with children with anxiety disorders is exponentially higher than that of families from the general population, due to, for example, expenses associated with seeking out psychological services and parents having to stay at home from work to care for their children (Bodden, Dirksen, & Bogels, 2008). Furthermore, it is assumed that parents of children with anxiety issues have higher productivity costs. Productivity cost refers to the societal cost of the lost labour time, whether or not the individual was paid for this time. The researchers at the

Children’s Mental Health Ontario (CMHO) found that 25% of parents reported missing work to care for their child having issues related to anxiety (Dass & Laporte, 2018). This finding by the

CMHO suggests that productivity costs associated with childhood anxiety may be large. Taken together, given the prognosis of childhood anxiety disorders and the significant challenges they

3 can create for children and their families, mental health professionals must be well-informed of empirically-based interventions for anxiety that can be implemented and further evaluated for effectively reducing children’s anxiety issues and enhancing their quality of life.

It is well-documented that untreated anxiety-related challenges can escalate to more severe psychopathologies in adolescence and adulthood (Schwartz, Barican, Yung, Zheng, &

Waddell, 2019). Therefore, middle and late childhood (i.e., ages 6 to 12) present an ideal opportunity to provide interventions. If children are armed with appropriate psychoeducation and strategies to cope with their anxiety-related issues in middle and late childhood, the prognosis of their anxiety may be better (Kösters et al., 2012). Early interventions and preventions may mitigate risks of developing anxiety disorders and other psychopathologies that may emerge in response to transitions and stressors in adolescence and adulthood (Maggin & Johnson, 2019).

For example, rumination is a shared etiological factor for both depression and anxiety (Albano,

Chorpita, & Barlow, 2003). Suppose an 11-year-old learns coping strategies to ruminate less in an anxiety intervention. The child may use the same coping strategies to ruminate less in response to interpersonal conflicts in adolescence, that might have otherwise deteriorated their mood. Therefore, it is important to evaluate the efficacy of anxiety interventions and preventions designed for middle and late childhood.

Interventions for Childhood Anxiety

Cognitive behavioural therapy (CBT) is often considered the intervention of choice for childhood anxiety disorders (Gibby, Casline, & Ginsburg, 2017). While CBT is effective, research has also shown that some children maintain their anxiety diagnoses after participating in

CBT (James, James, Cowdrey, Soler, & Choke, 2015; Warwick et al., 2017). The findings of the long-term efficacy trials of CBT suggest that for some children, their anxiety symptoms relapse.

Thus, the positive effects of CBT were not maintained in those cases (Gibby et al., 2017). As

CBT might not be as effective for all children (James et al., 2015), there needs to be continuing efforts in the research community to further develop and evaluate the efficacy and effectiveness of additional interventions for childhood anxiety disorders. A promising example of such a more recently developed and evaluated intervention for childhood anxiety is mindfulness-based cognitive therapy (MBCT; Semple, Reid, & Miller, 2005).

MBCT for Childhood Anxiety

MBCT fuses traditional concepts of cognitive therapy and more current mindfulness practices and philosophies to help individuals to become more aware, accepting, and compassionate of maladaptive and distressing thoughts and emotions that elicit and intensify their psychological distress (Segal, Williams, & Teasdale, 2002). MBCT has been adapted to meet the needs of children who have psychological challenges, such as anxiety (Racey et al.,

2018). CBT gets children with anxiety to recognize and change their irrational thoughts, beliefs, and fears (Kendall, 2006). On the other hand, MBCT supports children in experiencing the present moment openly and non-judgmentally. MBTC helps to re-orient children’s attention away from past or potential future concerns about events and experiences that often elicit stress and anxiety within them (Semple et al., 2005). MBCT also teaches children behavioural strategies to promote self-regulation and social-emotional resiliency within them. Lee and

Semple (2014) developed a manualized MBCT program intended for children between the ages of 9-12 who have anxiety symptoms. To the researcher’s knowledge, it is the only manualized

MBCT program available presently for childhood anxiety for the 9-12 age group. Thus far, few researchers have evaluated the efficacy of MBCT to reduce anxiety symptoms in children. From the few studies that have been conducted so far, the findings generally indicate that MBCT is

5 feasible and that children can learn how to apply mindfulness-based practices efficaciously in everyday life to reduce their distress associated with anxiety (Semple et al., 2005). Importantly, participation in MBCT has been found to be associated with reduced anxiety symptoms (Cotton et al., 2016; Semple, Lee, Rosa, & Miller, 2010).

Along with examining the effects of MBCT on psychological symptoms and disorders, researchers have been interested in identifying secondary outcomes associated with completing

MBCT, and how they relate to the changes seen with primary, psychological outcome(s).

Understanding the relations between the secondary and primary outcomes of participating in

MBCT begins to provide insights into its possible mechanisms of action. Identifying the mechanisms of action for an intervention tells us how the intervention may work to produce the intended primary outcome. With adults, there is emerging evidence that improvements in outcomes like mindfulness, rumination, cognitive reactivity, and emotional reactivity predict decreases in anxiety and depression (i.e., the primary outcomes) after completing MBCT

(Alsubaie et al., 2017). In comparison, researchers have studied fewer secondary outcomes for

MBCT with children. From the limited research that has been conducted thus far, particularly in the area of childhood anxiety, the findings indicate that children and adolescents completing

MBCT also make gains in mindfulness (e.g., Cotton et al., 2016; Esmaeilian, Dehghani,

Dehghani, & Lee, 2018) and improve their attention (Semple et al., 2010) and emotional regulation skills (Cotton et al., 2016). Gains in mindfulness were also found to be correlated with decreases in childhood anxiety symptoms reported and assessed after completing MBCT.

Additionally, there are other secondary outcomes, such as emotional reactivity that have been assessed as an effect of MBCT in adults, but not in children. Therefore, along with assessing

6 mindfulness, future investigations are needed to examine additional secondary effects of MBCT, and their relationships to decreases in anxiety symptoms in children after completing MBCT.

Statement of the Problem

It is well established that psychotherapeutic interventions are to be evaluated in a systematic and well-designed way in order to obtain reliable and valid evidence about their efficacy and applicability with targeted populations for their identified needs (Flynn, 1997). For

MBCT, an empirical review reveals that it is a promising approach to reducing anxiety symptoms in children (e.g., Cotton et al., 2016). However, the research is still in the very early stages, and limited studies have been published on this topic. In this regard, very few researchers have examined MBCT’s efficacy in clinically anxious children with comparison groups. So far, there have been two randomized controlled trials (RCT) of MBCT in which one of the aims was to assess whether it is also efficacious to reduce anxiety symptoms in children (Esmaeilian et al.,

2018; Semple et al., 2010). However, these RCTs were open trials for children with academic concerns and children of divorce, and all children participating in these trials were not necessarily clinically anxious before MBCT. Conducting RCTs of MBCT with clinically anxious children is important in assessing whether the decreases in anxiety symptoms seen in children after completing MBCT is significant compared to same-aged children with similar levels of anxiety severity who did not receive the intervention. Furthermore, knowledge of mechanisms of action for MBCT for childhood anxiety is sparse. To this end, additional studies are needed to consolidate our knowledge as to whether gains in mindfulness are a consistent, secondary outcome associated with the completion of MBCT for childhood anxiety. Plus, future studies need to explore new secondary outcomes like emotional reactivity that have not yet been assessed in children participating in MBCT. Examining secondary outcomes of MBCT for

7 childhood anxiety and whether those outcomes contribute to changes in children’s anxiety symptoms will provide further insights into mechanisms of action for the intervention.

Purpose of the Study

The overarching purpose of this study was to enhance our knowledge about the efficacy of MBCT for childhood anxiety. To this end, this study specifically had four aims. First, it investigated the efficacy of MBCT to reduce anxiety symptoms in children, who were aged 9-12, and it also examined whether possible declines reported in anxiety symptoms at post-MBCT were maintained at a one-month follow-up. Second, the study evaluated whether participation in

MBCT was perceived to have greater benefits in decreasing children’s anxiety symptoms than no intervention. Third, the study aimed to identify secondary outcomes that clinically anxious children might gain while participating in MBCT. Particularly, the secondary outcomes that were evaluated in this study were mindfulness and emotional reactivity. Fourth, the study examined how mindfulness and emotional reactivity changed in intervention participants while they were receiving MBCT, and whether those changes correlated with changes seen in their anxiety symptoms at post-MBCT and a one-month follow-up.

Overview of the Study

In line with the study aims described above, an RCT was employed to evaluate the efficacy of MBCT. There were three phases in this study: 1) baseline screening, 2) intervention evaluation phase, and 3) a one-month follow-up and intervention delivery for waitlist controls.

Children and their parents were recruited from schools in the Calgary area. Specifically, after ethics approval, the researcher (i.e., the author) requested school administrators to send out information about the study to parents and caregivers of students within the targeted age and grades range. Then with parental consent, parents and their children participated in the screening

8 phase of the study to determine children’s eligibility to participate in MBCT. By way of the use of self- and parent-report measures, participating children’s degree and range of anxiety symptoms, as well as their overall social-emotional functioning, were assessed. Children identified with elevated to very elevated levels of anxiety symptoms and with no severe atypical, attentional, or behavioural concerns were deemed to be eligible to participate in the intervention.

Eligible participants were invited to take part in the intervention evaluation phase of the study.

Procedures for stratified randomization were carried out while controlling for participants’ sex and levels of anxiety symptoms reported by their parents at baseline screening to determine whether the child would participate in the intervention during the evaluation phase or be a waitlist control. The waitlist controls received MBCT following the evaluation phase of the intervention.

A manualized program (Lee & Semple, 2014) was used to implement MBCT.

Intervention participants reported their anxiety symptoms at baseline screening, after completing

MBCT, and at a one-month follow-up. Parents of the intervention participants also reported on their children’s level of anxiety symptoms at the same time intervals. Self- and parent-reports of children’s levels of anxiety symptoms for waitlist controls were collected at baseline screening and post-MBCT (i.e., after the intervention participants have completed MBCT). During the evaluation phase, intervention participants also reported on their mindfulness and emotional reactivity at pre-MBCT, mid-MBCT, post-MBCT, and a one-month follow-up.

Overview of the Dissertation

Chapter two provides a review of the relevant background and empirical literature, including a review of childhood anxiety and anxiety disorders, interventions for childhood anxiety, and MBCT. Chapter two concludes by highlighting the gaps within the presented

9 literature leading to the purpose and design of the current study, including the questions to be addressed and associated hypotheses with respect to the study. The methods of the current study are subsequently presented in chapter three. Chapter four presents the results of the study.

Finally, chapter five provides a discussion of the results and the theoretical, empirical, and clinical implications. To end, chapter five discusses the limitations and significance of the study for future research.

Chapter Two: Literature Review

Chapter two provides a literature review to familiarize readers with the theoretical, conceptual, and empirical information and reasoning that guided the undertaking of this research study. To this end, the chapter begins with an overview of childhood anxiety disorders, including definitions and descriptions of their categories and symptoms, developmental courses and prognosis, etiology, and how their symptoms are measured. Subsequently, the chapter will provide a brief overview of current psychotherapeutic interventions for childhood anxiety disorders. Afterward, the chapter will present theoretical and empirical information with respect to MBCT (i.e., theoretical framework, efficacy evidence), and provide further information relative to the development and implementation of MBCT for childhood anxiety. Moreover, aspects of theory and research that are still unknown, unsubstantiated, or unclear (i.e., mechanisms of action) about MBCT will be presented. The following section of the chapter will provide a summary of the limitations of the current state of research on childhood anxiety and

MBCT to establish the rationale and purpose for the undertaking of the present study. The chapter concludes by posing the research questions and their respective hypotheses that guided the present study.

Childhood Anxiety

Anxiety is an affective state that a person experiences when they feel threatened by the potential occurrence of a future event or outcome that they perceive to be negative or harmful

(Dozois, McDermott, & Frewen, 2015). When the affect of anxiety escalates, persists, and intensifies to manifest as behavioral disturbances (e.g., significant distress or interference in the person’s social, academic, occupational or other important areas of functioning), the condition is referred to as an anxiety disorder and considered a psychopathology (APA, 2013). The affective

11 state of anxiety is often marked by excessive fears and worries. While fears and anxiety are inter- related, fear is a primitive, emotional response to a real or perceived threat that is imminent, whereas anxiety is experienced in anticipation of a future threat (Dozois et al., 2015). For children, transient fears and anxieties are normative, emotional responses, and states of typical development (Albano et al., 2003). However, for a child with an anxiety disorder, their fear and anxiety are excessive, persisting, and out of proportion to the actual likelihood of encountering the fear-or-anxiety-provoking threat or its impacts. The excessive and persistent fears and anxieties cause behavioral disturbance — escape or avoidance of the threat-provoking stimuli, situations, or events — and often lead to academic and psychosocial impairments.

Categories and their symptoms. Presently, the Diagnostic and Statistical Manual of

Mental Disorders-Fifth Edition (DSM-5; APA, 2013) presents ten categories of anxiety disorders: 1) separation anxiety disorder; 2) selective mutism; 3) specific phobia; 4) social anxiety disorder; 5) panic disorder; 6) agoraphobia; 7) generalized anxiety disorder (GAD); 8) substance or medication-induced anxiety disorder; 9) anxiety disorder due to another medical condition; and 10) other specified anxiety disorder. Some of these disorders are more prevalent in childhood (e.g., separation anxiety disorder, social anxiety disorder), and some have a very low prevalence rate in the general population and are much rarer in childhood (e.g., substance/medication-induced anxiety disorder; APA, 2013). While each anxiety disorder has distinct core symptoms and diagnostic features (i.e., the focus of the anxiety), many symptoms overlap across the disorders.

Separation anxiety disorder is characterized by recurrent, and excessive distress experienced by children when separated from home or their major attachment figures (APA,

2013). Children with separation anxiety disorders may often worry about the well-being or death

12 of attachment figures, and consequently, they may have constant needs to know the whereabouts of their attachment figures. Additionally, they may have excessive worries about an untoward event to themselves, such as being kidnapped or lost (APA, 2013). As a result of these separation worries, they may escape or avoid situations that result in being separated from their attachment figures (e.g., attending school).

Social anxiety disorder is marked by intense anxiety of a social situation in which children may be evaluated or scrutinized by others (APA, 2013). In social situations, children with social anxiety disorder experience excessive fears, and worries about being negatively evaluated (e.g., being judged as stupid), or they may have fears that they will behave in ways that will expose their social anxiety symptoms (e.g., sweating, stumbling). They may not only be anxious to interact or perform in front of adults but also to engage with peers.

Selective mutism is a rare anxiety disorder that is more likely to emerge in younger children than in adolescents and adults (APA, 2013). Children with selective mutism do not initiate verbal responses or verbally reciprocate responses when spoken to by others in social interactions. It may be typical for the child with selective mutism to speak in the home with their immediate family members but not in front of close friends, relatives, or people in their school

(Dozois et al., 2015). Selective mutism is often marked by high social anxiety.

Specific phobia is characterized by persistent, stable fears of objects or situations (APA,

2013). When exposed to the phobic stimulus, the child immediately experiences distress that can cause them to avoid the stimulus. Children with specific phobias are often reported to have fears of darkness, insects, blood, heights, animals, or injuries (Dozois et al., 2015).

Recurrent and unexpected panic attacks characterize panic disorder. When a child has a panic attack, they experience an abrupt surge of intense fear or discomfort that reaches a peak

13 within minutes. During the episode, the child will have four or more physiological and cognitive symptoms, including accelerated heart rate, sweating, feelings of choking, and fears of losing control (APA, 2013). While panic attacks may be associated with other anxiety disorders, the emergence of a panic disorder occurs when one of the following accompanies the unexpected, recurrent panic attacks: 1) persistent fear of experiencing future panic attacks, or 2) worry about the implications of the attack or its consequences, or both. Children may have panic attacks, but the emergence of panic disorders before age 14 is very rare (APA, 2013).

Finally, children may also struggle with GAD. Children with GAD have excessive worries and anxiety about several events and activities, and they find it very challenging to control these worries and anxieties (APA, 2013). The intensity, duration, and frequency of the worries and anxiety typically lasts longer than six months and are out of proportion to the actual possibility or impact of the expected event or activity. For childhood GAD, the presence of only one somatic, mood, or cognitive symptom (e.g., sleep disturbance, muscle tension, irritability, difficulty concentrating) is required for the diagnosis (APA, 2013). Common worries reported in childhood GAD include fears and anxieties of academic failures, natural disasters, family finances, and parents having marital and relationship conflicts (Albano et al., 2003).

Developmental course and prognosis. The developmental course and prognosis of childhood anxiety is dependent on the distinct features of the disorder. That said, according to evidence accumulated so far, there is a consensus that there are developmental relationships between the emergence and maintenance of anxiety disorders in childhood (Albano et al., 2003;

Manassis, 2000). Specifically, having an anxiety disorder in early childhood increases the risk for the child to develop a co-morbid anxiety disorder in later childhood and adolescence, and this risk substantially increases if the child does not learn adaptive self-regulation strategies to cope

14 with their anxiety (Last, Perrin, Hersen, & Kazdin, 1996). For example, separation anxiety disorder has an early onset, and research has shown that children with this disorder can be at risk of developing GAD and depression if their anxiety persists (e.g., Albano et al., 2003; Masi,

Mucci, Favilla, Romano, & Poli, 1999). Furthermore, there is evidence suggesting that the presence of separation anxiety disorder increases the risk for the emergence of panic disorders in older children (Last et al., 1996). Hence, various developmental trajectories can emerge from an early onset of separation anxiety disorder, and this is often due to the child’s internal dispositions

(e.g., temperaments, attributional style) and environmental influences (e.g., parenting style).

Additionally, the maintenance of certain anxiety disorders such as GAD and social anxiety disorders can result in the emergence of more severe psychological disorders such as depression, eating disorders, and substance abuse in adolescence and adulthood (Albano et al., 2003;

Manassis, 2000). Moreover, the risks for the emergence of co-morbid disorders after treatment or intervention increases during times of significant developmental changes and demands or periods of increased stress (Albano et al., 2003).

Etiology. Our current understanding of childhood anxiety disorders suggests that their etiology follows a complex, integrated model influenced by genetic, internal (e.g., temperament, cognitive processing and functioning, emotional functioning), and environmental factors (e.g., parental influences; Albano et al., 2003; Dozois et al., 2015). Concerning genetics, evidence accumulated over the past two decades indicates that anxiety disorders may be inherited

(Gregory & Eley, 2007). For example, research suggests high monozygotic concordance rates of anxiety disorders. Furthermore, findings of a more recent study demonstrated that 68% of homotypic continuity of anxiety in participating children were explained by genetic factors

(Trzaskowski, Zavos, Haworth, Plomin, & Eley, 2012). Moreover, childhood temperament, such

15 as behavioral inhibition, has been identified as a risk factor for anxiety in the middle to late childhood (Degnan, Almas & Fox, 2010). Additionally, parenting factors such as parental anxiety, parent-child attachment (e.g., excessive parental control, lack of warmth), and parenting style (e.g., overly protective and guarding responses towards the child), as well as the quality of peer relationships can also influence childhood anxiety (Degnan et al., 2010; Gross & Hen,

2004).

Cognitive factors. The development of childhood anxiety has also been associated with specific cognitive processes. Particularly, cognitive theories propose that biases in information processing play an important role in the emergence and maintenance of clinical anxiety

(e.g., Beck, Emery, & Grenberg, 1985; Hadwin, Garner, & Perez-Olivas, 2006). Information processing models suggest that clinically anxious individuals tend to pay increased attention to threat cue (i.e., attention bias), interpret ambiguous information as threatening, and have an increased propensity to remember emotional information in a negative or distressing fashion

(i.e., memory bias; Hadwin et al., 2006). With respect to attention bias, while all individuals irrespective of their anxiety level, orient their attention to threatening stimuli in the environment, clinically anxious individuals tend to direct more attentional resources to even moderately threatening stimuli. They scan the environment for threats more frequently and evaluate more stimuli as threatening (Mogg & Bradley, 1998).

The presence of attention bias in childhood anxiety had been investigated using a dot- probe paradigm, visual search paradigm, and Stroop tasks (Hadwin et al., 2006). For example, Waters, Lipp, and Spence (2004) used a picture-dot paradigm with pictures of snakes and spiders, and they found that clinically anxious children, who were, aged 9-12 showed attentional bias towards threatening pictures. On the other hand, Hadwin et al. (2003)

16 administered a visual search paradigm task with 7-10 aged children. They found that participants who were reported to be more anxious had faster reaction times to detect angry versus happy and neutral faces. Richards, Richards, and McGeeney (2000) also found that clinically anxious adolescents took significantly longer to name the threat-related words than neutral words.

The relationship between interpretation of ambiguity and childhood anxiety had been explored using pictures (e.g., Hadwin, Frost, French, & Richards, 1997), and stories (Muris,

Meesters, & Spinders, 2003). For example, across many research studies, clinical or community samples of children viewed or read stories with ambiguous plots and then were asked to interpret them. Findings from these empirical investigations suggest that children with clinical anxiety tend to make more negative interpretations of ambiguous stories than controls (e.g., Bogels,

Snieder, & Kindt, 2003). Moreover, clinically anxious children tend to report having more distressing emotions (e.g., fear, sadness) if they are placed in situations where they judge themselves to be less capable of coping with the perceived danger (e.g., Bogels et al.,

2003; Muris, Rapee, Meesters, Schouten, & Geers, 2003).

In contrast, we have relatively limited research examining the association between memory bias and childhood anxiety (Hadwin et al., 2006). For example, there is some evidence indicating that children with higher trait anxiety may recall more words with negative than neutral or positive connotations (e.g., Daleiden, 1998; Dalgleish et al., 2003). It is argued that children with anxiety tend to pay more attention to negative words, and hence, they have greater difficulty disengaging from such words. Consequently, children with anxiety end up recalling a greater number of negative words after the exposure task.

It is important to highlight that research suggests age moderates the influence of information processing biases in childhood anxiety (Hayden et al., 2006). That is, information

17 processing biases for anxiety are more prevalent during late childhood (i.e., ages 9-12) and adolescence. In younger age groups, information processing biases may not reliably predict the presence of clinical anxiety in children. Cognitive inhibition skills are less developed in early and middle childhood, irrespective of children’s presenting anxiety levels. However, older children who have not developed age-appropriate inhibition skills to engage from threatening stimuli may be at risk of developing clinical levels of anxiety. Challenges with inhibition may exacerbate attention and memory biases for threatening stimuli, and hence increasing children’s anxiety into clinical levels (Hayden et al., 2006). Considering how the above-discussed cognitive factors may predict the development and maintenance of anxiety disorders in children, interventions had been developed to aim to change, modify, and redirect their cognitive biases and processes to alleviate their anxiety (Beck & Haigh, 2014). The evaluations of child anxiety interventions to determine their benefits are dependent on sound instruments measuring anxiety in children both reliably and validly.

Measurement. A variety of approaches and clinical instruments have been developed and are currently in practice to measure anxiety in children in research, clinical, and community settings. The two common approaches to measuring childhood anxiety are: 1) clinical interviews

(structured, semi-structured, or unstructured); and 2) rating scales and self-reports. Clinical interviews allow for a comprehensive account of the presenting anxiety symptoms, related behaviors, and the degree of impairments perceived to be caused by the symptoms and behaviours, from multiple perspectives (i.e., the child, parents, teachers; Sattler & Hoge, 2006).

Clinical interviews are often administered to establish a diagnosis of childhood anxiety disorders.

Rating scales and self-reports are often used in combination to collect information from multiple perspectives about the presence and intensity of anxiety symptomatology in the child (Sattler &

Hoge, 2006). Items on rating scales and self-reports are typically presented in a Likert scale, with responses ranging on a frequency continuum (e.g., “Never” [0] to “Often” [3]). Ratings from the items are typically summed to provide scores that can be systematically quantified to determine the amount, degree, and magnitude of anxiety symptoms (Silverman & Ollendick, 2005). Rating scales and self-reports are quick to administer and score, and they are cost-efficient, which makes them preferred and feasible tools for research purposes (e.g., evaluating intervention efficacy; Spence, 1998).

There are various rating scales and self-reports available to measure overall child's anxiety symptoms, and they categorize the symptoms relative to anxiety subtypes based on the

DSM-IV or DSM-IV-TR taxonomy: 1) Multidimensional Anxiety Scales for Children-Second

Edition (MASC-2; March, 2012); 2) revised version of the Screen for Child Anxiety Related

Emotional Disorders (SCARED-R; Muris, Merckelbach, Schmidt, & Mayer, 1999); and

3) Spence Children's Anxiety Scale for Children (SCAS; Spence 1997, 1998). There are also self-reports available that measure specific components of anxiety (e.g., traits, worry level, physiological symptoms), such as the State-Trait Anxiety Inventory for Children (STAIC;

Spielberger, Edwards, Lushene, Montuori, & Platzek, 1973) and the Revised Children’s Manifest

Anxiety Scale, Second Edition (RCMAS-2; Reynolds and Richmond, 2008).

The SCARED-R was developed and normed with clinically anxious children from the

Netherlands (e.g., Muris, Merckelbach, Ollendick, King, & Bogie, 2002). The SCARED-R has

66 items, and it has nine subscales that cover the entire anxiety disorders’ spectrum that are prevalent in children, in accordance with the DSM-IV (Murris et al., 2002). The SCAS is another self-report anxiety inventory that measures the common childhood anxiety disorders as defined by the DSM-IV (Spence, 1997). The SCAS consists of 45 items and can be administered to

19 children and adolescents, aged 8-17. Spence developed the SCAS for clinical and research purposes with community samples, and its original normative data, psychometric properties, and factorial structure analyses were obtained from Australian samples of children and adolescents

(Spence, 1997). The STAIC is a widely used self-report measure to assess anxiety in 9-12 aged children (Turgeon & Chartrand, 2003). Adopted from its adult form, the State-Trait Anxiety

Inventory (Speilberger, Gorsuch, & Lushene, 1970), the STAIC consists of two 20 item-scales:

A State scale and a Trait scale. The State scale of the STAIC measures transitory anxiety reactions to specific situations. The Trait scale assesses stable predisposition to react with anxiety (i.e., it does not matter what the situation is; Turgeon & Chartrand, 2003). The RCMAS-

2 is also a common anxiety inventory for children and adolescents. It consists of 49-items, and yields a Total Anxiety Score, as well as three anxiety subscales: Physiological Anxiety, Worry, and Social Anxiety (Ang, Lowe, & Yusof, 2011). Additionally, the RCMAS-2 also yields a

Defensive score.

While the rating scales such as the SCAS and the SCARED-R measure anxiety symptoms as defined by the DSM-IV, the MASC-2 assesses anxious symptoms in accordance with the DSM-IV TR, a more recent version of the DSM. The MASC-2 is the most recently developed rating scale of child's anxiety. It had been updated from its first edition,

Multidimensional Anxiety Scale for Children (MASC; March 1997). The norms of the MASC-2 were developed on samples of children and adolescents residing in the United States and three

Canadian provinces (March, 2012, 2013). The MASC-2 has both self- and parent- reports. Importantly, the MASC-2 also produces an Anxiety Probability Score that allows researchers and practitioners to quickly assess the likelihood of the child having an anxiety disorder. In all, given the brevity and simplicity of the administration, scoring, and interpretation

20 procedures of the MASC-2, it is becoming a commonly utilized tool among researchers and practitioners for child anxiety measurement (Fraccaro, Stelnicki, & Nordstokke, 2015).

Poor concordance between self-reports of anxiety ratings and the ratings of their anxiety by other informants, including parents and teachers, can complicate the measurement of anxiety in children (Manassis, 2000). In general, there is a large body of evidence indicating that parents and the child often disagree about the psychological symptoms that the child is experiencing

(e.g., DiBartolo, Albano, Barlow, & Heimberg 1998; Frick, Silverthorn, & Evans, 1994). For child anxiety specifically, weak correlations between parent and child ratings of anxiety have also been found (e.g., Manassis, Tannock, & Monga, 2009; Miller, Martinez, Shumka, & Baker,

2014; Nauta et al., 2004; Syeda, 2014). Such inconsistencies between parent and self-ratings lead to the question as to whose ratings are more reliable and valid in assessing for child anxiety.

Some researchers suggest that children may be better at accurately reporting their anxiety.

Children may not openly express their worries or discuss their irrational fears with family members, or they may make efforts to hide their anxious thoughts and feelings (e.g., Edelbrock,

Costello, Duncan, Conover & Kala, 1985; Miller et al., 2014). Thus, parents may be unaware of the severity or degree of the anxiety symptoms that their child is experiencing. Additionally, the parent’s own anxiety could bias their perceptions about the degree or magnitude of their child’s anxiety (Briggs-Gowan, Carter, & Schab-Stone, 1996; Manassis et al., 2009).

Conversely, there is also evidence to support parents’ ratings of child anxiety as more reliable and valid (DiBartolo et al., 1998; Schniering, Hudson & Rapee, 2000). Parents may be likely to have a better understanding of the items queried on anxiety assessment questionnaires.

Besides, children may have challenges thinking retrospectively and answering questions that demand complex metacognition and reflections (Granero Perez, Ezpeleta Ascaso, Domenech

Massons, & de la Osa Chaparro, 1998; Schniering et al., 2000). Consequently, they may under- or- over-report their anxiety symptoms. Furthermore, children with certain coping styles (e.g., low on support seeking) may minimize their anxiety symptoms because they perceive them to be normative or socially desirable (Dadds, Perrin, & Yule, 1998; Manassis, Mendlowitz, & Menna

1997; Manassis et al., 2009).

In consideration of the inconsistencies between self-and-parent-ratings of anxiety, it is recommended that clinicians consider the perspectives of both the parent(s) and the child to make well-informed decisions about anxiety diagnosis. Similarly, researchers are recommended to collect both parent and child ratings of the child’s anxiety to comprehensively evaluate the efficacy of anxiety interventions (Manassis, 2000). Moreover, with respect to determining eligibility for an anxiety intervention, Manassis (2000; Manassis et al., 2009) has additionally argued that if the child does not acknowledge anxiety concerns, but the parent reports many and/or severe anxiety concerns for the child, then it can be assumed that the child is anxious

(Manassis, 2000; Manassis et al., 2009). Despite the complexity seen with child anxiety measurement, information collected from the abovementioned measurement approaches provide pertinent information to researchers and clinicians about the severity of a child’s presenting anxiety concerns. Along with the advancements we have seen with measurement of child anxiety, considerable research has been conducted to understand better how to support children with anxiety.

Interventions. Several intervention approaches, including psychotherapies and medications, could be beneficial in reducing anxiety in children (James et al., 2015). Examples of psychotherapies developed to treat childhood anxiety include behavioral therapy (e.g., exposure techniques), cognitive therapy, and CBT (Prochaska & Norcross, 2010). CBT is one of

22 the most commonly implemented psychotherapy for childhood anxiety (Walczak, Breinholst,

Ollendick, & Esbjorn, 2019). CBT is grounded on two theories: cognitive and behavioral, and these perspectives are combined to develop the intervention to alleviate presenting concerns associated with childhood anxiety (Mennuti & Christner, 2012). The cognitive theory states that children struggling with anxiety have extremely arbitrary schemas about their anxiety-provoking stimuli that influence the formation of their biases and interpretations they have about the stimuli. The activation of the biases and interpreting the stimuli are very threatening then induce distressing physiological, and emotional arousals, ultimately leading to avoidance or escape

(Prochaska & Norcross, 2010). According to behavioural theories, the environment (i.e., the behaviours of the others), along with children’s own behavioural deficits, could also impact how they process and cope with their anxiety-provoking stimuli (Mennuti & Christner, 2012). For example, environmental factors like parenting style, parents’ coping of their anxieties, and parent-child interactions can influence the content of children’s schemas and their thought processes, as well as how they learn to interpret their anxiety-provoking stimuli. Besides, the child may also have behavioural coping deficits such as poor self-regulation, and underdeveloped social skills. These behavioural coping deficits could also make it challenging for the child to deal with the anxiety-provoking stimuli (Mennuti & Christner, 2012). Therefore,

CBT interventions for childhood anxiety incorporate both cognitive and behavioral theories within their approaches. To this end, standard CBT interventions typically have four aims: 1) help the child to recognize physiological symptoms, maladaptive and distorted cognitions, and the emotional responses that arise in anxiety-provoking situations; 2) helps the child to challenge and modify their distorted cognitions; 3) develop appropriate coping and behavioral skills; and 4) evaluate the outcomes of those skills (Kendall, 2006).

Empirical supports and limitations of CBT for childhood anxiety. CBT is known to be the treatment of choice to reduce anxiety in children and adolescents (James et al., 2015;

Reynolds, Wilson, Austin, & Hooper, 2012). Findings of outcome studies suggest that CBT is beneficial in treating anxiety disorders for many children and adolescents. For example, meta- analyses evaluating the outcomes of CBT revealed that about 60% of children and adolescents no longer met the diagnostic criteria for their primary anxiety disorders after completing CBT

(James et al., 2013; Warwick et al., 2017). On the other hand, the response rate for waitlist controls in those outcome studies was only about 17.5%. Although 60% response rate of CBT is notable, it is also true that 40% of children and adolescents maintained their primary anxiety diagnoses after completing CBT. Hence, researchers have attempted to augment traditional CBT approaches to treat childhood anxiety disorders with additional components to improve its intervention effects. However, the results of adding such intervention outcomes to CBT are inconclusive (Brienholst, Esbjorn, Reinholdt-Dunne, & Stallard, 2012). Therefore, there needs to be a continuous research effort to examine empirical efficacy of alternative and supplemental interventions for childhood anxiety concerns. MBTC appears to be a promising intervention to reduce childhood anxiety concerns.

Mindfulness-based psychotherapies. In the past decade, contemporary psychology has seen the increasing popularity of mindfulness-based psychotherapy and mindfulness-training interventions to alleviate physical and psychological concerns in children and adults (e.g., Baer,

2003; Bishop, 2002; Hayes, 2004; Salmon, Lush, Jablonski, & Sephton, 2009). Mindfulness- based psychotherapies are often considered a third-wave of cognitive and CBT-related therapies in which mindfulness-based practices, influenced by Buddhist philosophies, are incorporated with standard cognitive-behavioral approaches (Hayes, 2004; Segal et al., 2002). Hayes (2004)

24 argues that three successive waves of behavioral therapy have evolved and surfaced thus far. The focus of the first wave of behavioural therapy emphasized on modifying behaviors to reduce psychological symptoms. The second wave evolved when researchers found the link between dysfunctional cognitions and maladaptive behaviours, and sought to develop interventions that focused on reappraising dysfunctional thoughts, such as cognitive therapy (Beck, 1976).

However, critics of the second wave therapy argue that modification of cognition does not necessarily elicit additional benefit to reduce the severity of psychological symptoms. For example, Longmore and Worrell (2007) argued that there is limited research suggesting that cognitive mediators (e.g., interpretation of information, judgements, and evaluation) facilitate symptomatic changes in second wave therapies. Arguments such as this prompted the rise of novel methods to address dysfunctional cognitions, leading to the development of diverse collections of interventions, now known as third wave therapies (Brown, Gaudiano, & Miller,

2011). Rather than changing the dysfunctional thoughts, third wave therapies emphasize their acceptance. Concerning mindfulness-based psychotherapies, there are two major types: MBSR and MBCT.

Mindfulness-based Interventions (MBIs)

In school and community settings, we usually see the implementation of two categories of interventions: (1) universal; and (2) targeted (Felver, Doerner, Jones, Kaye, & Merrell, 2013).

Universal interventions are delivered to all participants, classroom-or-school-wide, or in the community. They are prevention interventions aimed at teaching general skills and knowledge to promote well-being (Gutkins & Reynolds, 2009). On the other hand, targeted interventions are delivered with participants for whom the dosage and content of universal programming is not sufficient to remediate their presenting concerns. These participants are deemed to benefit from

25 programming that has content and training individualized to their specific concerns (e.g., anxiety, oppositional behaviours). Their aims and content focus are on education, skill-building, and strategies that are theoretically and empirically grounded to alleviate identified areas of concern that the intervention targets (Gutkins & Reynolds, 2009). Schools and communities often conduct screening assessments to identify participants who may be having challenges, and their challenges are at-risk to escalate without intervention. Delivery of targeted intervention attempts to arm participants with appropriate skills and strategies to better manage their challenges

(Felver et al., 2013). It is hoped that the dosage of targeted interventions will reduce the likelihood of presenting challenges to escalate and become pathological in the future. Thus, targeted interventions are also known to be a preventative approach. Finally, more intensive interventions are available in clinic and hospital settings. Intensive interventions are implemented with participants with pathological and clinical issues, since these participants require more intensive and individualized planning, care, and programming (Gutkins &

Reynolds, 2009). Given the enthusiasm for mindfulness programming with children and adolescents, mindfulness-based interventions (MBI) had been developed for all three dosages or categories (universal, targeted, and intensive).

Universal MBIs have received the most attention in the literature so far. Given the success of intensive mindfulness intervention with adults, MBIs have been transitioned to school settings beginning in the early 2000s (Burke, 2010). These universal MBIs focus on teaching general mindfulness skills in typical child and adolescent populations to enhance their general well-being. For example, they teach students about regulating attention and engage students in mindfulness meditations and related breathing activities, and they provide psychoeducation on brain development and emotions (Zenner, Herrnleben-Kurz, & Walach, 2014). Particularly,

MBIs in schools aim at improving students’ cognitive skills (e.g., attention, executive functions) and emotional awareness and regulation (Felver, Hoyos, Tezanos, & Singh, 2016). Many jurisdictions across the world including Canada, have pushed schools to incorporate social- emotional learning school-and-classroom-wide (Schonfeld et al., 2015). There is unanimous recognition across many educational jurisdictions that social-emotional well-being is critical for learning and academic functioning in students (Durlak, Weissberg, Dymnicki, Taylor &

Schellinger, 2011). Therefore, many jurisdictions have enthusiastically welcomed the transition of mindfulness programming in schools and classrooms (Klingbeil et al., 2017).

Over the past ten years, researchers have conducted systematic reviews and meta- analyses to examine the effects of universal MBIs on children and adolescents’ well-being in schools (e.g., Carsley, Khoury, & Health, 2018; Felver et al., 2016). For example, McKeering and Hwang (2019) conducted a systematic review of school-based MBIs to examine its effects and perceived benefits in participants aged 11-14. The findings of their review indicated that participation in school-based MBIs helped typical students to manage their anger, anxiety better.

Also, participation in MBIs was related to improved concentration and sleep quality. Similarly, a meta-analysis by Klingbeil et al. (2017) also provided substantive evidence in favour of school- based mindfulness interventions. According to their meta-analysis, at least small positive effects were found for all assessed intervention outcomes, including academic functioning, internalizing concerns, and social competence. Finally, Carsley et al. (2018) reviewed 24 RCTs of MBIs conducted in elementary and high schools. They found that compared to control groups, MBIs had small to moderate significant effects pre-post intervention. However, MBIs with older youth and programs that consisted of multiple mindfulness activities were associated with larger effects

27 on mental health and overall well-being. These results suggest that MBI program characteristics could moderate outcomes in students in schools.

In summary, many universal MBIs have been developed and implemented with children and adolescents in the past decade or so (Klingbeil et al., 2017). Examples of some of these

MBIs are General Mindfulness Training (Mendelson et al., 2010), Learning to Breathe (Bluth et al., 2016), and Mindful Enhancement program (Raveepatakarul, Suttiwan, Iamsupasit, &

Mikulas, 2014). These MBIs integrate general mindfulness and social-emotional teachings to promote multiple emotional and behavioural outcomes in children and adolescents (Klingbeil et al. 2017). Hence, there are considered to be more generalist prevention interventions for children and adolescents. Generally, empirical reviews of universal MBIs suggest that they improve psychosocial outcomes in typical student populations in schools (Carsley et al., 2018). Therefore, school-based, universal MBIs are deemed to be a good candidate for social-emotional programming in classrooms and schools.

The success seen with intensive MBIs (i.e., mindfulness-based psychotherapies) with adults led to the development of targeted and intensive MBIs for specific childhood psychopathologies (Klingbeil et al., 2017). These child-based targeted and intensive MBIs adapt contents from adults focused MBSR and MBCT to develop psychotherapeutic interventions for specific psychopathologies such as anxiety, depression, etc. (Felver et al., 2016; Kallapiran et al.,

2015). Psychopathology-specific MBIs typically differ from universal and targeted MBIs uniquely developed for school-based implementation (Kallapiran et al., 2015). As described in the earlier sections, while MBIs for school-based implementation seek to enhance multiple psychosocial outcomes in typical and at-risk students, psychopathology-focused MBIs aim to alleviate specific psychological symptoms in children and adolescents. It is also important to be

28 aware of empirical support currently available for targeted and intensive MBIs for specific childhood psychopathologies. As the focus of this study is on a targeted MBCT program for childhood anxiety, a review of the literature is presented on targeted and intensive MBCTs implemented with children and adolescents with mental health issues or diagnosed psychopathologies. Before a detailed discussion on MBCT evaluations with children and adolescents is provided, readers are first familiarized with definitions and concepts relating to

MBCT.

MBCT

First developed by Segal et al. (2002), MBCT integrates training of mindfulness skills with CBT therapy techniques. Particularly, in MBCT, it is argued that individuals can become mindfully aware of how their potential maladaptive thoughts can influence their behavioural and emotional responses. After learning to have this mindfulness awareness, individuals participating in MBCT learn to use appropriate mindfulness-based strategies and cognitive-behavioural techniques to tolerate and accept those thoughts rather than elaborating on them (Sears, 2015).

To better understand the theoretical premise and clinical applications of MBCT, particularly with children, we first must be familiar with the concept of mindfulness and children’s capacity to develop mindfulness.

Mindfulness. Mindfulness is understood to operate in two components: 1) self-regulation of attention, and 2) orientation to the present experience (Bishop et al., 2004). The first component emphasizes the individual’s ability to self-regulate their attention, so it is maintained in the present, immediate experience. When attention is maintained on the present experience, it allows for increased recognition of mental (e.g., thoughts, emotions) and physiological events that are part of the present experience. When we are to bring our attention intentionally to the

29 present moment, it also fosters non-elaborative awareness of thoughts, emotions, and physiological sensations. That is, rather than ruminating or elaborating thoughts about one’s experience, origins, implications, and associations, being mindful brings our awareness to only the experience of the present moment (Teasdale, Segal, Williams, & Mark, 1995). The second component of the mindfulness model involves adopting a particular orientation towards one’s present experience that is characterized by curiosity, openness, non-judgments, and acceptance

(Bishop et al., 2004).

Mindfulness and child development. Learning mindfulness practice is a fundamental aspect of mindfulness-based psychotherapies (Segal et al., 2002). Hence, it is important to assess whether children have developmentally appropriate capacities of intentional awareness and orientation underlining the mindfulness practice (Satlof-Bedrick & Johnson, 2015). Research examining children’s capacities to be mindful from a developmental perspective is relatively sparse (Roeser & Zelazo, 2012). That said, some developmental psychologists who postulate that the growth of mindfulness parallels the development of metacognition in children (Satlof-

Bedrick & Johnson, 2015). Specifically, over the last years, there has been an increased effort in better understanding the relationship between metacognition and mindfulness (Jankowski and

Holas, 2014). Mindfulness can be considered a metacognitive skill (i.e., thinking about thinking,

Flavell, 1979). Like mindfulness, metacognition is also thought to consist of two related cognitive processes: monitoring and control (Nelson, Stuart, Howard, & Crowley, 1999; Schraw

& Moshman, 1995). Like metacognition, mindfulness requires monitoring of the stream of thoughts and emotions while having control of cognitive processes such as attention and self- regulation (Bishop et al., 2014). Moreover, Shapiro, Carlson, Astin, and Freedman (2006) argue that mindfulness leads to reperceiving, which is a metacognitive skill. When we attend to

30 thoughts, emotions, and bodily sensations through openness and non-judgments, we shift our perspectives. Specifically, thoughts, emotions, and bodily sensations that were perceived to be subjective first, through cognitive shifting, become objective, and allow us to experience them more independent of our expectations, experiences, or attitudes (Norman, 2017). Hence, mindfulness is typically considered to be a “disciplined introspective metacognitive way of knowing” (Satlof-Bedrick & Johnson, 2015, p. 84), which ultimately is said to lead to the broader and foundational ways of having an inner understanding of ourselves. It begins with the awareness of thoughts, extends to emotions and physiological arousals, and then moves to a final understanding and acceptance of their impermanence, which arguably contributes to enhancements of our physical and psychological well-being (Grossman, 2010).

Development of introspection is thought to be a multileveled cognitive achievement.

During the preschool stage, children are thought to develop the initial cognitive processes of introspection, such as deliberately engaging in mental imagery (Eisbach, 2013; Papaleontiou-

Louca & Thoma, 2014). Then, in middle childhood (i.e., ages 7-10), children begin to have an awareness of the ongoing spontaneous stream of thoughts (Satlof-Bedrick & Johnson, 2015).

Furthermore, the development of introspection is theorized to be dependent on the introspection content, the contextual supports (e.g., strategies taught to the child), and individual differences in introspective disposition (e.g., attentional capacities; cognitive flexibilities; Estes, 1998). As such, the development of mindfulness in children is predicted to be multileveled as well. For example, the growth of mindfulness in children is predicted to proceed from sensory/bodily awareness to more complex skill development of taking awareness of thoughts and emotions and developing accepting and non-judgmental attitudes towards them. The cultivation of mindfulness practice also requires disciplined practice and guidance (e.g., structured interventions, home

31 practices). Finally, children’s capacity to be mindful is influenced by individual dispositions and differences (Grossman, 2010). The MBCT programs adopted for children mirror this theoretical progression to guide how and what children need to develop mindfulness. For example, the teaching of mindfulness skills in these programs (e.g., Lee and Semple, 2014) typically proceeds with guiding children to observe their breathing and engaging them in related sensory activities before advancing to more cognitive-related mindfulness strategies (e.g., identification of choices). In addition to guiding mindfulness intervention content and approaches, understanding how children may develop mindfulness also influence our practice of how we are to measure mindfulness in children (i.e., formats and contents of measurement tools). The preceding sections describe the advancements of tools to measure mindfulness in children.

Measurement of mindfulness. Quality evaluations of mindfulness-based psychotherapies with children are dependent on using reliable and valid instruments to measure its expected outcomes, including mindfulness. According to the review conducted by Goodman, Madni, and

Semple (2017), self-report measure is the most common approach to assess mindfulness in children. However, it is to acknowledge that the use of self-reports to measure mindfulness, particularly with children, could be problematic. A child who has not participated in any mindfulness learning may have fewer insights about when his or her mind wanders or when it is judgemental. As a child engages in mindfulness learning and begin to cultivate mindfulness, they may gain a more accurate perception of the true nature of his or her mind. Hence, when children are initially assessed of their mindfulness before any mindfulness learning, their self-reports may not be reliable (Goodman et al., 2017). Nonetheless, in the absence of alternative standardized approaches to measure mindfulness presently (e.g., parent or teacher observations), researchers have been using self-reports to assess mindfulness in children.

As described in the earlier sections, mindfulness is a complex and multifaceted construct

(Bishop et al., 2004), and these components are theoretically inter-related and hard to isolate.

Therefore, measures that tap into different components of mindfulness (e.g., present moment awareness, attitudes of openness, and curiousness) are deemed to be more holistic measures of mindfulness (Goodman et al., 2017). Along with examining what constructs of mindfulness are being assessed in the measures, their psychometric properties are also to be considered when determining which measure to select to assess changes in mindfulness in children. The following sections provide a review of self-report measures for mindfulness presently available for children. As the participants of the current study were between the ages of 9 and 12, only measures that assess mindfulness within that age group are included.

According to Goodman et al. (2017) review of mindfulness measures for children and adolescents, there are three self-report questionnaires available to assess mindfulness in children between the age of 9-12. These measures are: Mindfulness Scale for Pre-Teens, Teens, and

Adults (MSPTA; Droutman, 201 as cited in Goodman et al., 2017) 5); 2) Mindfulness Inventory for Children and Adolescents (MICA; Briere, 2011, as cited in Goodman et al., 2017); and 3)

Mindfulness Attention Awareness Scale for Children (MAAS-C; Lawlor, Schonert-Reichl,

Gadermann, & Zumbo, 2014). Of note, while the Children Acceptance and Mindfulness Measure

(CAMM; Greco, Baer, & Smith, 2011) has been a commonly utilized instrument in research, it is for use with children and adolescents aged 10-17.

The MPSTA is a 19-item self-report scale for children and adolescents aged 9-19. A preliminary evaluation with 413 children and adolescents revealed a four-factor solution, fitting the MPSTA data: attention and awareness, being non-reactive, being non-judgmental, and being non-self-critical (Droutman, 2015). The second mindfulness measure, MICA is a self-report for

33 children and adolescents aged 8-18 and has 25 items. The MICA consists of five subscales, which are self-acceptance, person-centered awareness, equanimity, metacognitive awareness, and acceptance of internal experience. The MICA is an experimental measure, and its psychometrics had not been tested yet (Goodman et al., 2017). Both the MPSTA and the MICA have not been yet validated in clinical samples (Goodman et al., 2017).

The third mindfulness measure, MAAS-C, is a 15-item self-report scale for children aged

9-13. The MAAS-C had been adopted from the adult version of the measure, Mindfulness

Attention Awareness Scale (MAAS; Brown & Ryan, 2003). The MAAS-C uses an indirect approach to measure mindfulness. That is, it assesses raters’ mindlessness states (Lawlor et al.,

2014). Brown and Ryan (2003) argued that the assessment of mindlessness might be more an appropriate measure of mindfulness in individuals without much mindfulness training.

Evaluations with the MAAS showed higher criterion validity for mindfulness than direct measurement of mindfulness. The MAAS-C is single-factor scale and primarily focuses on measuring the present-moment experience, and it was negatively correlated with depression, rumination, and anxiety in children in grades 4 to 8 (Lawlor et al., 2014). Not the MAAS-C, but the adolescent version of the MAAS, Mindfulness Attention Awareness Scale for Adolescents

(MAAS-A; Brown, West, Loverich, & Biegel, 2011) had been validated with clinical populations. The MAAS-C and the MAAS-A contain similar items, but MAAS-C uses more child-friendly language. When comparing the MPSTA, MICA, and the MAAS-C, the MAAS-C appears to be the only measure that has a published, validation study (i.e., Lawlor et al., 2014).

In summary, the assessment of mindfulness in children is an emerging practice in research, clinics, and school and community settings. With exception to the MAAS-A, the psychometrics of the mindfulness measures for children as well as adolescents had been derived

34 from community samples (Goodman et al., 2017). Thus, they need to be validated with clinical populations to enhance their applicability for use as a measurement tool in intervention evaluations with clinical samples. Furthermore, future evaluations need to examine the correlations between and among the existing self-report measures of mindfulness for children to determine the convergence between and among them. These improvements in the assessment of mindfulness in children are critical to enhance the overall rigor of the mindfulness research field.

While these improvements are in progress, the researcher may consider his or her participants’ age range and specific components of mindfulness of interest to determine which measure to use to assess mindfulness in his or her study (Goodman et al., 2017). Along with advancing the assessment approaches for mindfulness, understanding how mindfulness-based psychotherapy may contrast with some of the most commonly utilized interventions in the field is important to advance the field.

MBCT vs. CBT. MBCT employs many cognitive-behavioural principles and techniques for working with thoughts, emotions, somatic sensations, and behaviours. For example, both

MBCT and CBT use the A-B-C model (activating event, beliefs, consequences; Beck & Haigh,

2014) to teach people how thoughts, emotions, and behaviors all affect each other. Like CBT,

MBCT also teaches people about automatic and maladaptive thought patterns and uses thought records and relapse prevention plans (Sears, 2015). However, there is a fundamental difference between MBCT and CBT in how individuals are taught to relate to their thoughts, emotions, and somatic sensations of themselves. For instance, CBT methods often target change in the contents of thoughts, using systematic techniques to question the logic, utility, or validity of the thinking.

Once clients learn to notice their maladaptive, automatic thoughts, then they can train to restructure their thoughts into a more rational or functional alternate (Sears, Tirch, & Denton,

2011). However, one limitation of this thought restructuring technique is that sometimes clients can argue with their own mind to reason or rationalize their maladaptive thinking (i.e., outthinking oneself; Sears, 2015). In addition, mood-state dependent principles suggest that when people are feeling anxious or depressed, it is easier for their brain to access depression-or- anxiety-related memories. Consequently, people may find it harder to restructure maladaptive thoughts in that state (Teasdale et al., 2000). In contrast, MBCT participants are explicitly taught the decentering practice, which is noticing, writing down, and challenging their relationship with the thoughts (Sears, 2015). This decentering of thoughts also assumes to uncouple the affective components that associate with automatic maladaptive thoughts in clients. Clients learn to recognize that they have thoughts, emotions, and somatic sensations instead of overly identifying with them (Sears, 2015). For example, when thoughts arise like “they will laugh at me,” MBCT participants practice noticing that “I am having a thought that they will laugh at me.” Rather than engaging in internal debates with this automatic thought, participants learn to take note of these thoughts and identify them as signs of stress, anxiety, etc. Participants then learn to not to engage with the thought, but shift their attention to the present-moment experience, opening their awareness for more conscious responding (e.g., taking considered action to deal with the situation, Sears, 2015). Conscious responding is thought to prevent MBCT participants from engaging in automatic reactions such as avoidance and withdrawal that might worsen their psychological concerns (Sears, 2015).

The strengths in efficacy between MBCT and CBT have been empirically evaluated with adults. For example, Manicavasagar, Perich, and Parker (2011) conducted an RCT to examine the differential impacts on adults’ depressive symptoms after completing MBCT vs. CBT. The results of their RCT indicated that there were no significant differences between the MBCT and

CBT conditions at post-intervention. Completion in MBCT and CBT led to a similar degree of improvement in depression and rumination. However, for MBCT participants, their decreases in rumination had a significant relationship with their growth in mindfulness. Therefore, the findings of Manicavasagar et al. (2011) suggest that mindfulness training in MBCT present individuals with an additional coping tool to reduce their rumination, which is known to deteriorate internalizing concerns such as depression and anxiety. Similarly, Melyani, Alahyari,

Azadfallah, Ashtiani, and Tavoli (2014) examined the efficacy of MBCT vs. CBT as well. Their findings also indicated that there were no significant differences in intervention outcomes for depression between MBCT and CBT. However, MBCT participants reported greater improvements with cognitive reactivity and self-compassion at post-intervention.

Segal et al. (2002) initially developed MBCT as a prevention treatment to reduce depression relapse in adults. It was theorized that the cultivation and practice of mindfulness would provide additional strengths and benefits in supporting individuals to better cope with their depressive symptoms. For some individuals, cognitive restructuring, an active ingredient of

CBT may not be as helpful in reducing their cognitive reactivity that escalates their negative affect. In contrast, mindfulness techniques used in MBCT, such as decentering and cultivation of self-compassion, may be more effective in reducing their cognitive reactivity and improving their mood (Sears, 2015). As described in the earlier sections, mindfulness is a multifaceted construct (Bishop et al., 2004). Practice and embodiment of mindfulness is not only limited to breathing or body-based mindfulness activities. Practicing mindfulness also involves developing an attitude of non-judgment and compassion to accept thoughts, emotions, oneself, and the environment (Teasdale et al., 2000). Increased self-criticism, negative self-talk, and feelings of hopelessness and worthlessness could create barriers for individuals to apply cognitive restricting

37 taught in CBT. Therefore, intervention techniques that have augmented focus on acceptance and compassion may be more applicable to help individuals navigate their self-criticism and feelings of worthlessness and hopelessness, as well as eventually improve their depression (Sears, 2015).

However, we have limited knowledge about the differential impacts of MBCT vs. CBT on anxiety symptoms and disorders, especially in children. Depression and anxiety share some common etiological factors (Dozois et al., 2015). Hence, it can be predicted that MBCT may have increased benefits on those who experience excessive cognitive reactivity in response to encountering or anticipating an encounter with their anxiety-provoking stimuli (Lee and Semple,

2014). However, researchers need to test this theoretical rationale empirically to better understand how different intervention techniques may moderate outcomes for anxiety.

Implementations and evaluations of MBCT with children and adolescents. There has been a surge in publications in the past decade to report efficacies of MBCT with adults to alleviate various mental health concerns like anxiety and depression. However, research on

MBCT with children and adolescents is still in its infancy (e.g., Burke, 2009; Kallapiran, Koo,

Kirubakaran, & Hancock, 2015). Comparatively, a lesser number of studies are published describing the efficacy of MBCT. With children and adolescents, these evaluations of MBCT took place in clinical, community, or school settings. A brief review of MBCT evaluations undertaken is presented below to inform readers of what we presently know about MBCT’s efficacy (i.e., primary and secondary outcomes) and applicability to children and adolescents.

MBCT had been implemented with children and adolescents with attention/deficit and hyperactivity disorder (ADHD) and related behavioral disorders. To elaborate, Haydicky,

Shecter, Winer, and Ducharme (2015) evaluated the efficacy of MyMind, an MBCT program, with adolescents aged 13-18 with ADHD (n = 18). The purpose of this evaluation was to

38 investigate the effects of MBCT to reduce behavioural and emotional concerns in adolescents with ADHD as well as on family functioning (e.g., decreasing parenting stress). MyMind has eight separate, weekly sessions for participants and their parents. Parent-and-self reports of participants’ emotional (e.g., anxiety, social withdrawal, depression) and behavioural (e.g., conduct problems) were collected at pre-and-post intervention as well as at 6-week follow up.

Severity and frequencies of behavioral and emotional concerns were collected using the

Connors, 3rd Edition (Conners, 2008), and the Revised Anxiety and Depression Scale (Chorpita,

Yim, Moffitt, Umemoto, & Francis, 2000), respectively. Haydicky and colleagues’ (2015) findings indicated a significant reduction in participants’ attentional, conduct, and peer problems at post-intervention, as reported by their parents. Moreover, these parent-reported changes were maintained at follow-up. Parents also reported significant decreases in parenting stress and increases in mindful parenting after completing the intervention. While there were no significant changes in adolescent reported behavioural concerns from pre- to -post-intervention, clinical changes were evident for oppositional defiant disorder symptoms. For emotional concerns, there was no significant decline in adolescent reported concerns at post-intervention, but when compared from pre-intervention, the levels of depressive and anxiety symptoms significantly dropped at follow-up. The adolescents in the study continued to receive daily reflection questions and reminders to engage in mindfulness practice, which might have encouraged them to continue their mindfulness practice to synthesize their learning and integration of mindfulness into their day-to-day activities. Thus, Haydicky et al. (2015) postulated that the adolescents in their study needed more time and daily mindfulness practice to gain self-awareness of how their depressive and anxiety symptoms might have been reduced through participation in MBCT. There have been other evaluations of the MyMind program; most of them were preliminary (e.g., Bogels,

Hoogstad, van Dun, Schutter, & Restifo, 2008). For example, when MyMind was provided with adolescents with ADHD and co-morbid behavioral disorders, results demonstrated significant improvements in self-reports of attention, emotional and behavioural problems, and sustained attention as measured through a neuropsychological task from pre- to -post intervention (Bogels et al., 2008). Additionally, van der Oord, Bogels, and Peijnenburg (2012) examined the efficacy of MyMind among children, aged 8-12, with ADHD. They found significant declines in parent- reported ADHD symptoms for the child after completing the program. Parents also reported significant improvements with their mindfulness on the MAAS, as well as reduced parental stress and over-reactivity from pre- to -post-MyMind. Notably, van der Oord et al. (2012) did not collect self-reports to assess symptoms reduction in this younger group of participants.

Altogether, these MyMind findings present emerging evidence for the effects of MBCT in children and adolescents with ADHD in enhancing their behavioural and emotional well-being, mainly from parents’ perspectives.

MBCT had also been adapted for adolescents struggling with depression, particularly for treatment-resistant depression. Ames, Richardson, Payne, Smith, and Leigh (2014) published the first empirical evaluation of MBCT for adolescent treatment-resistant depression. In their study,

7 adolescents, ages 12-18 who were having residual depressive symptoms from a prior psychological treatment for depression or co-morbid depression with anxiety concerns, completed 8-week of MBCT. Along with assessing for the primary outcome, decreases in depression symptoms (Moods and Feelings Questionnaire; Angold et al., 1995), Ames et al.,

(2014) also measured secondary outcomes that might be associated with participating in MBCT, including rumination (Child Response Style Questionnaire; Meiser-Stedman, Dalgleish, Smith,

Yule, and Glucksman, 2007), worry (Penn State Worry Questionnaire; Meyer, Miller, Metzger,

& Borkovec, 1990), and mindfulness (CAMM; Greco et al., 2011). The small sample size limited the analyses of these outcomes. Nonetheless, at post-MBCT, large effect sizes were seen with the decreases in depression symptoms (d = .77), while modest effect sizes were found with the decreases in worry and rumination (d ranging between .41 and .48). However, improvements in mindfulness only had small effect sizes (d = .33).

Similarly, MBCT was also implemented and evaluated with another group of adolescents

(n = 18), aged 14-18, who were referred from a CBT program for only having a partial recovery from their acute depression episode after undergoing the CBT intervention (Racey et al., 2018).

The 8-week MBCT program evaluated in the study was an adaptation of an MBCT program used with adults (Segal et al., 2002). The parents also attended 8-week parallel sessions on mindfulness. Baseline screenings indicated that most of the participants were still struggling with moderate levels of depression, and half of them were taking anti-depressants. Thus, the group of participants was particularly vulnerable for relapse and at risks of experiencing increased depression (Racey et al., 2018). While the primary purpose of the evaluation was to examine the efficacy of MBCT to reduce depressive symptoms, Racey et al. (2018) also assessed secondary outcomes in relation to participating in MBCT in their participants. These secondary outcomes were mindfulness (MAAS), self-compassion (Self-Compassion Scale; Neff, 2015), rumination

(Rumination Response Scale; Treynor, Gonzalez, & Nolen-Hoeksema, 2003), and thoughts decentering (The Experiences Questionnaire Decentering Subscale; Fresco et al., 2007). At-pre- and post-MBCT, participants and their parents reported on the primary and secondary outcomes for themselves. Statistically significant improvements were seen across all the outcomes for the participants. For parents, significant changes were demonstrated in rumination, self-compassion, and decentering from pre- to -post-MBCT.

Taken together, initial research conducted with children and adolescents with treatment- resistant depression demonstrates promise in MBCT’s efficacy to reduce their depressive symptoms. Furthermore, researchers had assessed secondary outcomes that may be associated with completing MBCT in adolescents with treatment-resistant depression. From the very limited research that had been conducted, we have preliminary findings suggesting that these secondary outcomes of MBCT may be improvements in rumination, worry, self-compassion, and mindfulness. However, improvements with these secondary outcomes have not been examined with respect to the changes seen with depressive symptoms at post-MBCT. Hence, we are not sure as to what process variables (i.e., mechanisms of action) facilitate the decreases in depression in adolescents after completing MBCT. This remains an important gap in MBCT research with children and adolescents.

Finally, general limitations with design and evaluation methods were noted in all of these

MBCT efficacy studies. First, many of these researchers did not have control groups to examine whether the changes seen in children and adolescents after participating in MBCT were significantly higher than children and adolescents who have not received MBCT (i.e., understanding effect sizes of MBCT). Second, the studies generally consisted of smaller sample sizes. Third, some researchers also did not conduct follow-up evaluations to examine the maintenance of outcomes seen at post-MBCT. Therefore, more empirical evaluations of MBCT with children and adolescents addressing these limitations are needed to add to and strengthen the research base of MBCT to inform clinical practice.

MBCT for childhood anxiety. In recent years, clinicians and researchers have been exploring whether MBCT is a suitable and efficacious treatment of choice to alleviate anxiety in children. In MBCT for childhood anxiety, the philosophies and premises of mindfulness informs

42 how maladaptive and intrusive cognitions associated with anxiety are approached and addressed.

To elaborate, a basic premise of mindfulness is to intentionally pay attention and experience the present moment with openness and non-judgments (Bishop et al., 2004). Children struggling with anxiety concerns tend to excessively orient their attention towards past or potential future experiences with their stressors or perceived threats (i.e., anxiety-provoking stimuli; Hayden et al., 2006). When children attend so excessively to their past or future experiences, they also often expand thoughts, catastrophize thoughts, and engage in cognitive reactivity. Expansion and catastrophizing of thoughts further escalate distressing emotions such as fear, anger, and sadness, which also intensifies anxieties in children (Hayden et al., 2006). Therefore, in MBCT, children learn to apply mindfulness practice in coping with those intrusive thoughts through openness and non-judgments. In other words, MBCT teaches children to take note and observe their thoughts, emotions, and physiological reactions through openness and not to judge or expand on them, while intentionally bringing their attention to the present moment. Furthermore, mindfulness practices teach children to respond to their stressful stimuli or situations reflectively (i.e., thoughts are not facts) rather than reflexively, and so they can effectively counter experiential avoidance strategies, which are attempts to alter the intensity or frequency of unwanted internal experiences (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). These avoidant strategies are assumed to be contributing to the maintenance of children’s anxieties, and mindfulness practices can help them to better combat this maladaptive approach. Finally, it is argued that mindfulness practices of MBCT offer an additional benefit of helping children to better cope with the physiological responses (e.g., stomach aches) associated with their anxieties. Particularly, the slow and deep breathing coupled with physical exercises involved in mindfulness practices, may alleviate bodily symptoms and responses of distress by balancing sympathetic and

43 parasympathetic responses (Kabat-Zinn, 2006). In summary, these theoretical rationales suggest that MBCT could be a suitable and beneficial therapeutic approach to alleviate anxiety concerns in children. In consideration of these theoretical rationales, MBCT has been implemented to target childhood anxiety (Felver et al., 2013). While limited, there had been some empirical investigations to evaluate the efficacy of MBCT for children with anxiety concerns. The sections below present the details of these investigations.

Semple and colleagues (2005) developed and implemented one of the first MBCT programs for childhood anxiety symptoms. According to empirical reviews (e.g., Felver et al.,

2016; Kallapiran et al., 2015), there is only one manualized MBCT currently available that exclusively target childhood anxiety symptoms. Lee and Semple (2014) developed this program for children aged 9-12, who are, having anxiety symptoms, and not necessarily anxiety disorders.

Therefore, researchers have primarily used and evaluated the program as a targeted MBI for childhood anxiety management. In their investigation, they provided a six-week MBCT with 5 children, aged 7 to 8, who were nominated by their teachers for their presenting anxiety behaviours in the classroom. Following the nominations, the school psychologist screened the participants to confirm their eligibility to take part in MBCT for anxiety. Semple et al. (2005) did not detail how the school psychologists screened the participants to confirm their eligibility for the intervention. At post-MBCT, teachers reported significant improvements in academic functioning, internalizing concerns, and externalizing concerns for the participants, as shown on their ratings on the Child Behaviour Checklist-Teacher Report Form (Achenbach, 1991). School psychologists also observed the participants in their classrooms at pre- and post-MBCT and reported notable improvements in their internalizing (e.g., anxiety, depression) and externalizing behaviors (e.g., attentional problems). Semple et al. (2005) also collected self-reports of

44 participants’ anxiety using the MASC and STAIC at pre- and post-MBCT, but these results were excluded from the analysis. Despite that their teachers’ and school psychologists’ reports indicated that the participants had high enough anxiety concerns to participate in MBCT, 4 of the

5 participants did not report subclinical or clinical levels of anxiety symptoms on the MASC or the STAIC. This finding adds to the growing body of literature highlighting the inconsistencies in anxiety severity between self-reports and adult reports of children’s anxiety symptoms

(Manassis, 2000). Nevertheless, when inquired, participants indicated that they 1) understood the concepts of mindfulness taught in the program, 2) found the activities interesting and expressed pleasure in being part of the program, and 3) were also able to develop applications of mindfulness in their everyday lives, providing support for MBCT’s acceptability and appropriateness for the age range. While Semple and colleagues (2005) demonstrated emerging evidence for MBCT’s efficacy to alleviate concerns among children with anxiety, the study had limitations. First, it had a very small sample size, with no comparison control, and the school psychologists were aware that the participants were undergoing an intervention for their anxiety concerns, which explicitly or implicitly might have biased their clinical observation of participants’ behaviors in the classroom post- MBCT.

In addressing these limitations, Semple and colleagues (2010) developed a manualized,

12-week MBCT program for childhood anxiety symptoms and examined its efficacy through an

RCT. Particularly, the RCT was implemented with 25 children, between the ages of 9 and 13 from mostly low-income families. Selection of participants was based on an educational psychologist’s nomination. The educational psychologist was providing a remedial reading intervention with children from low-income neighbourhoods, and they nominated children demonstrating anxiety behaviours in the intervention sessions. No other formal baseline

45 assessment was conducted to examine the participants’ eligibility to take part in MBCT for anxiety symptoms. Participants completed the MASC and STAIC to report on their anxiety symptoms at pre-and-post MBCT. At pre-MBCT, 6 of the 25 participants reported clinically elevated levels of anxiety symptoms on the anxiety measures. At post-MBCT, anxiety levels of the three participants from the clinical group were no longer reported to be in the clinical range.

This suggests that for the 50% of the participants, the reported decreases in their anxiety symptoms were clinically significant at post-MBCT. Parents also completed the CBCL at pre- and-post MBCT, and compared to the waitlist controls, significant, secondary improvement was reported in participants’ attentional problems, and this improvement was maintained at a 3- month follow-up.

In another evaluation of the same MBCT program developed by Semple and colleagues

(2010), an open trial was implemented with children of divorce in Iran (Esmaeilian et al., 2018).

A sample of 83 children of divorce aged 10-13 participated in the 12-week MBCT program.

Participants’ school records were screened to eliminate participants with excessive disruptive behaviours (i.e., ineligibility criteria). The participants were randomized to either receive the intervention or be no-treatment controls. The purpose of the evaluation was to investigate whether participation in MBCT was associated with improvements in clinical symptoms: anxiety

(STAIC), depression (Children Depression Inventory, Kovacs, 1992), and anger (State-Trait

Anger Inventory for Children-2; Speilberger, 1999). Esmaeilian et al. (2018) also assessed the effects of MBCT on mindfulness using the CAMM in their participants as a secondary outcome.

From pre- to post-MBCT, there were significant decreases in participants’ reported state and trait anxiety, state and trait anger, and depression symptoms. These differences were also significantly lower in the intervention group compared to the control group. Furthermore, the

46 decreases and the group differences seen in these clinical symptoms were maintained at a 2- month follow-up. Esmaeilian et al. (2018) also found significantly higher mindfulness growth in the MBCT group compared to the control group, and this growth and the group difference were maintained at a 2-month follow-up. Finally, they examined the relationship between the primary outcomes of MBCT and the secondary outcome, mindfulness in their study. Specifically, their results suggested that the changes in mindfulness that their participants reported from pre- to post-MBCT mediated the decreases indicated in anxiety, depression, and anger for the same time interval. Hence, this was one of the first, published studies in the childhood MBCT field to examine the relationship between its primary and secondary outcomes. Examinations of the relationships in the study suggested that growth in mindfulness may be associated with the clinical changes observed in children after completing MBCT.

MBCT was also implemented with children and adolescents aged 9-17 (n = 11) with anxiety disorders who were at risk of developing bipolar disorder due to having a parent with the disorder (Cotton et al., 2016). The adolescents underwent a structured, clinical interview to confirm their diagnosis of an anxiety disorder to determine their eligibility to participate in

MBCT. In addition to evaluating the efficacy of MBCT to reduce participants’ anxiety, Cotton et al. (2016) assessed whether participation in MBCT was also associated with improvements in mindfulness and emotional regulation. At pre- and post-MBCT, participants reported on their state and trait anxiety on the STAIC, as well as on their mindfulness on the CAMM. Parent- reports of their children’s emotional regulation skills were collected using the Emotion

Regulation Checklist (Shields & Cichetti, 1997) at pre- and post-MBCT. Clinicians-rated anxiety symptoms were also collected at pre- and post-MBCT using the Pediatric Anxiety Rating Scale

(PARS; Research Units on Pediatric Psychopharmacology Anxiety Study Group [RUPP], 2002).

At pre-MBCT, mindfulness significantly correlated with participants’ report of trait anxiety and clinician-rated anxiety, and parent-reports of emotional regulation significantly correlated with clinician-rated anxiety. These correlations provided conceptual insights to Cotton et al. (2016) as to how anxiety in their participants was related to the intended secondary outcomes of the study: mindfulness, and emotional regulation before intervention. Following the completion of MBCT, significant decreases in anxiety were seen in participants according to self-reports (only for trait anxiety) and clinician-reports. Parents also reported significant improvements in their child’s emotional regulation from pre- to -post-MBCT. At post-MBCT, only mindfulness was significantly correlated with self-reports of trait anxiety and clinician-reported anxiety. Emotion regulation did not significantly correlate with either anxiety or mindfulness at post-MBCT.

While there was no significant growth in mindfulness in participants from pre- to -post-MBCT, increases in mindfulness were significantly correlated with decreases in clinician-rated anxiety, and participant-reported trait anxiety. In line with a study by Esmaeilian et al. (2018), this finding also suggests that changes in mindfulness may be related to the decreases in anxiety potentially observed in children and adolescents after completing MBCT.

In summary, from the limited research that has been conducted in MBCT for childhood anxiety, the findings suggest that MBCT may be efficacious in reducing anxiety symptoms in children and adolescents. So far, there have been four published studies on this topic, and hence, the research is its initial stage. Hence, future evaluations of MBCT are required to enhance our understanding of its benefits for children struggling with anxiety concerns. Specifically, additional evaluations of MBCT are needed with clinically anxious children to assess its applicability and efficacy to alleviate clinical levels of anxiety symptoms. In line with that, future

MBCT evaluations for childhood anxiety are also to be conducted with comparison groups.

Presently, there is no published investigation of MBCT evaluation in which the effects of MBCT to reduce anxiety symptoms had been compared with a control group with similar levels of anxiety severity. This is a significant gap in the field that would be worthwhile to address in future studies.

Finally, in addition to understanding whether MBCT is efficacious to reduce anxiety symptoms, it important to study how MBCT may operate to produce the intended primary outcome. Therefore, secondary outcomes that may be related to the primary outcomes, and the intervention components are to be monitored and measured. For childhood anxiety and MBCT, attention (Semple et al., 2010), emotional regulation (Cotton et al., 2016), and mindfulness

(Esmaeilian et al., 2018) had been measured as secondary outcomes. Mechanisms of action in interventions do not likely operate alone, but the interaction of different mechanisms assumedly facilitate the changes in the primary outcome (Alsubaie et al., 2017). Hence, exploration of additional secondary outcomes for MBCT concerning child anxiety is warranted. Child anxiety, and mindfulness theories, as well as the adult literature of MBCT could guide researchers as to what additional secondary variable may be of relevance for the intervention. Before reviewing the adult literature for MBCT and mechanisms of action, it will be first necessary to discuss how mechanisms of actions are defined, conceptualized, and measured in intervention evaluations.

Mechanisms of action in MBCT. In addition to better understanding the clinical efficacy of MBCT, it is important to understand its mechanisms of action. Once we have a greater understanding of the mechanisms through which MBCT reduces psychological symptoms, it will enable us to refine it to potentially enhance its effectiveness and durability

(Alsubaie et al., 2017). A mechanism is the process variable that is responsible for the change in an intervention (Kazdin, 2007). Identifying mechanisms of action for interventions shed further

49 light on the theories that explain the etiology of respective psychopathologies and how to alleviate them. In intervention efficacy study designs, researchers often employ mediational analysis to find an intervening variable that may account statistically for the relationship between the independent variable (i.e., symptoms level at pre-intervention) and dependent variable (i.e., symptoms level at post-intervention; Kazdin 2007, 2009). If mediational analyses are to be employed to identify potential mechanisms of action for interventions, it is recommended that the mechanisms of action and outcome variables are measured at multiple time points throughout the implementation phase of the intervention to examine: 1) whether the changes in the mechanisms of action precede the changes seen on outcome variables, and 2) whether the changes in mechanisms of action observed at an earlier time point in the intervention mediate the changes on the outcome variable from pre- to -post-intervention.

Thus far, research aimed at understanding mechanisms of action for MBCT has been predominantly conducted with adults with depression. For example, van der Velden and colleagues (2015) conducted a systematic review of 23 studies evaluating the efficacy of MBCT to reduce major depressive disorder in adults. These studies were first coded to determine their quality (i.e., appropriate randomization and blindness; number and reasons for dropouts, etc.).

For 12 out of the 23 studies, the review revealed that improvements in mindfulness, rumination, worry, compassion, or meta-awareness predicted the reduction of depressive symptoms at post-

MBCT. Furthermore, 8 of the 23 studies provided preliminary evidence that outcomes like emotional reactivity, alterations in attention, memory specificity, self-discrepancy, and momentary positive or negative affect might play a role in how MBCT reduces depressive symptoms in adults. In this review by van der Velden et al. (2015), when a study was scored to be “poor-quality” in accordance with their pre-determined criteria (e.g., conducted correlational

50 analyses to identify possible mechanisms or the study had not been replicated), the findings obtained from the study were categorized as preliminary.

Gu, Strauss, Bond, and Cavanaugh (2015) conducted another meta-analysis to identify mechanisms of action that improved mental health symptoms (e.g., depression, anxiety) in mindfulness-based psychotherapeutic interventions. In their review, they argued that even though the finding that emotional reactivity might be a mechanism of action for MBCT had not been replicated yet, due to the rigorous method employed to reveal this finding (i.e., Britton, Shahar,

Szenpsenwol, & Jacobs, 2012), this evidence is strong. Hence, future researchers need to study emotional reactivity as a possible mechanism of action for MBCT to see whether Britton et al.

(2012) findings replicate. The details of Britton et al. (2012) study will be presented in later sections of this chapter.

Gu at al. (2015) also concluded from their review that there is moderate and consistent evidence to suggest that mindfulness, rumination, and worry might also be the mechanisms of actions for MBCT. That said, the review also highlighted many key methodological limitations in the studies. For example, many of the evaluations measured psychological outcomes and assumed mechanisms of action only at pre- and post-MBCT. Many of the evaluation also performed correlational instead of mediational analysis to discern the relationships between primary outcomes and mechanisms of action for MBCT.

Similarly, Alsubaie et al. (2017) conducted an updated systematic review of MBCT and

MBSR studies to identify possible mechanisms of action for the interventions. Of the candidate mechanisms reviewed, increased self-reported growth in mindfulness most consistently mediated superior clinical outcomes after mindfulness-based psychotherapy. Their review also highlighted that more researchers were conducting mediational instead of correlational analyses to identify

51 potential mechanisms of action for MBCT. However, many of them continued only to measure primary outcomes and mechanisms of action at pre- and post-intervention and did not follow the

Kazdin criteria to examine intervention mechanisms (2007, 2009). Hence, the conclusion drawn from these mechanisms of action studies for MBCT is not definitive. Alsubaie et al. (2017) emphasized that researchers need to follow the Kazdin criteria (2007, 2009) when assessing mechanisms of mindfulness-based psychotherapies so that the results can be interpreted and applied with greater confidence. To further the discussion on this topic, the sections below present a more detailed review of two of the mechanisms of action for MBCT that have received some attention to date: —mindfulness and emotional reactivity.

Mindfulness as a mechanism of action. The development of psychotherapies such as

MBCT, is rooted in the theoretical assumption that learning and integration of mindfulness would influence improvements on psychological symptoms like anxiety and depression (Segal et al., 2002). Therefore, when researching mechanisms of action for mindfulness-based psychotherapies, it is important first to examine whether growth in mindfulness actually mediates changes in the primary, psychological outcomes (Gu et al., 2015). So far, mindfulness as a mechanism of action for MBCT had been mostly evaluated with adults. Specifically, mindfulness had been predominantly measured in intervention studies in which the primary psychological outcome was depression, followed by stress (Gu et al., 2015). In a couple of studies, mindfulness as a mechanism of action had been measured in adults with co-morbid anxiety disorders or symptoms completing MBCT (e.g., Green & Beiling, 2012). Generally, the results of these MBCT studies suggest that improvements with mindfulness are linked to better psychological outcomes. To elaborate, Alsubaie et al. (2017) in their systematic review to find mechanisms of action for MBCT found 6 RCTs for residual depression in which mindfulness

52 was also measured in participants (Batink Peeters, Geschwind, van Os, & Wichers, 2013; Bieling et al., 2012; Kearns et al., 2015; Kuyken et al., 2010; Shahar, Britton, Sbarra, Figueredo, &

Bootzin, 2010; van Aalderen et al., 2012). These researchers conducted a regression analysis to examine whether mindfulness was a mechanism of action for MBCT. Their findings revealed that overall improvements in mindfulness measured at post-MBCT statistically mediated the significant declines in depressive symptoms in adults from pre- to -post-MBCT. These findings infer that gains with mindfulness were associated with the decline in depression severity, and hence, these researchers postulated that mindfulness might be a mechanism of action for MBCT.

However, a limitation of these studies was that mindfulness was only measured in participants at pre- and post-MBCT. Thus, it is uncertain whether the changes in mindfulness preceded the changes in depressive symptoms.

With respect to MBCT with children and adolescents, mindfulness had been mainly measured as a secondary outcome. As described in the earlier sections of this chapter, in some

MBCT evaluations, children and adolescents reported significant growth in their mindfulness after intervention (e.g., Esmaeilian et al., 2018; Racey et al., 2018). Additionally, Esmaeilian et al. (2018) and Cotton et al. (2016) presented preliminary evidence that growth in mindfulness was associated with decreases in anxiety symptoms in their respective samples. However, to expand knowledge on this topic, researchers need to measure mindfulness and the primary, psychological outcome at various time intervals before, during, and after MBCT to examine whether the changes in mindfulness precede the changes in the primary outcome. Future MBCT evaluations implementing such designs will further enhance our understanding as to whether mindfulness may be a mechanism of action in MBCT with children and adolescents.

Emotional reactivity. Emotional reactivity describes emotional responses with respect to emotional sensitivity, intensity, and persistence (Nock, Wedig, Holmberg, & Hooley,

2008). That is, emotional reactivity refers to the extent to which an individual experiences emotion in response to environmental stimuli (i.e., emotional sensitivity; the threshold of stimuli needed to induce an emotional response), how strongly the individual experiences the emotions

(i.e., emotional intensity), and finally for how long the emotions prolongs for the individual (i.e., emotional persistence). Many theoretical frameworks emphasize the need to examine emotional reactivity in relation to psychopathology, such as anxiety disorders (e.g., Davidson, 2003; Gross,

2002). For anxiety disorders specifically, emotional reactivity may explain why or how the behavioural problems associated with anxiety occur (Nock et al., 2008). A behavioral problem in anxiety disorders is usually escaping or avoiding the anxiety-provoking stimuli (Dozois et al.,

2015). It is possible that when an individual with anxiety disorder encounters or thinks of potentially encountering the anxiety-provoking stimuli, not only the stimuli (or the thought of the stimuli) evokes emotions, but the emotions evoked are so intense and prolonged that it likely drives them to escape or avoid the stimuli to eliminate to reduce the distress associated with the heightened emotional reactivity. Therefore, heightened emotional reactivity may not only induce anxiety in individuals but may influence its maintenance (Carthy, Horesh, Apter, Edge, and

Gross, 2010). In line with this theoretical framework, anxiety interventions should then have an emphasis to help individuals better manage and tolerate their emotional reactivity to ultimately alleviate their anxiety concerns.

Emotional reactivity and childhood anxiety. Previous researchers have empirically examined the relationship between emotional reactivity and anxiety among both adults and children (Carthy et al., 2010). Heightened emotional reactivity in childhood anxiety is likely

54 related to the biased reappraisal of the anxiety or threat-provoking stimuli (i.e., how we cognitively interpret the stimuli or the situation; Carthy, Horesh, Apter, & Edge Gross, 2010). To examine this theory, Carthy and colleagues (2010) presented images of threatening stimuli or scenes to children aged 10-17 with anxiety disorders (i.e., the clinical group) and a control group

(i.e., non-anxiety children). Upon seeing the images, the participants were to report their thoughts and the intensity of their emotions experienced. Afterwards, participants from both groups were taught a few cognitive reappraisals strategies (e.g., identifying positive aspects of the threatening images), and then they were presented with another series of threatening images and re-evaluated on their frequency and skill to use the learned reappraisal strategies.

Participants from the clinical and controls groups also completed a questionnaire to report on their everyday use of cognitive reappraisal strategies. The results of the study (Carthy et al.,

2010) demonstrated that relative to the control group, children with anxiety disorders who responded to the threatening images with increased levels of fears, were also less successful at using reappraisals and less frequently used reappraisals in everyday life. However, when the researchers of the study taught the children with anxiety disorder reappraisal strategies, use of those strategies reduced the children’s emotional intensity as seen in their self-reports. This finding suggests that the use of cognitive reappraisal strategies may help children to decrease their emotional reactivity to anxiety-provoking stimuli, and it potentially could be a process that also fosters decreases in their overall anxiety symptoms.

Measurement of emotional reactivity. Emotional reactivity can be measured using psychophysiological methods, performance-based activities, and self-reports (Preece, Becerra, &

Campitelli, 2018). Previously, some researchers had opted only to use psychophysiological methods or performance-based activities to measure emotional reactivity (i.e., objective

55 measurement of emotional reactivity). It has been argued that individuals with psychopathologies might have distorted perceptions of their emotional experience, and their retrospective subjective ratings of their emotional experience may not always be objective or consistent (Preece et al.,

2018). Reporting of emotional experience may be particularly demanding for children. They are to be aware of their emotions, can monitor their emotions, and to remember and integrate their emotional experience retrospectively to effectively communicate about their emotional experience (Zeman, Cassano, Perry-Parish, & Stegall, 2006). Hence, many researchers had assessed emotional reactivity more objectively in children and adolescents to examine its relationship with anxiety. For example, there is evidence illustrating that adolescents with anxiety symptoms tend to have hyper-activated amygdala when exposed to visuals of fearful faces (Killgore & Yurgelun-Todd, 2005; Thomas et al., 2001). Furthermore, there is evidence of children with anxious behaviours having elevated heart rates when presented with stories of socially threatening situations (Beidel, 1991) and scary video clips (Weems, Zakem, Costa,

Cannon, & Watts, 2005).

Despite the demands and limitations of using self-reports to measure emotional reactivity, researchers and clinicians may also find it helpful to have subjective accounts of individuals’ emotional experience (Nock et al., 2008). Children too may have access and awareness of their emotional experience that an observer may not have (Adrian, Zeman, & Veits, 2011). Clinically, it is also fruitful to get a sense of children’s perception of their emotional reactivity, even if they are inconsistent or biased. Besides, some objective measurement approaches may be impractical or expensive for research and clinical purposes (Preece at al., 2018), and hence, it is also helpful to have alternative, more feasible approaches to measure emotional reactivity. That said, not many self-reports are currently available for emotional reactivity for children and adolescents.

Nock et al. (2008) developed the measure, Emotion Reactivity Scale to use with adolescents

(ages 12 and older). The Resiliency Scales for Children and Adolescents (RSCA; Prince-

Embury, 2006) also has a subscale to assess emotion reactivity. The RSCA is developed for children and adolescents, who are, aged 9-18. The psychometric properties of the RSCA had been published, and it has been validated with clinical populations. Hence, the subscale of the

RSCA appears to be a reasonable measure to get self-reports of emotional reactivity in children aged 9 and older.

Emotional reactivity and MBCT. Originally, MBCT was developed with the intent to reduce cognitive reactivity in individuals who were treatment-resistant to depression (Segal et al., 2002). In recent years, theoretically, MBCT has been expanded to make it applicable for broader clinical symptoms and disorders, including the integration of emotional regulation models into its approaches (Chambers, Gullone, & Allen, 2009; De Raedt and Koster, 2010).

Cognitive reactivity is theorized to be an important process change in MBCT (Segal et al., 2002).

Emotional reactivity is the affective component of cognitive reactivity, and hence, it is also be believed to change during the course of MBCT. In MBCT, individuals are taught to change their relationship with both maladaptive thoughts and emotions, to hold them into awareness, and to accept them with open and non-judgmental attitudes. These mindful approaches are predicted to help people develop compassion towards their thoughts and emotions that initially caused them a lot of distress, reducing the reactivity of their emotional experience with negative affect- producing stressors.

Furthermore, MBCT aims to reduce cognitive rumination, an aspect of cognitive reactivity. Concerning childhood anxiety specifically, it is predicted that MBCT may reduce

57 cognitive rumination about anxiety stressors in children and decenter the relationship they have with thoughts about their stressors (Semple et al., 2005). To explain using the principles of

MBCT, it is predicted that when children learn to observe thoughts rather than expanding or further interpreting them, this decentering may help them to reduce the reactivity of the emotions otherwise experienced when they engage in rumination or catastrophizing of thoughts relating to anxiety-provoking stimuli (Britton et al., 2012). Furthermore, a central feature of MBCT is the learning and application of mindfulness-based breathing and sensory practices, and these practices may also reduce the intensity and prolonging of the distressing emotions in children with anxiety concerns to reduce their heightened emotional reactivity.

While the theoretical considerations presented above provide reasonable rationales to suggest that emotional reactivity may be an important process change in MBCT to reduce anxiety symptoms, limited research has tested this rationale empirically, either in children or adults. Thus far, only Britton and colleagues (2012) published a study that examined whether

MBCT was efficacious in reducing emotional reactivity in adults with depression and co-morbid anxiety symptoms. In their investigation, they conducted an RCT, and they had their intervention and control participants take a social stress test at pre- and post-MBCT, and participants provided self-reports of their emotional reactivity at several times before, during, and after the stress test. Britton et al. (2012) used the Spielberger's State Anxiety Inventory for adults (STAI-

YI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) to measure emotional reactivity in their participants. They argued that while the STAI-YI was initially developed to assess anxiety in adults, researchers had recently begun to measure a broader type of emotional distress using the STAI-YI. Britton et al. (2012) found that the intervention participants had greater decreases in emotional reactivity, anxiety, and depression from pre- to -post-MBCT compared to the

58 changes seen with these variables among the waitlist controls. Furthermore, decreases in emotional reactivity in the intervention participants at post-MBCT partially mediated the decreases in depressive symptoms from pre- to -post-MBCT. Specifically, intervention participants were quicker to recover from the distress that the social stress reportedly induce than the controls. These findings suggest that MBCT may reduce depression symptoms in adults through decreasing the prolonging of their distressing emotions, a component of emotional reactivity.

There is also emerging evidence that participation in MBCT may reduce emotional reactivity in children and adolescents with anxiety disorders. For example, Strawn and colleagues (2016) examined the neurophysiology of MBCT among children and adolescents

(aged 9-17) with anxiety disorders. At pre- and post-MBCT, participants completed functional magnetic resonance imaging while performing a continuous processing task with emotional and neutral distractors. Strawn et al. (2016) found that decreases in participants’ anxiety were correlated with the changes in the activation levels in the bilateral insula and anterior cingulate.

The bilateral insula is known to be involved in subjective states and experiences of emotions, and the anterior cingulate has been shown to be important for cognitive processing and emotion regulation (Strawn et al., 2016). Considering that emotional sensitivity and intensity are components of emotional reactivity and emotional reactivity affects one’s ability to regulate emotions (Carthy et al., 2010), Strawn and colleagues’ (2016) findings provide initial support for the rationale that MBCT may reduce emotional reactivity in children and adolescents with anxiety.

Although the above studies provide initial support that participation in MBCT may reduce emotional reactivity, emotional reactivity was only measured at pre- and post-MBCT. For

59 example, Britton et al. (2012) only had their participants take the social stress test at pre- and post-MBCT. In both of the above studies, emotional reactivity was not measured at any point while participants were undergoing MBCT. Therefore, we cannot yet confidently assert that emotional reactivity precedes the changes seen on the primary, psychological outcomes (anxiety or depression) in those studies. Future research needs to measure emotional reactivity before, during, and after MBCT to see how the variable changes as individuals progress through MBCT.

Gaps and Limitations of the Literature

As clinicians, researchers, and general service providers for child’s mental health, we are responsible for providing interventions that are grounded in good quality, empirical evidence.

While we have seen a surge of mindfulness-based interventions with children in clinics, schools, and other community settings (Kallapiran et al., 2015), limited empirical investigations had been conducted to systematically evaluate their efficacies in general. This is particularly true for research concerning mindfulness-based psychotherapies with children having psychological concerns. With respect to MBCT for childhood anxiety, specifically, the literature review revealed only four published empirical investigations thus far. Therefore, continuous investigations are warranted to establish a stronger research base in this area to inform clinical practice. From the very few studies that have evaluated the effects of MBCT to reduce childhood anxiety symptoms, their methodological limitations confine our understanding of how MBCT may truly benefit children with anxiety struggles. First, not many MBCT evaluations have been conducted with clinically anxious children and compared its efficacy with comparison groups.

Second, additional secondary outcomes that are theoretically and clinically relevant to MBCT and anxiety symptoms should be measured in MBCT evaluations to gain better insights into possible mechanisms of action for MBCT for childhood anxiety. Enhanced understanding of

60 possible mechanisms of action of MBCT for childhood anxiety will help us to refine the intervention to improve its efficacy, effectiveness, and sustainability. Taken together, future studies addressing these limitations will be worthwhile to conduct to strengthen the overall research and clinical base of MBCT.

Statement of Problem and Research Questions for the Current Study

This research study was undertaken to address some of the empirical limitations described in the earlier sections of this chapter. In line with that, the primary purpose of the research was to investigate the efficacy of MBCT to reduce anxiety symptoms in children, aged-

9-12, and who were indicated to have either elevated or very levels of anxiety symptoms on parent- and/or -self-reports of a diagnostic anxiety questionnaire at baseline screening. The secondary purpose of the research was to evaluate whether the changes seen in anxiety symptoms in participants at post-MBCT are significant to the changes seen in anxiety symptoms among waitlist controls who did not receive the intervention. Finally, the tertiary purpose of the research was to measure the changes in mindfulness and emotional reactivity in participants as they were undergoing MBCT and to determine whether these changes are associated with reduced anxiety symptoms in participants at post-MBCT and a one-month follow-up. The primary specific research questions and their respective hypotheses of the study were as follows:

1. Do overall anxiety symptoms significantly change in the children participating in

12-week MBCT from baseline screening to post-intervention?

In accordance with previous research studies that have indicated that MBCT is beneficial in reducing anxiety symptoms in children (e.g., Cotton et al., 2016; Esmaeilian et al., 2018), it is predicted that through participation in the 12-week of MBCT-C, anxiety symptoms in

61 participants will be significantly reduced from baseline screening to post-intervention as assessed through parent- and self-reports of MASC-2.

2. Are the changes seen in overall anxiety symptoms from baseline screening to post-

intervention maintained in the intervention participants at a one-month follow-up?

It is hypothesized that the changes seen in overall symptoms from baseline screening to post-intervention would be maintained in the intervention participants at a one-month follow-up.

This hypothesis is in line with emerging evidence showing that gains such as decreases in anxiety symptoms from participation in MBCT were maintained in the participants at follow-up evaluations (Esmaeilian et al., 2018).

3. Are the levels of overall anxiety symptoms significantly different between the

intervention and control groups at post-MBCT?

In consideration of the previous research supporting the benefits of participating MBCT to reduce anxiety symptoms in children and adolescents (e.g., Cotton et al., 2016; Esmaeilian et al., 2018), it is predicted that the levels of anxiety symptoms will be significantly lower in the intervention group than the waitlist control group. It is assumed that the MBCT approaches and strategies will help the intervention participants to reduce their anxiety symptoms leading to a significant difference in the levels of anxiety symptoms between the intervention and control groups at post-MBCT.

4. How do mindfulness and emotional reactivity change in the intervention participants

at the mid-point (i.e., mid-MBCT) and after completing MBCT?

According to the previous research suggesting that participation in MBCT improved mindfulness in children and adolescents with internalizing concerns (e.g., Ames et al., 2014;

Cotton et al., 2016; Racey et al., 2018), it is hypothesized that the intervention participants in this

62 study will have significant improvements in their mindfulness from pre- to -post-MBCT.

Furthermore, given that we also have some evidence indicating that mindfulness mediated decreases in depression and anxiety in adults after participating in MBCT (Gu et al., 2015), it is also hypothesized that significant improvements in mindfulness would be seen from pre- to mid-

MBCT.

It is also predicted that the severity of emotional reactivity will significantly decrease from pre- to -post MBCT in the intervention participants. While no previous researchers have examined emotional reactivity with respect to MBCT and childhood anxiety, this prediction is put forward based on theoretical knowledge of MBCT as described in the earlier sections as well as from the preliminary evidence suggesting that participation in MBCT reduced over activation in brain regions involved in emotional regulation and cognitive processes (Strawn et al., 2016).

Also, in line with evidence indicating that emotional reactivity may be a potential mechanism of action for MBCT (Britton et al., 2012), it is also hypothesized that emotional reactivity would significantly decrease from pre- to -mid-MBCT in the intervention participants.

5. Are the changes seen in mindfulness and emotional reactivity between pre- and post-

MBCT maintained in the intervention participants at a one-month follow-up?

It is hypothesized that the gains obtained from the MBCT between pre-and-post- intervention, as in improvements in mindfulness and decreases in emotional reactivity would be maintained at one-month-follow-up in the intervention participants. There is emerging evidence that MBCT outcomes (e.g., improved mindfulness) were maintained in the children and adolescents at follow-up evaluations (e.g., Esmaeilian et al., 2018; Haydicky et al., 2015).

6. Do the expected changes with mindfulness and emotional reactivity reported by

participants at mid-MBCT, post-MBCT, or a one-month follow-up significantly

correlate with the decreases in their anxiety symptoms at post-MBCT and a one-

month follow-up?

It is predicted that the changes reported in mindfulness and emotional reactivity at mid-

MBCT or post-MBCT will significantly correlate with the decreases indicated in self-and-parent reports of anxiety symptoms at post-MBCT and a one-month follow-up. This prediction is put forward based on emerging evidence with childhood anxiety, adult MBCT literature, and well our theoretical understanding of anxiety. First, we have developing evidence that improvements in mindfulness was associated with decreases in anxiety symptoms in children and adolescents with anxiety disorders (Cotton et al., 2016). Second, there is research supporting that there is a possibility that emotional reactivity might be the process fostering decreases in internalizing concerns in adults and children and adolescents completing MBCT (Britton et al., 2016). Third and finally, theories presented in the earlier sections suggest that mindfulness and emotional reactivity might influence children’s levels of anxiety symptoms.

Chapter Three: Methods

Chapter three describes the methods employed to undertake the research investigation.

These methods were developed and implemented to address the specific research questions and to examine the hypotheses, as stated in chapter two. To this end, the chapter presents the research design, followed by descriptions of the study participants and the measures administered to collect the research data. Subsequently, the details of the research intervention and the study procedures, a description of the preliminary and primary analyses conducted to address the research questions, and a discussion of the ethical considerations of the study are provided.

Research Design

This research investigation was undertaken to examine the efficacy of a mindfulness- based group psychotherapy, MBCT, to reduce anxiety symptoms in children. Specifically, the study had three phases. The first phase was the baseline screening, and in this phase, participants were screened to determine if they were eligible to participate in the study intervention. In the second phase, an RCT with waitlist controls was employed to evaluate the efficacy of the study intervention. RCTs are considered to be the gold standard design to assess intervention efficacy and effectiveness in healthcare, medicine, and social sciences, including psychology (Backmann,

2017). RCTs follow an experimental design consisting of at least two conditions: Typically, an experimental intervention condition and a control condition, used for comparison on outcomes

(Solomon, Cavanaugh, & Draine, 2009). Anxiety symptoms of participants in the intervention condition were measured at baseline screening (phase one), at the end of the intervention, and a one-month follow-up. Intervention participants also reported on their mindfulness and emotional reactivity at pre-, mid-, and post-intervention and a one-month follow-up. In the third and final phase of this study, waitlist controls received MBCT, and intervention participants came in for a

65 one-month follow-up to be assessed on the maintenance of the outcomes (i.e., anxiety symptoms, mindfulness, and emotional reactivity).

Power Analysis

A power analysis was conducted to determine the minimum number of participants that were required to detect significant mean differences reasonably. Considering the limited amount of research available in MBCT and childhood anxiety, meta-analyses of mindfulness studies with adults were reviewed to find a nominal estimate of an effect size to do the power analysis for this study. In the review conducted by Baer (2003), the nominal effect was found to be 0.59 (SD =

0.41). At alpha = .05 and a power of 80%, the minimum sample size to detect significant group differences was found to be 9 participants for each group. This approach was also used by

Semple et al. (2010) to conduct a power analysis for their RCT of MBCT.

Participants

Forty children (20 females; 20 males) who were aged 9-12, along with either one or two parents, participated in the baseline screening. The mean age for the group of participants screened to assess eligibility to participate in MBCT was 10.20 (S.D. = 1.04). For 3 of the participants, both parents attended the baseline screening and filled out the screening measures together. Fathers attended the baseline screening for 5 participants. Mothers attended the baseline screening for the remaining 32 participants.

From the 40 participants screened, 27 participants (67.50%) met the eligibility criteria to participate in the study intervention. Two of the participants’ parents withdrew their participation from the intervention before randomization; they lived quite far away from the University of

Calgary, and the weekly commute to the intervention was not feasible for them at that point.

Thus, in total, 25 participants (15 females; 10 males) were part of the intervention phase of the

66 research, 12 in the intervention group, and 13 waitlist controls. The mean age for the group of these participants (intervention participants and waitlist controls, combined) was 10.11 (S.D. =

1.19) after randomization. During the intervention phase, one intervention participant dropped out of the study following the third MBCT session, and the sample size of the intervention group decreased to 11 from 12.

Participants not meeting the eligibility criteria. Thirteen participants were found to be ineligible to participate in the study intervention. The researcher provided resources for alternative psychological supports and services in the community to the parents of all participants who were found to be ineligible to participate in the research intervention. Nine of the 13 participants were found to be ineligible because their parent- or self-reports of anxiety symptoms were not elevated enough at baseline screening. Two of the 13 participants were reported to be having an elevated level of anxiety symptoms by their parents, but they had selective mutism; parents of these participants voluntarily revealed the information to the assessor (i.e., the author) during baseline screening without being prompted. During the baseline screening, these participants with selective mutism appeared to be excessively distressed communicating with the assessor, as evident by their crying. To minimize their distress, they were not asked to complete the baseline screening measures. Upon consultation with the researcher’s supervisor, it was decided that a group MBCT was not the best fit for these participants. These participants might benefit more from an intervention that targets specific anxieties associated with selective mutism.

Finally, 2 of the 13 participants were found to be ineligible to participate in the intervention due to the presence of possible atypical behaviors at baseline screening. During baseline screening, these 2 participants engaged in stereotypic and repetitive motor movements.

Furthermore, one of the participants appeared very distressed when asked for verbal assent (e.g., crying, throwing pens at his parent). He wanted to continue reading his book rather than transitioning to the research task. To minimize his distress, the assessor did not have him complete the baseline measures. Additionally, parents of these 2 participants reported elevated levels of atypical symptoms on the baseline screening measure assessing children’s social- emotional and behavioral functioning.

Measures

Anxiety symptoms. The Multidimensional Anxiety Scale for Children-Second Edition

(MASC-2; March, 2012) was administered to measure participants’ anxiety symptoms through both self and parent reports. The MASC-2 assesses anxiety symptoms across multiple domains, as addressed in the DSM-IV-TR for school-aged children and adolescents. It is a common assessment tool for anxiety for both clinical and research settings, and it is designed for youth, who are aged 8-19. It consists of 50 items presented on a Likert scale, with responses ranging from "Never" (0) to "Often" (3). Responses are summed and converted to standardized T-scores that adjust for age and gender, with higher MASC-2 T-scores indicative of more severe anxiety symptomology. The standardized T-scores obtained are also accompanied with corresponding qualitative descriptors (e.g., elevated range).

The MASC-2 distinguishes between clinically anxious and non-anxious children (March,

2012). The MASC-2 is reported to have adequate convergent and divergent validity. In terms of internal consistency, the MASC-2 manual reports coefficient alphas of 0.92 and 0.89 for the overall total score in the self-and parent-report samples, respectively. In addition, the manual reports very good test-retest reliability; the alpha coefficients for overall total scores are 0.89 and

0.93 for self-and parent reports, respectively. To measure the discriminative validity of the

MASC-2, clinical and normative groups were compared, and clinical groups scored significantly higher on all the MASC-2 subscales, with moderate to large effect sizes (March, 2013).

Furthermore, analysis revealed that MASC-2 ratings completed by the clinical and normative groups predicted their group membership (p <.01).

Social-emotional and behavioral functioning. The Conners Comprehensive Rating

Scale (CBRS; Conners, 2010) was administered to assess participants’ social-emotional and behavioral functioning at baseline screening. The CBRS assesses a wide range of behavioral, social, emotional, and academic concerns in children aged 6-18 through multiple informant rating scales (i.e., parent-teacher-and self-reports; Sparrow, 2010). The present study utilized both the parent and self-report scales. The parent-and self-report scales consist of 201 and 177 items, respectively, presented in a Likert scale, with responses ranging from “Not True at All”

(0) to “Very Much True” (3). Responses are summed and converted to standardized T-scores for

Content Scales, DSM-5 Symptom Scales, and Validity Scales (i.e., positive and negative impression and inconsistent responding indices; Conners, 2010). Examples of Content Scales yielded by the CBRS include emotional distress, upsetting thoughts, and defiant/aggressive behaviors. Furthermore, examples of DSM-5 Symptom Scales produced by the CBRS include

ADHD- predominantly inattentive type, manic episode, and obsessive-compulsive disorder. The

CBRS assessment reports also map items with each DSM-5 diagnostic criterion for respective disorders to indicate for which disorders the child needs further, immediate assessment (Connors,

2010).

The CBRS also assesses children’s level of impairment in different settings. It also draws the assessor's attention to social-emotional well-being indicators (e.g., bullying perpetration) and critical items (e.g., self-harm behaviours) to review. Furthermore, it asks raters to describe the

69 child’s strengths and weaknesses. However, these CBRS domains (e.g., critical items, strengths, and weaknesses) do not yield scores.

The internal consistency and test-retest reliability are reported to be very good, with consistent internal coefficients (Cronbach’s alpha) ranging from .69 to .97 for Content Scales, and 2-to 4-week test-retest reliability coefficients range from .56 to 96, at p < .001 (Conners,

2010). In consideration of these psychometric properties of the CBRS, Vacca (2012) suggests that it is both a reliable and valid instrument for professionals and researchers to utilize during the assessment of children’s social, emotional, and behavioral concerns.

Mindfulness. The MAAS-C (Benn, 2004) was used to measure mindfulness in intervention participants. The MAAS-C was adopted from the adult version of the MAAS questionnaire (Brown & Ryan, 2003) to use with younger populations (Benn, 2004). It consists of 15 items, presented in a Likert scale and responses ranging from “Almost never” (1) to

“Almost always” (6). The items on the MAAS-C are distributed into cognitive, emotional, and physical domains of being mindful. Furthermore, the items consist of statements that aim to measure raters’ mindless states. In developing the adult version of the questionnaire, Brown and

Ryan (2003) found that statements representing mindless states are more accessible to individuals as they are generally more likely to be in mindless rather than mindful states. Thus, the raw scores from all the items are reverse scored to calculate the sum, and the sum is then converted into a mean score to calculate the rater’s average level of mindfulness. Lawlor et al.

(2014) validated the MAAS-C for use with students in grades 4 to 7, and exploratory factor analysis confirmed a unidimensional factor structure. Reliability testing with children in grades 4 to 7 revealed high internal consistency and adequate convergent and discriminant validity.

Emotional reactivity. The Emotional Reactivity (REA) Scale from the RSCA (Prince-

Embury, 2007) was used to measure emotional reactivity in children. The REA Scale is a 20- item self-report questionnaire designed for children and adolescents who are ages 9-18. The response options on the REA scale are presented in a 5-point Likert scale, with options ranging from “Never” (0) to “Almost always” (4), with lower scores indicative of emotional resiliency and high scores indicative of emotional vulnerability. The REA Scale consists of three subscales: sensitivity or threshold for reaction and intensity of the reaction, length of time it takes to recover from emotional upset and impairment, and impact on functioning due to emotional arousal. The raw scores for each subscale are summed and converted into scaled scores, ranging from 1 to 19.

The alpha co-efficient is reported to be strong (0.90 for the sample aged 9-11, and 0.91 for the same aged 12-14) for the RSCA (Prince-Embury, 2007). Furthermore, the test-retest stability is reported to be highly correlated (0.88). Finally, the REA Scale has also shown good validity when distinguishing between children with anxiety disorders and depression, and children with no psychopathology (Prince-Embury, 2007).

Research Intervention

The research intervention implemented and evaluated in the study was called the

Mindfulness-Based Cognitive Therapy for Anxiety Children (MBCT-C; Lee & Semple, 2014). It was one of the first manualized programs developed to guide mental health clinicians in providing manualized group MBCT-C with children aged 9-12 with elevated anxiety symptoms.

The developers, Randye Semple, and Jennifer Lee directly adapted the MBCT and MBSR programs, which were designed for use with adult populations (e.g., Kabat-Zinn et al., 1992;

Segal et al., 2002) to create MBCT-C. That is, while the specific intervention techniques, activities, and the content of the program were modified to meet the appropriate developmental,

71 cognitive, and emotional needs of children in this age range, the underlying theory, aims, and approaches are consistent with adult MBCT and MBSR programs (Lee and Semple, 2014).

The MBCT-C program aims to reduce anxiety symptoms in children through the development of mindfulness. In this regard, children first learn conceptually and experientially about mindfulness, and then learn how to apply mindfulness to cope and accept thoughts, emotions, and bodily sensations that comprise the experience of distressing anxiety (Lee and

Semple, 2014). In the first phase of learning about mindfulness, children learn to observe and identify their thoughts, emotions, and bodily sensations in day-to-day moments and events and how these components interactively inform their lived experiences of those moments and events.

It is the hope that the development and cultivation of mindfulness will help children to identify their habituated and automatic cognitive responses and reactions to events (i.e., automatic pilot mode), which at times take away from accepting and living in the present moment with openness

(Lee & Semple 2014; Semple et al., 2005).

In learning to apply mindfulness to cope with anxiety, it is thought that the MBCT-C program will also cultivate self-compassion in children. Children are taught about the choices

(i.e., choice points) they can make in living in their present moment (Lee & Semple, 2014). To further explain choice points, children are taught that while they may not have control over the content of their thoughts and their corresponding emotions, they do have the capacity to make choices as to how they can respond or react to those thoughts (Sears, 2015). The capacity to adaptively react to these thoughts and emotions is further assumed to be enhanced when children become aware that their thoughts may not always be facts (Lee & Semple, 2014). Children are taught that they can either engage in elaboration or expansion of their thoughts that in result elevate the intensity, range, and degree of distressing emotion or exercise mindfulness to observe

72 thoughts as thoughts and recognize more ways and opportunities to stay in the present moment

(Sears, 2015). Such learning of mindfulness skills is also thought to possibly develop greater capacity in children to tolerate difficult thoughts and non-judgmentally accept strong emotions such as fears and sadness (Lee & Semple, 2014).

Intervention structure and activities. The MBCT-C program (Lee and Semple, 2014) consisted of 12 weekly 90-minute sessions. Previous evaluators of the MBCT-C programs (e.g.,

Semple et al., 2010) defined program completion as attending at least 8 of the 12 sessions. These sessions aim to engage participants in various physical, sensory, art, and musical activities to help them develop mindfulness awareness and cultivate skills to be in the present moment (see

Appendix A). Mindfulness is a way of living to accept the present moment with openness and no judgment; it is an everyday skill that relies upon opportunities, practice, and intention to be developed (Willard, 2010). With children, considering that their capacities with self-observation and general cognitions are still developing, it is important that they are provided with explicit and contextual learning opportunities to learn about mindfulness (Willard, 2010). Therefore, the first three weeks of the MBCT-C focused on introducing the participants to the basic concepts of mindfulness, followed by six sessions dedicated to providing experiential learning of mindfulness using the five senses. Specifically, for weeks 4 to 10, each session dedicated its focus to one sense at a time (e.g., hearing mindfully) so that participants could learn how to be mindful using each of their senses. For example, there was a session that aimed at teaching mindfulness hearing using musical activities (Lee & Semple, 2014). Focusing on one sense at a time breaks down the learning of mindfulness into concrete concepts and steps for children and provide coaching of various ways in how they could practice mindfulness day-to-day.

In addition to sensory and movement-based activities to teach children about mindfulness, an important aspect of the MBCT-C was to engage participants in ‘practice inquiry’

(Lee & Semple, 2014). After each activity and exercise, participants were guided in practice inquiries to help them 1) reflect on their overall experience of doing the mindfulness practice, 2) to discuss the thoughts, emotions, and bodily sensations that might have arisen during the practice, and 3) to identify how they were all interconnected. Furthermore, the practice inquiries guided participants as to how the mindfulness practices could be integrated and applied into their daily lives, particularly events that elicit anxiety. Finally, the MBCT-C sessions taught participants different cognitive and behavioural coping strategies that could accompany the mindfulness practices to help them better tolerate and manage anxiety symptoms.

Participants also received a ‘travel folder’ on the first MBCT-C session, and they were instructed to bring it to every session. This ‘travel folder’ contained sessions summaries, mindfulness-based poems, and instructions and worksheets for home practice. Each week, participants were assigned two to three home practices to enhance their familiarity and learning of skills taught in each session. Some of the home practices (e.g., three-minute breathing spaces) remained the same for each week so that participants had increased opportunities to learn and identify ways in which mindfulness could be integrated and become a regular practice of their daily life.

Parental components. There was a 90-minute parent orientation on the second week of the intervention. During this orientation, parents received information about the program as well as the basics of MBCT. Additional resources (e.g., information about books) about mindfulness and MBCT were shared with parents in case they were interested in seeking out more learning on the topic. In the orientation session, parents also participated in an experiential mindfulness

74 activity (i.e., raisin mindfulness) so that they can better relate to their child’s mindfulness training. Participation in mindfulness activities might have also helped parents to understand better how their children could use mindfulness to cope with their anxiety problems. Finally, attending parents brainstormed, discussed, and learned ways in which they could support their child in regularly participating in home-practices of mindfulness. Similarly, a wrap-up session with parents also took place at the end of the intervention. During this session, parents discussed and reflected on their child’s experiences with the intervention and offer feedback about aspects that worked or did not work about the intervention.

Intervention fidelity. It is crucial to monitor intervention fidelity to determine a functional relation between the intervention itself and the effect observed (Moncher & Prinz,

1991), in this case, reduced anxiety symptoms, increased mindfulness awareness, and reduced emotional reactivity in intervention participants. For this study, two components were considered to assure that MBCT-C was implemented and evaluated with fidelity: 1) preparedness and skills of the interventionist to implement the program, and 2) collection of specific information to demonstrate fidelity. A summary of these components is provided below.

First, the intervention was provided by the researcher (i.e., the implementer), who had undergone training in MBCT. To elaborate, the implementer sought out training to conduct

MBCT from the Centre for Mindfulness Studies in Toronto, Ontario. After her training courses, during her pre-doctoral internship (2017-2018), she implemented individual and group MBCT with children struggling with anxiety, mood concerns, and aggression under the supervision of licensed clinical psychologists in the United States, having competencies with mindfulness-based psychotherapies. Furthermore, the implementer had also previous experiences of providing brief

75 mindfulness interventions with students and teachers in elementary classrooms as well as with parents.

In addition, it has been emphasized that mindfulness therapists need to participate and support their regular practice of mindfulness (Hick, 2008). Personal practice of mindfulness is not only important to make sure that teaching of mindfulness in MBCT and other mindfulness- based psychotherapies with clients is implemented with fidelity, but also in helping the implementer to conduct mindfulness-based psychotherapy sessions mindfully (i.e., being in the present moment, reducing anticipations of what will happen in the session but being open and accepting of experience that clients will bring into sessions). During the researcher’s pre-doctoral internship, she received individual mentorship as to how an emerging mindfulness therapist might develop personal practice of mindfulness. Along with mentorship, she was afforded professional development opportunities to enhance her skills of being mindful (e.g., structured classes of mindfulness meditations). During the intervention in this study, the implementer maintained her regular and personal practice of mindfulness outside the intervention. Finally, the implementer was supervised by her primary research supervisor, who is also a Registered

Psychologist in Alberta, to receive clinical guidance on conducting group therapy and working with children with anxiety symptoms. She met with her supervisor bi-weekly for an hour supervision. Along with in-person supervision, she kept a journal of her personal experiences and reflections of conducting the sessions, and she shared them with her supervisor as well.

Some clinical supervision models have trainees engage in regular personal reflections to help them identify and process internal factors (e.g., confusion, dissonance, discomfort) triggered in certain events and interactions and relating them to the actual practice (e.g., therapy; Bernard &

Goodyear, 2014). Personal reflections paired with self-monitoring are assumed to be an

76 important tool to train supervisees on self-supervision for eventual independent practice (Bernard

& Goodyear, 2014).

Second, the MBCT-C evaluated in this study was a manualized program. For each session, the manual (Lee and Semple, 2014) provided instructions for activities and scripts on how to introduce and carry out activities and guiding questions on how to lead inquiries and discussions. After each session, the implementer completed the MBCT-C Adherence Scale

(MBCT-AS; Semple and Sears, 2014); she obtained permission from the developers to use the

MBCT-C AS for this study. The MBCT-C AS is composed of 20 items presented in a Likert scale with responses are ranging from “Not at all” (0) to “Clear-Consistent” (2). The maximum adherence score that can be obtained from the MBCT-C AS is 40. The MBCT-C AS measures the interventionist’s adherence to different variables with respect to conducting the program with fidelity. Examples of these variables include maintaining group cohesion, implementation of sensory-based activities, generalizability of session activities to real-life applications, and teaching of cognitive coping skills. The range and mean of the adherence scores are provided in the subsequent results chapter.

Procedures

Phase one: Baseline screening. The researcher first obtained ethics approval for all three phases of the study from the Conjoint Faculties Research Ethics Board at the University of

Calgary to conduct the research. She then sought out partnerships with public, private, and charters schools in the Calgary area, Alberta, to recruit participants for the study. Specifically, after additionally seeking ethics approval with independent school boards, if needed, the researcher contacted school principals to see if they were willing to share information about the study with their respective students’ parents and caregivers. If the school principal was willing,

77 then the researcher shared a research letter and flyer about the study (see Appendix B). The research letter and flyer described the purpose of the research and asked interested parents and caregivers to contact the researcher if they thought that their child was experiencing excessive worries, fear, or anxiety. The letter and the flyer also had information on the tasks that parents and children would be asked to do if they were to consent and assent to take part in the baseline screening. They also had information about the subsequent components and phases (i.e., randomized draw; participation in a psychological intervention) of the study. Some schools sent home paper copies of the research letter and flyer to all their students, who were aged 9-12

(grades 4 to 7), while others opted to send the information electronically. In total, 30 public schools, 5 charter schools, and 4 private schools were contacted in the Calgary area. Out of the

39 schools, principals of 8 schools (i.e., a response rate of 20.5%) shared information about this study with their respective students’ parents and caregivers.

Interested parents then contacted the researcher to find out additional information about the study. Most parents opted to contact the researcher via e-mail, while a few contacted the researcher via telephone. A designated e-mail address using the secured University of Calgary server was created to permit electronic correspondence with participants’ parents. When contacted, the researcher took a two-step approach to complete the subsequent steps for baseline screening. In step one, the researcher had a telephone conversation to familiarize the parent about

1) the purpose and method of the study, and 2) the type of commitment expected from participants and their families if they consented to have their child participate in the study (e.g., coming to the University of Calgary main campus to attend baseline screening and intervention sessions). Parents who provided initial verbal consent to have their child participate in the study came in for the baseline screening with their child at the University of Calgary's main campus.

The baseline screening was conducted by the researcher (i.e., the assessor), who had doctoral-level training with psychological assessments and interpreting standardized social- emotional and behavioral measures. During baseline screening, the assessor met with the parent first to go over the informed consent process. The parent provided their consent by signing the informed consent form (see Appendix C) in person. Afterward, the assessor met with the child and described the purpose of the baseline screening using lay language and obtained their written assent. After the receipt of parental consent and child assent, the child and parent independently completed the two baseline screening measures, MASC-2 and CBRS, in separate rooms. The assessor was physically present with child participants while they completed the measures. The assessor asked child participants whether they would like to complete the measures on their own or have the assessor read the items to them out loud. Children were also informed that they could ask questions about items on the measures anytime for clarification and further explanation if needed. Most child participants opted to fill out the measures on their own, but almost all of them asked questions to seek clarifications about items on the measures. Furthermore, the assessor met with the parent after they filled out the measures to see if they had any questions or concerns about them. Many times, the parent needed clarification on items on the CBRS. The baseline screening appointment typically took about an hour.

Eligibility criteria. Following each baseline screening appointment, the assessor scored the parent- and self-reports of the MASC-2 and CBRS to determine whether the participant met the eligibility criteria to participate in the research intervention. The scorings of the MASC-2 and

CBRS were computed using their respective online scoring software. There were two criteria that participants were required to meet to be found eligible to participate in the research intervention.

One, the parent- or self-report of the MASC-2 or both, needed to indicate that the child was

79 experiencing at least elevated level of overall anxiety symptoms. That is, the T-score of the overall anxiety symptoms index on the parent-or-self-report needed to be 65 or higher. The

MBCT-C program (Lee and Semple, 2014) was developed for children with anxiety symptoms, and hence, technically, it was not mandatory for participating children to have a confirmed diagnosis of an anxiety disorder.

The second eligibility criterion was developed on the premise to make an informed and ethical decision as to whether MBCT would be an appropriate fit for children with co-morbid social-emotional and behavioural problems. Specifically, MBCT has not been comprehensively evaluated with children with significant atypical (e.g., mania, psychotic symptoms) and severe behavioural and aggressive issues (Lee and Semple, 2014). As such, there is insufficient empirical evidence to suggest how enhanced mindful awareness may impact the intensity of presenting, co-morbid atypical issues.

Furthermore, it was particularly important to screen for self-harm ideations and behaviours in children, such as their suicidal ideations, thoughts, or attempts. Mindfulness-based psychotherapies have been theorized to reduce suicidal ideations in children by reducing children’s cognitive reactivity to self-harm thoughts and impulses. However, not many researchers have empirically tested this theory among children and youth (Chesin et al., 2016).

Children with co-morbid, significant mood, atypical, or behavioural problems would benefit more from alternative interventions and treatments that are more individualized and specialized to their needs and challenges. Concerning MBCT importantly, it is to acknowledge that presenting, co-morbid problems would likely make it more challenging for children to engage in the practice and learning of mindfulness, particularly in a group context (Lee and Semple, 2014).

In considerations of the abovementioned reasons, the T-scores on the CBRS indices assessing the child’s atypical (i.e., Manic Episode, Autism Spectrum Disorder), and behavioural symptoms (i.e., ADHD-Predominantly Hyperactivity/Impulsivity Type, Defiance, Aggression) were examined first to see if they were very elevated (T-score of 70 or higher). If the T-scores for those CBRS indices were elevated, then as the next step, it was examined whether a sufficient number of symptoms were endorsed to increase the probability for the child to meet the DSM-5 diagnostic criteria for the respective disorder. It is important to note that a score on the CBRS index could be elevated (e.g., due to ratings of [Very Much True] on two symptoms), but for the same CBRS index, the rater may not endorse all the DSM-5 symptoms for the respective disorder. According to CBRS (Connors, 2010), when ratings suggest that sufficient items are endorsed to meet all the DSM-5 symptoms count for a disorder, then the assessor is strongly urged to follow up with additional evaluations to explore whether the child should be diagnosed with the disorder. Additionally, the CBRS items belonging to the Self-Harm and Critical-Item indices were also examined to determine a participant’s eligibility. To summarize, the exclusion criteria were meeting DSM-5 symptoms count on the CBRS for ADHD-predominantly hyperactivity/impulsivity type, oppositional defiant disorder, conduct disorder, manic episode, and autism spectrum disorder as well as elevated concerns reported for the Self-Harm index.

Following the scoring and interpretation of the MASC-2 and CBRS, the researcher contacted parents of participants to inform them whether their child was found to be eligible to participate in the research intervention. If a participant was found to be eligible, their parent was also informed of the subsequent steps and explicitly reminded that they could withdraw their child’s participation from the study at any point (i.e., the child was not mandated to participate in the intervention).

Phase two: Randomization and intervention evaluation. The present study implemented stratified randomization to assign participants in the intervention or the waitlist control condition. When creating two groups for an RCT, groups are to be comparable for participant characteristics to improve the reliability and validity of the results obtained from the

RCT (Suresh, 2011). Participant characteristics (i.e., covariates) could influence how they adhere and respond to the tested intervention. Therefore, when comparing two groups to examine intervention efficacy, the groups should have at least somewhat equal distributions of the covariates that could vary participants’ response to the intervention. When the groups are similar, the researcher can postulate with greater confidence that the differences in the outcomes found at post-intervention and follow-up are more likely to be due to the differences in the intervention condition, rather than the differences in participants’ characteristics between groups (Suresh,

2011). A stratified randomization method attempts to control and balance the influence of covariates on the dependent variable (i.e., the intervention outcome; Kim and Shin, 2014), and it is conducted in two steps. In the first step, a separate block for each combination of covariates are created, and the participants are assigned to the appropriate block of covariates. After all the participants have been identified and assigned into blocks, simple randomization is conducted within each block to assign participants into one of the study groups (Suresh, 2011).

In the present study, the covariates that the researcher had control over were the participant’s age, sex, and their levels of anxiety symptoms reported at baseline screening. To begin the randomization procedure, MedCalc © was used to generate matched pairs of participants (n = 25) based on the identified covariates of the study. The purpose of this step was to find pairs of participants who were matched on their age, sex, and parent-reports of levels of anxiety symptoms. Parent-reports rather than self-reports of anxiety symptoms was a covariate

82 because more parents reported elevated levels of anxiety symptoms for their child than children themselves, and thus, most ‘nominations’ for the intervention came from parents. The process of finding matched pairs using age, sex, and anxiety symptoms was found to be too conservative as

MedCalc © could not find enough matched pairs. Therefore, age was dropped from the covariate list, and another trial was run to find new matched pairs. Given that the manualized research intervention was developed for children ages 9-12, the underlying assumption is that children in this age range will likely have similar developmental and cognitive capacities to adhere to the different intervention components. Once the matched pairs were created, using the random number generator function on the Microsoft Excel program ©, participants from each pair were randomly assigned “1” or “2”. The numbers 1 and 2 were set to be for the intervention and waitlist controls condition, respectively. This randomization produced 12 participants for the intervention condition, and 13 waitlist controls.

Intervention provision. Following the randomization procedure, participants in the intervention condition received the intervention weekly for 12 weeks. Prior to beginning the intervention, informed consent (see Appendix C) was obtained from all parents, and verbal assent from participants was obtained. Lee and Semple (2014) recommends the MBCT-C groups to consist of 4-6 participants. Therefore, two intervention groups were created. Both groups received the intervention on the same day (i.e., one morning-group and one afternoon-group), and the intervention was provided at the University of Calgary’s main campus. The morning group consisted of 3 male and 3 female participants, and their age ranged between 10 and 12.

The afternoon group had 4 female and 2 male participants, and their age ranged between 9 and

11. The assignment of participants in groups was dependent on participants’ availability to attend the intervention.

During the course of the intervention, participants reported on their mindfulness and emotional reactivity at the beginning of sessions taking place on weeks 1, 6, and 12. On week 12, participants also completed MASC-2 to report on their anxiety symptoms. The researcher also maintained weekly communication with participants’ parents. To this end, weekly e-mails were sent to parents with the following information and updates: a summary of session contents, a description of home practices, and reminders for the upcoming session. At the end of the intervention, parents of all intervention participants were provided with information about community services and resources to continue supporting their children with possible elevated anxiety symptoms.

Phase three: Follow-up and the waitlist controls receiving MBCT. Intervention participants and their parents were invited for a one-month follow-up at the University of

Calgary. Parents completed the MASC-2 to report on their child’s anxiety symptoms.

Intervention participants completed the MASC-2, MAAS-C, and the REA subscale of the RSCA to report on their anxiety symptoms, mindfulness, and emotional reactivity, respectively.

Participants were given the option of either independently completing the questionnaire or had the researcher read the items on the questionnaires out loud.

According to the study protocols, control participants were to receive MBCT after intervention participants had completed MBCT (i.e., the end of the intervention phase of the study). After the completion of the intervention phase, all waitlist control parents (n = 13) were contacted to fill out study questionnaires for post-MBCT group comparison analyses as well to see if they were interested in having their child receive MBCT then. Eight of the 13 control parents responded to the researcher and informed that they were still willing to have their child to receive MBCT then. Three of the 13 control parents were still interested in having their child

84 participate in MBCT, but they were unable to have their child attend the sessions due to scheduling conflicts or pre-planned vacations plans. These 3 control parents completed the

MASC-2 online through the Multi-Health Systems Inc. assessment platform to report on their child’s anxiety symptoms for that time interval. Two of the 13 control parents did not respond to the researcher, even though the researcher made multiple attempts to get hold of them through calling and e-mailing them. In summary, 8 of the 13 controls received the MBCT in the third phase of the study, and parent- and self-reports of anxiety symptoms were also collected from them before controls beginning MBCT.

Study Objectives

To recall from chapter two, the present study has six research questions, and they are as follow:

1. Do overall anxiety symptoms significantly change in the children participating in 12-

week MBCT from baseline screening to post-intervention?

2. Are the changes seen in overall anxiety symptoms from baseline screening to post-

intervention maintained in the intervention participants at a one-month follow-up?

3. Are the levels of overall anxiety symptoms significantly different between the

intervention and control groups at post-MBCT?

4. How do mindfulness and emotional reactivity change in the intervention participants

at the mid-point (i.e., mid-MBCT) and after completing MBCT?

5. Are the changes seen in mindfulness and emotional reactivity between pre- and post-

MBCT maintained in the intervention participants at a one-month follow-up?

6. Do the expected changes with mindfulness and emotional reactivity reported by

participants at mid-MBCT, post-MBCT, or a one-month follow-up significantly

correlate with the decreases in their anxiety symptoms at post-MBCT and a one-

month follow-up?

Data Analyses

The analyses of the study data were performed in IBM Statistics 26.0 (SPSS, IBM-SPSS,

2019). Initially, a chi-square test was conducted to examine age and sex distribution of participants between the intervention and waitlist control conditions. Independent samples t-tests were also performed to determine the equivalence of the levels of parent- and self-reports of anxiety symptoms between the intervention and waitlist control groups at baseline screening.

Repeated-Measures analyses of variance (ANOVAs) were administered to examine whether the level of anxiety symptoms, mindfulness, and emotional reactivity significantly changed in the intervention group from baseline screening or pre-MBCT (for mindfulness and emotional reactivity) to a one-month follow-up. Two-by-two ANOVAs with group allocation (i.e., intervention or control condition) as the independent factor and anxiety symptoms as the within- subject factor were performed to see if there was a group X time interaction effect between the intervention and control group. Findings from these analyses answered research questions one to five.

Finally, Pearson product-moment correlations were conducted to address the sixth and the seventh research questions of the study. Initially, one of the purposes of the present study was to identify potential mechanisms that may be mediating changes in participants’ anxiety symptoms from pre- to -post-MBCT as well as from pre-MBCT to a one-month follow-up. As recommended in the intervention literature (e.g., Kazdin, 2007; Judd & Kenney, 1981), performing mediational analyses could be one approach to identify mechanisms for intervention outcomes. If mediational analyses were to be conducted for the present study data, the

86 independent variable was to be the level of anxiety symptoms reported at baseline screening, and the dependent variables were to be the level of anxiety symptoms, reported at post-MBCT and a one-month follow-up. Furthermore, mindfulness and emotional reactivity were to be the mediators. However, there were only 11 intervention participants in the present study, and the size of the sample was not large enough to achieve adequate power for mediational analyses

(Fritz & MacKinnon, 2007). In order to perform a mediational analysis, it is important first to examine if the mediator significantly correlate with the independent and dependent variable.

Therefore, as initial steps, correlations were computed to examine how the outcome variables

(i.e., mindfulness, emotional reactivity, and self- and parent-reports of anxiety) correlated with one another before, at-mid-point, and after MBCT. Then change scores (Time 2 – Time 1) were calculated for the variables that demonstrated significant changes from one time-interval to another. Correlations with these change scores were also performed to examine the association between changes in the outcome variables before and after intervention.

Ethical Considerations

In conducting this study, there were a few ethical considerations. When conducting intervention research, appropriate ethical protocols are to be developed to support participants reporting self-harm ideations and/or behaviors. For baseline screening, according to these protocols, if a participant was to be reported having suicidal ideations and/or active attempts or engaging in self-harm behaviors or harmful behaviours towards the others, appropriate resources for urgent and immediate psychological and psychiatric service in the community were to be provided to their parents. The Conjoint Faculties Research Ethics Board of the University of

Calgary approved a list of these referred service for urgent psychological care. It is to be noted

87 that none of the participants at baseline screening were reported to be engaging in self-harm thoughts or behaviors or harmful behaviours towards the others.

A second ethical consideration is that, given that MBCT is a psychological intervention, participation in MBCT might have subjected participants to sensitive discussions that elicit distress in them. Alternatively, participants’ anxiety might have increased significantly during the course of the intervention for which more one-on-one intensive intervention would have more appropriate. Initially, the practice of mindfulness can also bring increased awareness of distressing thoughts and emotions in children. It is hoped that continued participation in MBCT would teach children to decenter their distressing thoughts and engage in effective self-regulation in order to better cope with their presenting emotional issues (Lee and Semple, 2014). It is important to note, however, that the review of prior research evaluating the present MBCT-C program did not report any cases where participants experienced an extreme level of distress and were required to be terminated from the program (Semple et al., 2005; 2010). Nonetheless, study protocols were developed and implemented to have regular check-ins and a monitoring of participants’ well-being while they took part in the intervention. For example, at the beginning of each session, the intervention implementer checked-in with each participant about their week, anxiety level, events that resonated with them from that week. Similar check-in therapeutic techniques were also implemented to wrap up each group session. Furthermore, the implementer conducted weekly check-ins with parents to inquire about participants’ general well-being in person when participants were getting dropped off or picked up from the intervention.

During the third intervention session, one of the participants demonstrated excessive distress to participate in group exercises (e.g., mindfulness eating, mindfulness body scans, etc.).

When checked in with the participant, she indicated that she was becoming increasingly nervous

88 about doing these exercises in front of her peers due to fears of judgments and negative social perceptions. The participant’s parent also reported an increase in their child’s anxiety in social settings (e.g., asking to leave the playground when other children walked in). At the fifth MBCT session, she appeared very distressed (e.g., crying) and refused to enter the intervention room.

According to the study protocols, the participants were to withdraw if the experience and engagement in the intervention were causing excessive distress. Upon consultation with the researcher’s clinical/research supervisor, the participant was asked to withdraw her participation from the intervention and the study. The parent of the participant reported that she was already seeing a Registered Psychologist once to twice a month. Additional resources for psychological and psychiatric services and supports were also offered.

Chapter Four: Results

Chapter four presents the results of the current study. The chapter initially presents the preliminary results, which includes participant characteristics, reports about the intervention, outcomes of the randomization, data inspection, and description analysis. Afterward, the results obtained from the primary data analysis methods are organized according to specific research questions provided in chapters two and three.

Participants

As noted in chapter three, 27 out of the 40 participants screened met the eligibility criteria to participate in the RCT for the MBCT-C intervention. Demographic characteristics as well as participants levels of anxiety, inattention, hyperactivity depression, and atypical symptoms (i.e., manic symptoms, autism-related symptoms) as reported on parent and self-reports on respective questionnaires (i.e., MASC-2; and the CBRS) are reported in Tables 1 and 2. Pearson’s product correlation was computed to find the correlation between parent- and self-reports of participants’ overall levels of anxiety symptoms on the MASC-2, and the correlation was negative and not significant (r = -0.27, p = .174).

Table 1

Sex and Age Distributions of Twenty-Seven Participants Meeting Eligibility Criteria to Participate in MBCT

N (%)

Sex Females: 16 (59) Males: 11 (41) Age 9 years: 7 (26) 10 years: 11 (41) 11 years 5 (18) 12 years 4 (15)

Table 2

Means, Standard Deviations, and Ranges of T-scores of Anxiety and Social-Emotional and Behavioural Symptoms Reported by the Eligible Participants at Baseline Screening

Parent-reports Self-reports

Symptoms M (SD) Range M (SD) Range

Anxiety 74.00 (7.65) 29.00 63.32 (10.83) 38.00

Inattention 63.95 (10.89) 44.00 58.71 (7.46) 25.00

Hyperactivity 58.11 (8.87) 28.00 53.42 (7.89) 25.00

Depression 65.36 (12.15) 48.00 59.06 (7.68) 21.00

Manic episode 62.78 (12.15) 48.00 56.23 (7.14) 21.00

Autism 58.94 (8.95) 34.00 n/a n/a Spectrum Disorder Note. n/a = not available. T-scores of anxiety symptoms were measured from the MASC-2, and the T-scores of the remaining social-emotional and behavioral symptoms were measured from CBRS. On both CBRS and MASC-2, a T-score of 65 and higher is interpreted to be elevated. The CBRS self-report measure does not have a sub-scale for autism spectrum disorder.

Determining eligibility. Parent- and self-reports of the MASC-2, as pairs, were examined to determine participants’ eligibility for the study intervention. Out of the 27 pairs, there were 11 pairs (41%) in which both the parent- and self-reports of MASC-2 indicated overall anxiety symptoms within the elevated to the very elevated range. In one pair, the child reported an elevated range of overall anxiety symptoms on the MASC-2, but the parent-reported anxiety symptoms for the child was in the high average range. In the remaining 15 pairs (56%), parents reported overall anxiety symptoms for the child in the elevated to the very elevated range, but the children’s reported anxiety symptoms were below those ranges.

Preliminary Analysis

Intervention participants vs. waitlist controls. Randomization was conducted with 25 participants. The chi-squared test showed no significant difference in age and sex distributions between the intervention and the control group, χ2 = (3, n = 25) = 7.38, p = .061. Table 3 further reports the age and sex distribution of participants in each of the two groups. Independent samples t-tests were also computed to analyze the mean consistencies in the levels of anxiety symptoms between the intervention and the control groups after randomization; these mean values are reported in Table 4. For parent-reports, there was no significant difference between the two groups after randomization, t (23) = 0.36, p = .723, d = 0.11. Similar observation was also seen for self-reports of the overall anxiety symptoms between the two groups, t (23) = -

0.21, p = .834, d = 0.09.

Table 3

Age and Sex Distributions of Intervention Participants and Waitlist Controls after Randomization

Intervention Participants Waitlist Controls n n Sex Females: 7 Females: 8 Males: 5 Males: 5

Age Age 9: 3 Age 9: 4 Age 10: 5 Age 10: 5 Age 11: 3 Age 11: 2 Age 12: 2 Age 12: 2

Intervention

Intervention attendance. Eleven out of the 12 intervention participants completed the

12-week MBCT. Therefore, the attrition rate for the intervention was about 8%. As reported in chapter three, one participant was withdrawn from the intervention in Week 5. Out of the 11

92 intervention completers, 6 of them attended all twelve sessions. Two of the 11 participants missed only one out of the twelve intervention sessions, while another 2 participants missed two sessions. Finally, one of the 11 participants missed three of the twelve intervention sessions.

Intervention fidelity. As noted in chapter three, there were two intervention groups; one group attended morning sessions, and the second group attended afternoon sessions. Adherence was tracked for each session in the groups. The maximum score that can be obtained for adherence to the MBCT-C Adherence Scale is 40. There is only one general adherence scale currently available for all twelve sessions, and it is important to note that there are some items

(e.g., teaching about choice-points, learning to commit to self-compassion) on this scale that are not applicable or relevant for all sessions, particularly the earlier sessions in the intervention program. Therefore, there was variability in scored adherence across sessions. The adherence score for the morning (M = 28.83, SD = 7.96) and the afternoon (M = 26.67, SD = 7.85) groups ranged between 14 and 40.

Data Inspection and Descriptive Analyses

Tables 4 and 5 provide description information of the study variables. The study variables were inspected for their normality to determine whether parametric tests could be conducted using the variables. To inspect their normality, the skewness and kurtosis of each variable, along with their histograms and boxplots, were evaluated to see whether they fall within the acceptable ranges (Tabachnick & Fidell, 2007). The study data corresponding to each of the variables was closely examined to see whether each of the variable data set had any outliers. The respective z- values for all study variables were lower than z = +/-3.29, which is considered to be the cut-off to identify extreme outliers (Tabachnick & Fidell, 2007). Overall, all the variables were deemed to

93 meeting the normality assumptions, and hence, parametric tests were conducted to answer the research questions of the study.

Table 4

Descriptive Information of the Primary Study Variable: Anxiety Symptoms Measured at Different Time Intervals

n M SD Minimum Maximum Skewness Kurtosis

Intervention Participants Parent- Baseline 11 74.36 7.90 65.00 87.00 0.51 -0.87 reports screening Post- 11 63.09 11.07 38.00 79.00 -0.87 1.81 MBCT MBCT FU 11 61.27 10.30 46.00 79.00 0.40 -0.74

Self- Baseline 11 63.09 9.95 50.00 80.00 0.32 -0.98 reports screening Post- 11 57.36 8.74 45.00 79.00 1.46 3.61 MBCT MBCT FU 11 58.36 9.39 43.00 79.00 0.53 1.86

Waitlist Controls Parent- Baseline 13 73.46 8.00 61.00 90.00 0.50 0.24 reports screening Post- 11 75.64 11.72 57.00 90.00 -0.38 -1.48` MBCT Self- Baseline 13 63.77 12.28 42.00 79.00 -0.31 -0.95 reports screening Post- 8 68.00 13.40 44.00 82.00 -1.14 0.08 MBCT Note: The time-interval, “post-MBCT” for the waitlist controls, refers to the end of the intervention phase. That is, the information was collected when the intervention participants completed their MBCT, and the controls were waiting to receive MBCT; FU = Follow-up.

Table 5

Descriptive Information of the Secondary Study Variables: Mindfulness and Emotional Reactivity Measured at Different Time Intervals

n M SD Minimum Maximum Skewness Kurtosis Mindfulness Pre- 11 3.43 0.72 2.13 4.87 0.21 1.03 MBCT

Mid- 11 4.05 0.65 3.07 4.93 -0.11 -1.42 MBCT

Post- 11 4.50 0.84 2.80 5.46 -0.86 -0.06 MBCT

MBCT 11 4.43 0.75 3.05 5.33 -0.50 -0.68 FU

Emotional Pre- 11 9.55 2.11 5.00 12.00 -0.74 0.85 Sensitivity MBCT

Mid- 11 7.91 2.07 5.00 13.00 1.39 3.42 MBCT

Post- 11 8.73 2.65 5.00 13.00 0.44 -1.07 MBCT

MBCT 11 8.36 2.80 4.00 13.00 0.31 -0.83 FU

Emotional Pre- 11 10.36 2.11 7.00 13.00 -0.28 -1.35 Recovery MBCT

Mid- 11 10.36 4.03 6.00 19.00 1.26 0.84 MBCT

Post- 11 10.09 2.81 7.00 16.00 0.98 0.21 MBCT

MBCT 11 10.72 3.13 8.00 17.00 1.00 -0.09 FU

Emotional Pre- 11 12.00 2.10 9.00 16.00 0.48 -0.34 Impairment MBCT

Mid- 11 11.72 3.38 6.00 18.00 0.36 0.15 MBCT

Post- 11 10.73 3.50 5.00 19.00 1.05 3.03 MBCT

MBCT 11 10.72 3.32 4.00 17.00 -0.31 1.61 FU Note. FU = Follow-up. For mindfulness, averages were calculated from the total MAAS-C raw scores to determine participants’ overall mindfulness awareness. Mindfulness awareness was measured on 6-point scales (1 = almost never, and 6 = almost always). For subscales of emotional reactivity (i.e., emotional sensitivity, emotional recovery, and emotional impairment), scaled scores (ranging between 0 and 19) were obtained using the RSCA. A scaled score of 13 or higher is considered to be heightened emotional reactivity.

Primary Analyses

Primary outcomes: Decreases in anxiety symptoms. Three research questions and corresponding hypotheses were developed with respect to the expected primary outcome of completing MBCT:

1. Do overall anxiety symptoms significantly change in the children participating in 12-

week MBCT from baseline screening to post-intervention?

2. Are the changes seen in overall anxiety symptoms from baseline screening to post-

intervention maintained in the intervention participants at a one-month follow-up?

3. Are the levels of overall anxiety symptoms significantly different between the

intervention and control groups at post-MBCT?

One-way ANOVAs with repeated measures were computed to analyze the changes in the intervention participants’ anxiety symptoms from baseline screening to one-month after completing MBCT. The T-scores indicating the overall level and range of anxiety symptoms on the MASC-2 were used as the dependent variable on these analyses. Individual analyses were computed for parent- and self-reports of anxiety symptoms.

Parent-reports of the intervention participants. Mauchly’s test of sphericity confirmed that the data for parent-reports of anxiety symptoms for intervention participants met the sphericity assumption for a one-way ANOVA with repeated measures as the resulting p-value (p

= .283) was higher than the critical value of .05. The analysis showed that according to parent- reports, intervention participants’ anxiety symptoms significantly decreased from baseline screening to one-month follow-up, F (2, 20) = 9.84, p <0.001, 휂2 = 0.50. The group means of parent-reports of anxiety symptoms and their standard deviations for each of these time intervals are provided in Table 4. Parents of intervention participants reported a significant decrease in anxiety symptoms by 11.27 T-scores (p = .016) from baseline screening to post-MBCT, and an additional, significant decrease of 13.09 T-scores (p = .002) from baseline screening to a one- month follow-up. There were no significant changes in parent-reported anxiety symptoms from post-MBCT to a one-month follow-up, with an overall decrease of 1.81 T-scores (p = .49) between post-MBCT and a one-month follow-up.

Self-reports of the intervention participants. The resulting p-value of Mauchly’s test of sphericity was lower than the critical value of 0.05 (p = .008) for the self-reports of anxiety symptoms data of the intervention group. As such, the Greenhouse-Geisser correction was applied to the degree of freedom to report the analysis for the one-way ANOVA with repeated measures. The analysis revealed no significant changes in overall anxiety symptoms as reported by the intervention participants from baseline screening to a one-month follow-up, F (1.20,

12.04) = 2.45, p = .14, 휂2 = 0.20. Intervention participants reported a group decrease of 5.73 T- scores (p = .092) in anxiety symptoms from baseline screening to post-MBCT, and a decrease of

4.73 T-scores (p = .199) from baseline screening to a one-month follow-up. According to self- reports, the group’s anxiety symptoms increased by 1.00 T-score (p = .445) from post-MBCT to

97 a one-month follow-up. Notably, 5 of the 11 intervention (45%) participants reported overall anxiety symptoms on the MASC-2 at baseline screening that fell within the elevated or every elevated range. At post-MBCT and a one-month follow-up, 4 of the 5 participants’ overall anxiety T-scores were lower than 65, meaning their respective scores were below the elevated range as classified by the MASC-2.

Intervention participants vs. controls. At the end of the intervention phase (post-MBCT),

11 waitlist-control parents reported on their child’s anxiety symptoms. As 2 of the waitlist- control parents did not respond to the researcher to complete the MASC-2 at post-MBCT, it was important to make sure that the “new” control group was equivalent to the intervention group at baseline screening before conducting group analyses for post-MBCT comparisons. An independent t-test revealed that there was no significant mean difference in parent-reports of anxiety symptoms at baseline screening between the intervention (M = 74.36, SD = 7.90) and the new control (M = 73.91, SD = 8.57) groups, t (20) = 1.29, p = .898. For self-reports, 8 waitlist controls reported on their anxiety symptoms at post-MBCT. An additional independent t-test was computed and similarly, no significant mean difference in self-reports of anxiety symptoms between the intervention (M = 63.09, SD = 9.95) and the new control (M = 67.00, SD = 14.89) group was found, t = -0.69, p = .501. The findings from these t-tests suggest that the new control group was not significantly different with respect to the levels of anxiety symptoms reported by the control participants and their parents at baseline screening. Therefore, it was adequate to conduct group comparison analyses at post-MBCT despite the attrition in the control group.

Two-by-two ANOVAs with group allocation (i.e., intervention or control) as the independent factor and anxiety symptoms as the within-subjects factor were individually conducted for parent- and self-reports of anxiety symptoms. For parent-reports of anxiety

98 symptoms, the resulting p-value of the Levine test (p = .921) indicated that the data meets requirements for the homogeneity of variance assumption for a mixed model ANOVA. The analysis did not reveal a main effect for anxiety symptoms, F (1, 20) = 3.46, p = .078, 휂2 = 0.15.

However, there was a significant interaction between the changes in parent-reports of anxiety symptoms from the baseline screening to post-MBCT and group allocation, F (1, 20) = 6.41, p =

.020, 휂2 = 0.24. This analysis was followed up with an independent t-test to compare the mean consistency of overall MASC-2 anxiety symptoms between the intervention and the control group, for parent-reports. The examination of parent-reports indicated the participants in the intervention group (M = 63.09, SD = 11.07) were reported to be experiencing significantly lower levels of anxiety symptoms than the participants in the control group (M = 75.64, SD = 11.72) at post-MBCT, t (20) = -2.58, p = .018, d = 1.11.

For self-reports of anxiety symptoms, the resulting p-value of the Levine test was .097, suggesting that the data also met the requirement for the homogeneity of variance assumption for a mixed model ANOVA. According to the analysis, there was no main effect for changes in anxiety symptoms as reported by all the participants (intervention and control) from the baseline screening to post-MBCT, F (1, 17) = 1.47, p = .24, 휂2 = 0.08. Additionally, no significant interaction was observed between the changes in anxiety symptoms as reported by participants from the baseline screening to post-MBCT and their group allocation, F (1, 17) = 2.97, p = .103,

휂2 = 0.15. The findings obtained from the analysis using self-reports of anxiety symptoms as the within-subject factor are to be interpreted with caution, though. The control group at the end of the intervention phase had 8 participants, a number lower than what was recommended to be the minimum group size on power analysis to detect group differences reasonably.

Secondary outcomes: Changes in mindfulness and emotional reactivity. In this study, two research questions with corresponding hypotheses were proposed that guided the analyses to examine potential changes in the expected secondary outcomes of completing MBCT:

4. How do mindfulness and emotional reactivity change in the intervention participants

at the mid-point (i.e., mid-MBCT) and after completing MBCT?

5. Are the changes seen in mindfulness and emotional reactivity between pre- and post-

MBCT maintained in the intervention participants at a one-month follow-up?

Changes in mindfulness. A one-way ANOVA with repeated measures was performed to examine the changes in mindfulness as perceived by the intervention participants from pre-

MBCT to a one-month follow-up. The total mean score obtained on the MAAS-C was the within-subject factor for the analysis. The resulting p-value of the Mauchly’s test of sphericity was 0.003, suggesting that the mindfulness did not meet the requirement for the sphericity assumption for a one-way ANOVA with repeated measures. Therefore, the Greenhouse-Geisser correction was applied to the degree of freedom to report the results of the analysis. The analysis indicated that the intervention participants perceived significant increases in their mindfulness from pre-MBCT to a one-month follow-up, F (1.66, 16.59) = 9.73, p = .002, 휂2 = 0.49.

Intervention participants reported a significant increase in their mindfulness by 0.61 score (p =

.014) on the MAAS-C from pre- to -mid-MBCT, and significant increases of 1.06 score (p =

.007) and 1.00 score (p = .002) from pre- to -post MBCT, and pre-MBCT to a one-month follow- up, respectively. Mindfulness was reported to be increased by 0.45 score (p = .067) and 0.39 score (p = .073) from mid-to-post-MBCT, and mid-MBCT to a one-month follow-up, respectively. Finally, intervention participants reported an increase of 0.06 score (p = .107) from post-MBCT to a one-month follow-up.

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Changes in emotional reactivity. Three separate one-way ANOVA with repeated measures were computed to analyze the changes in emotional sensitivity, emotional recovery, and emotional impairment, as reported by the intervention participants from pre-MBCT to a one- month follow-up. The total scaled scores obtained from subscales (i.e., Emotional Sensitivity,

Emotional Recovery, and Emotional Impairment) of the REA Scale (Prince-Embury, 2007) were the within-subject factors for the three one-way ANOVA with repeated measures, separately.

The resulting p-values for the Mauchly’s test of sphericity were 0.467, 0.075, and 0.665 for the emotional sensitivity, emotional recovery, and emotional impairment data, respectively.

According to the analysis with the one-way ANOVA with repeated measures, no significant changes in emotional sensitivity was seen from pre-MBCT to one-month follow up, F

(3, 30) =2.82, p = .056, 휂2 = 0.429. Similarly, no significant changes in emotional recovery was found between pre-MBCT to one-month, follow-up, F (3, 30) = 0.32, p = .321, 휂2 = 0.740.

Finally, the intervention participants did not report significant changes in emotional impairment from pre-MBCT to a one-month follow-up, F (3, 30) = 2.97, p = .059, 휂2 = 0.23.

Anxiety, mindfulness, and emotional reactivity. Finally, the sixth research question of the study tested whether the changes observed with either mindfulness or emotional reactivity were related to the decreases with intervention participants’ anxiety symptoms after intervention.

Specifically, the question was:

6. Do the expected changes with mindfulness and emotional reactivity reported by

participants at mid-MBCT, post-MBCT, or a one-month follow-up significantly

correlate with the decreases in their anxiety symptoms at post-MBCT and a one-

month follow-up?

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To address this research question, first, Pearson product-moment correlations were performed between and among all the outcome study variables applicable for each time interval

(see Tables 6, 7, 8, and 9) of the intervention phase. These correlations were intended to provide a preview of how each of the outcome variables related to one another at time interval and how these relationships possibly changed as the intervention progressed. As indicated in Table 6, before starting MBCT, levels of mindfulness, emotional sensitivity, recovery, and impairment reported by participants did not significantly correlate with either parent-or-self-reports of anxiety indicated at baseline screening. The only significant correlation was seen between mindfulness and emotional sensitivity in participants, r = .69, p = .0019. That is, mindfulness reported by participants had a significant, negative correlation with their perceived levels of emotional sensitivity.

Table 6

Correlations before MBCT

Baseline or Pre-MBCT measures 1 2 3 4 5 6

1. Mindfulness - -.53 -.14 -.69* -.43 .29 2. Emotional sensitivity - .40 .34 .35 .27 3. Emotional reactivity - .29 .29 .48 4. Emotional impairment - .29 -.30 5. Self-reported anxiety - -.21 symptoms 6. Parent-reported anxiety - symptoms Note. * p < 0.05.

At mid-MBCT, participants reported on their mindfulness and emotional sensitivity, recovery, and impairment. To recall from chapter three, self-or-parent-reports of anxiety symptoms were not collected then. As seen in Table 7, significant, negative correlations were found between mindfulness and emotional reactivity (r = .-73, p = .010), and emotional

102 impairment. There was also a significant positive correlation between emotional reactivity and emotional impairment as perceived by participants at mid-MBCT (r = .83, p = .002).

Table 7

Correlations at mid-MBCT

Mid-MBCT measures 1 2 3 4

1. Mindfulness - -.15 -.73* -.69* 2. Emotional sensitivity - .23 .21 3. Emotional reactivity - .83** 4. Emotional impairment - Note. * p < 0.05. ** p < 0.001.

After the completion of MBCT, as seen in Table 8, for intervention participants, only significant correlations were seen between their mindfulness and emotional sensitivity (r = .-82, p = .002), and self-reports of anxiety symptoms (r = .67, p = .025), and both of them were negative correlations. At a one-month follow-up (see Table 9), mindfulness had significant, negative correlations with emotional sensitivity (r = .-87, p < .001), self-reports of anxiety symptoms (r = .-80, p = .003), and parent-reports of anxiety symptoms (r = .-74, p = .01).

Furthermore, emotional sensitivity had significant, positive correlations with self-reports (r =

.70, p = .017) and parent-reports (r = .73, p = .011) of anxiety symptoms. Lastly, at a one-month follow-up, emotional impairment had significant, positive correlations with emotional recovery

(r = .66, p = .029) and self-reports of anxiety symptoms (r = .65, p = .031).

Table 8

Correlations at post-MBCT

Post-MBCT measures 1 2 3 4 5 6

1. Mindfulness - -.82** -.28 -.19 -.67* -.05 2. Emotional sensitivity - .33 .29 .53 .18 3. Emotional reactivity - .69 .55 .48 4. Emotional impairment - .51 .06

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5. Self-reported anxiety - .32 symptoms 6. Parent-reported anxiety - symptoms Note. * p < 0.05. ** p < 0.001.

Table 9

Correlations after one-month following MBCT completion

Follow-up MBCT measures 1 2 3 4 5 6

1. Mindfulness - -.87** -.34 -.44 -.80** -.74** 2. Emotional sensitivity - .38 .33 .70* .73* 3. Emotional reactivity - .66* .48 .31 4. Emotional impairment - .65* .10 5. Self-reported anxiety - .50 symptoms 6. Parent-reported anxiety - symptoms Note. * p < 0.05. ** p < 0.001.

Change Analysis. Pearson product-moment correlations with change scores were computed to assess the relationship between the change in a secondary outcome with decreases in the primary outcomes, anxiety symptoms. As described earlier in the chapter, prior analysis revealed that according to the perceptions of the intervention participants, there was a significant growth in their mindfulness from pre- to -mid-MBCT, and this growth was maintained at post-

MBCT and a one-month follow-up. However, there were no significant changes in participants’ reports of their emotional sensitivity, recovery, or impairment during or after MBCT. Thus, change scores were calculated for only one of the tested secondary outcomes, mindfulness (mid-

MBCT to pre-MBCT). Change scores were also calculated for parent- and self-reports of anxiety symptoms (post-MBCT to pre-MBCT). A significant, negative correlation was found between growth in mindfulness from pre- to -mid-MBCT and decreases in anxiety symptoms as reported by participants from pre- to -post-MBCT, r = .65, p = .03. However, the correlation between

104 growth in mindfulness reported by participants from pre- to -mid-MBCT and decreases in parent-reports of anxiety symptoms from pre- to -post-MBCT was not significant, r = .07, p =

.835.

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Chapter Five: Discussion

The present study was undertaken to expand our understanding of MBCT for childhood anxiety. To this end, a randomized controlled trial with waitlist controls was conducted to investigate the effects of MBCT on decreasing anxiety symptoms in children aged 9-12. The study also investigated whether or not participation in MBCT was associated with improvements in children’s mindfulness and emotional reactivity. Lastly, the study also assessed whether possible improvements in children’s mindfulness and emotional reactivity reported while or after completing MBCT were related to changes in their anxiety symptoms as indicated at post-MBCT or a one-month follow-up.

Chapter five discusses the findings from this study with respect to the results obtained from the preliminary and primary analyses (i.e., the study’s research questions, specifically). The chapter then assesses the significance and relevance of the results of the study in terms of their theoretical, empirical, and clinical implications. Next, a discussion of the study’s strengths and limitations are presented, as well as directions for future research and conclusions.

Self- and Parent-Reports of Anxiety and Determining Eligibility

Among participants who were found to be eligible to take part in MBCT, the concordance between parent- and self-reports was weak and not significant. In this sample, at baseline screening, most parents reported greater range and severity of anxiety symptoms for their children on the MASC-2 compared to the range and severity seen on children’s self-reports for their anxiety symptoms. The disagreement between parent- and -self-ratings for child’s anxiety symptoms commonly occurs, and the correlation between the two perspectives is even weaker in clinical samples compared to non-clinical samples (Barbosa et al., 2002; Manassis et al., 2009; Miller et al., 2014; Nauta et al., 2004). In non-clinical samples, younger age (Miller et

106 al., 2014), female sex of the child, lower parental education (Wren et al., 1997), and developmental factors (Manasiss et al., 1997) have been found to be associated with child- reports of their anxiety on rating scales. However, limited research has been done to identify antecedents leading to disagreements of parent- and self-reports of anxiety symptoms in clinical samples.

Manassis et al. (2009) conducted a study with children, aged 8 to 12 years old, with anxiety disorders. They found that depressive symptoms, support-seeking coping style, and maternal psychopathology predicted higher ratings of anxiety symptoms on self-reports. On the other hand, maternal psychopathology and clinician-rated child’s functioning predicted higher ratings of anxiety symptoms on parent-reports. Parents’ psychopathology could bias their perceptions about their children’s anxiety, and hence, parental psychopathology increases the risks for misidentifying non-anxious children as anxious. Simultaneously, it also true that parental psychopathology could increase the child’s genetic vulnerability to develop anxiety symptoms (Manassis et al., 2009). That is, parent ratings may not only be influenced by their biases, but the level of impairments that children are having at home or in school as a result of their presenting anxiety symptoms (i.e., child functioning). However, lone reliance on parent- reports to assess child anxiety holds the risk of missing children with clinical anxiety concerns.

There may be some children who internalize their worries and fears, and they may not openly express their anxiety with parents and teachers (Miller et al., 2014). Therefore, the recommendation is to collect both parent- and self-reports of child anxiety symptoms, as well as to give equal weight to both perspectives when making decisions about assessment, diagnosis, and intervention efficacy (Manassis et al., 2009). Per this recommendation, equal weight was given to parent- and self-reports of anxiety symptoms to determine a participant’s eligibility to

107 take part in this study intervention. Furthermore, parent- and self-reports of anxiety symptoms were also collected at post-intervention and follow-up evaluations to assess the efficacy of

MBCT from both the parent’s and the child's perspective, independently.

Intervention Attendance

Attendance is a crucial component of intervention research (Nock & Ferriter, 2005) and could influence intervention effects and fidelity (Gearing et al., 2011). The number of sessions required to be attended for optimal attendance is moderated by the dosage of the intervention

(Nock & Ferriter, 2005). Semple et al. (2010) suggested that attendance for at least 8 out of the

12 sessions is required to assume that a child has completed the MBCT-C program. Further, 54%

(n = 6) of the intervention participants in this study attended all the 12 sessions, and 91% (n =

10) of participants attended at least 10 of the 12 sessions. Finally, all the participants attended at least 8 of the 12 sessions, and thus, they were all intervention completers and included for the current analyses. Similarly, in the previous evaluations of the MBCT-C program, the percentage of participants completing the intervention was also observed to be high. Specifically, the attendance for intervention completion ranged between 80% to 89% in the previous evaluations of the MBCT-C (Cotton et al., 2016; Esmaeilian et al., 2018; Semple at al., 2010). It is important to note that the 2 of the previous MBCT evaluations (i.e., Esmaeilian et al., 2018; Semple et al.,

2010) took place in schools, which might have influenced stronger attendance rates. In the present study, the intervention was provided at an external site, and parents brought their child to the sessions.

The severity of children’s anxiety disorders could influence children’s intervention attendance (Kendall & Sugarman, 1997). In this study, the sample consisted of participants with elevated to very elevated levels of anxiety symptoms as indicated on the MASC-2, and the

108 presence of an anxiety disorder was not necessary. Hence, it could be that the participants’ severity of their clinical symptoms did not significantly interfere with their participation in the intervention, and thus, they could complete the program. Notably, there was one participant who dropped out as the severity of her socially anxiety symptoms made it increasingly distressing for her to participate in a group environment. This suggests that the severity of anxiety symptoms, may also lead to premature termination in a group MBCT program.

When assessing child therapy attendance, parental factors are important to consider as the child depends on their parent to bring them to the intervention. As such, child therapy researchers propose four parental barriers to regular intervention attendance: 1) facing obstacles and stressors (e.g., parent experiencing issues with their significant others); 2) poor relationship with the therapist; 3) perceptions that the intervention is not relevant; and 4) perceptions that the intervention is too demanding (Kazdin, Holland, & Crowley, 1997). Although this study did not evaluate factors influencing attendance, certain MBCT-C program components (Lee and Semple,

2014) might have affected attendance. For example, many of the parents in this study attended the orientation session at the beginning of the program, where they learned about mindfulness and MBCT. At the session, they also took part in a couple of mindfulness practices that their children were doing at intervention sessions. Finally, the orientation session provided an opportunity for parents to discuss how they could help their children practice and integrate mindfulness into their daily lives. Parents are more likely to have their child complete intervention when they have stronger beliefs that the intervention will be effective (Nock &

Kazdin, 2001). Thus, the orientation activities might have influenced the parents’ perception of the relevance of MBCT to address their child’s concerns. In addition, at baseline screening, the families were asked about their weekly availability, and their availability was considered for

109 scheduling the intervention sessions. The common reasons for missing an intervention session in this study were pre-scheduled vacations and when the child had to attend an extra-curricular activity. Hence, this effort to improve the accessibility of the intervention might have also contributed to more consistent attendance. In the future, researchers should examine parents’ beliefs and perceptions about MBCT and related accessibility factors in order to see their relationships with intervention attendance and outcomes. Examination of factors influencing

MBCT session attendance and their relationships with intervention efficacy will provide a more comprehensive account of MBCT’s acceptability and efficacy.

Intervention Fidelity

Fidelity is an important measure to consider to appropriately interpret intervention effects

(Perepletchikova & Kazdin, 2005). Along with tracking intervention attendance, the researcher measured the fidelity for intervention delivery in this study. Specifically, the researcher (i.e., the interventionist) self-scored the MBCT-C AS (Semple & Sears, 2014) immediately after every session. Previous researchers have not reported their adherence scores for implementing the

MBCT-C program. Furthermore, the program developers did not yet publish details about minimum adherence scores necessary on the MBCT-C AS to demonstrate acceptable fidelity.

That said, it is important to note that the lack of comprehensive guides for intervention fidelity is not unique to MBCT-C, but a concerning gap in the development and implementation of behavioral, social, and psychological interventions (Gearing et al., 2011).

Due to having one general adherence scale for all sessions of the MBCT-C program, adherence scores for some of the sessions could be misleading. For example, item 16 on the

MBCT-C AS asks the scorer to rate how well the implementer emphasized “Choice Points”.

Choice Points was a mindfulness-based strategy that was introduced and discussed with

110 participants in session 8 and onwards. Therefore, before session 8, the scores on that item was 0.

Similarly, there were other items on the MBCT-C AS (e.g., emphasizing commitment to self- care and compassion) that were not applicable for all the sessions and, thus, the total score adherence scores for some of the sessions are misleading. In fact, it appeared that the MBCT-C

AS was developed in a manner where adherence was supposed to increase with each session. In the future, it might be helpful to develop individualized adherence scale for each MBCT-C session. Each MBCT-C session has individualized themes and dedicated activities and discussions. Assessing how well each of the session components is implemented according to the

MBCT-C manualized instructions may be a more helpful measure of the program’s fidelity for delivery.

Primary Intervention Outcomes: Decreases in Anxiety Symptoms

Intervention parents reported significant decreases in the number and severity of their child’s anxiety symptoms from baseline screening to after MBCT. Furthermore, according to intervention parents, decreases with the number and severity of anxiety symptoms seen in children at post-MBCT from baseline screening were maintained after one month. At post-

MBCT, 6 of the 11 participants’ anxiety symptoms were reported to be below the elevated range as classified on the MASC-2 (i.e., T-score below 65). At a one-month follow-up, 7 of the 11 participants were reported to be having levels of anxiety symptoms lower than the elevated range on the MASC-2. Thus, after one month of completing MBCT, according to parent-reports, 64% of the participants were no longer meeting the eligibility criteria implemented in the study to identify needs for the intervention.

On the other hand, according to the MASC-2 self-reports, levels of anxiety symptoms did not significantly change in the intervention group from baseline screening to post-MBCT.

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Additionally, the intervention group did not perceive any significant changes in the levels of their anxiety symptoms from post-MBCT to a one-month follow-up. The levels of anxiety symptoms, as reported by intervention participants, generally declined from baseline screening to post-MBCT and a one-month follow-up, but these decreases were not statistically significant. At baseline screening, the overall group mean for anxiety symptoms on the self-reports was not elevated but close to approaching the elevated range on the MASC-2. Specifically, in the intervention group, 5 out of the 11 children reported elevated to very elevated levels of anxiety symptoms at baseline screening. Therefore, 6 intervention participants did not perceive to be experiencing elevated or very elevated levels of anxiety symptoms before MBCT. Therefore, it was expected that these 6 children were less likely to report significant decreases in their anxiety symptoms at post-MBCT or a one-month follow-up. For the 5 out of 11 children who reported elevated to very elevated levels of anxiety symptoms on the MASC-2 at baseline screening, all of them, except 1, reported anxiety symptoms below the elevated range on the MASC-2 at post-

MBCT and a one-month follow-up. This suggests that children who perceived themselves to be clinically anxious before MBCT, 4 out of 5 of them reported clinically significant decreases in their anxiety symptoms after intervention.

Analyses were also carried out to address the study’s research question as to whether there were significant differences in the level of anxiety symptoms at post-MBCT between the intervention and control groups. According to the MASC-2 parent-reports, control participants did not have a significant change in the levels of their anxiety symptoms while they were waiting to receive MBCT. Moreover, parents of intervention participants reported significantly lower levels of anxiety symptoms for their children at post-MBCT compared to the levels of anxiety symptoms that control parents then reported for their children. The effect size measuring the

112 decreases in the parent-reports of anxiety symptoms from baseline screening to post-MBCT between the two groups was large, according to general, intervention benchmarks assigned to interpret effect sizes (i.e., Cohen’s d; Haase, Waechter, & Solomon, 1982).

Alternatively, when the MASC-2 self-reports were examined for waitlist controls, similar to intervention participants, control participants also did not report significant changes in the level of their anxiety symptoms while they were waiting to receive MBCT. Similarly, according to the MASC-2 self-reports, there were no significant differences in the levels of anxiety symptoms between the intervention and control groups. However, regarding the 6 controls who reported elevated or very elevated levels of anxiety symptoms at baseline screening, their anxiety ratings at post-MBCT remained in the elevated or very elevated range on the MASC-2. In other words, these 6 controls continued to perceive themselves to be elevated in number and range of anxiety symptoms at the end of their wait time.

Previous RCTs examining the effects of MBCT to reduce anxiety symptoms as one of their primary outcomes had only been conducted with children with academic concerns (Semple at al., 2010) and children of divorce (Esmaeilian et al., 2018). Both of these RCTs were open trials, and many of the children in those RCTs were not necessarily having a very severe or elevated number of anxiety symptoms at pre-MBCT. Hence, this is the first RCT of MBCT to the researcher’s knowledge with children who were reported to be having elevated anxious symptoms by their parents and/or themselves. Overall, the findings of the present RCT suggest that when two groups of children with similar levels of anxiety symptom severity were compared, according to parent-reports, children completing MBCT had significantly reduced levels of anxiety symptoms than those who were waiting to receive MBCT.

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It is important to consider that the differences seen in the parent-reports of anxiety symptoms at post-MBCT between the intervention and control groups might not be (or only) due to the effects of MBCT. There might be alternative explanations for these group differences at post-MBCT. For example, intervention parents knew that their child was receiving a psychological intervention (i.e., not blinded by the randomization outcome), and hence, they might have been expecting their child to lessening their anxiety symptoms (Nock & Kazdin,

2001). They might have put increased emphasis or attention to behaviours that were indicative of changes in their child’s anxiety while their child was undergoing MBCT, thus influencing their reports of their child’s anxiety at post-MBCT and a one-month follow-up. On the other hand, waitlist control parents were aware that their child did not receive MBCT, and this could have influenced their expectations and observations of whether their child’s anxiety would decrease at post-MBCT. In efforts to design a more objective evaluation of MBCT’s efficacy, future researchers need to compare the effects of MBCT to reduce anxiety symptoms with active controls or alternative interventions like CBT. In such designs, MBCT and comparison groups would be receiving an intervention, and biases that parents may have when their child receives an intervention versus when they do not, may have less interference on efficacy outcomes.

Additionally, it is important to highlight that intervention participants did not report significant decreases in their anxiety symptoms from baseline screening to post-MBCT and a one-month follow-up. There were also no significant differences in the levels of anxiety symptoms between the two groups at post-MBCT, according to self-reports of anxiety symptoms. In the present study, participants were not required to have a diagnosis of an anxiety disorder, but rather the presence of at least elevated levels of anxiety symptoms as reported by themselves and/or their parents on the MASC-2. In other words, a dimensional rather than a

114 categorical approach was employed in the study to determine participants’ eligibility. The dimensional approach was utilized, since the primary purpose of the study was to investigate whether MBCT is efficacious to reduce anxiety symptoms, rather than to treat anxiety disorders.

In addition, anxiety severity indicated by at least one rater (either the parent or the child) was sufficient to determine eligibility. As a result of these study methods, the study sample became heterogeneous in terms of anxiety severity, specifically concerning the levels of anxiety symptoms that children reported to experiencing at baseline screening. To elaborate, about 44% of participants (intervention and control combined) perceived themselves to be having elevated levels of anxiety symptoms on the MASC-2 at baseline screening, while the remaining did not.

Although there was some heterogeneity in anxiety severity reported by parents, the range of anxiety symptoms reported for the child was much narrower at baseline screening. All parents

(intervention and controls) except one agreed that their child was experiencing at least elevated levels of anxiety symptoms at baseline screening. As such, factors like heterogeneity in anxiety severity and small sample size might have had additive influences on the pattern of the results obtained for before/after intervention and group comparison analyses with self-reports.

Moreover, age can also influence a child’s perception of anxiety severity. Generally, emotional awareness is expected to grow with age and development (Veriman, Brouwers, &

Fontaine, 2011). In a previous MBCT evaluation, significant decreases in self-reports of childhood anxiety were found with an older sample (i.e., M age = 13.20; Cotton et al., 2016).

Participants in Cotton et al.’s (2016) might have had more advanced awareness of their emotions and their changes. Furthermore, some parents in the current sample might have mental health concerns. Previous research findings (e.g., Manassis et al., 2009) suggest that parents with anxiety disorders and related psychopathologies could be hypersensitive to their child’s

115 challenges and perceive them to be more severe than they truly are. Therefore, parental psychopathology could influence how severely parents rate their child’s anxiety symptoms, providing another alternative rationale as to why inconsistencies between parent- and self-reports of anxiety symptoms was found in this study. To discern the inconsistencies between parent and child ratings of anxiety symptoms, previous researchers have often employed clinician ratings of anxiety as an additional outcome variable to assess the effects of interventions (e.g., Cotton et al.,

2016; James et al., 2015). In line with this, it is recommended that clinician ratings of anxiety symptoms should be integrated with self- and parent-reports of anxiety to examine the effects of

MBCT more comprehensively, from multiple perspectives.

Secondary Intervention Outcomes and Changes

Mindfulness. The present study also evaluated whether children reported to be having elevated to very elevated levels of anxiety symptoms on the MASC-2 also enhanced their mindfulness after completing MBCT, and whether this growth was evident as early as mid-

MBCT. In line with the hypothesis proposed, the findings suggest that in the perceptions of intervention participants, they had significant growth in their mindfulness from pre- to -post-

MBCT, and this growth was maintained at a one-month follow-up. Specifically, intervention participants perceived significant growth in their mindfulness on the MAAS-C as early as mid-

MBCT, after completing six sessions of the MBCT-C program (Lee & Semple, 2014). Notably, no significant growth in mindfulness was found between mid-MBCT to post-MBCT or a one- month follow-up, or post-MBCT to a one-month follow-up. These findings suggest that according to intervention participants, participation in MBCT helped them to gain greater awareness of 1) their thoughts, emotions, and bodily sensations at different situations, 2) being in the present moment with more openness, and 3) noticing and reducing tendencies of being on

116 automatic pilot mode. The MAAS-C assesses these listed aspects of mindfulness (Lawlor et al.,

2014). The findings align well with previous research that suggested mindfulness is also a secondary outcome associated with completed MBCT in children and adolescents (e.g.,

Esmaeilian et al., 2018; Racey et al., 2018).

It is of interest that intervention participants reported significant growth in mindfulness as early as mid-MBCT. In the first six weeks of the MBCT-C program (Lee and Semple, 2014), participants took part in various mindfulness-focused program activities such as learning to eat and walk mindfully, as well as listening to sounds and music mindfully (Lee and Semple, 2014).

A three-minute breathing space (Lee & Semple, 2014), which is common MBCT practice, was introduced to participants and repeated at every session for a few times, and participants were also encouraged to do this practice as frequently needed and preferred outside the sessions.

Participants were also introduced to the concept of how thoughts, emotions, and bodily sensations are interconnected, and most of the mindfulness practices were followed by discussions emphasizing the thoughts, emotions, and bodily sensations that arise from these practices. Furthermore, while doing these mindfulness practices, participants were taught to take notice of when their mind wandered off to past or future situations or even judging the practice, and then bringing their awareness to the present practice (Lee and Semple, 2014). Considering that the growth in mindfulness in intervention participants largely occurred in the first six weeks of the MBCT-C program, at least according to the perceptions of the participants, this finding presents preliminary support that the program activities described here may be efficacious to teach children about mindfulness, and they may also have beneficial effects on children’s mindfulness growth.

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Mindfulness and self-reports of anxiety. The study also examined whether the changes in intervention participants’ perceived growth in mindfulness were related to the changes that they reported with levels of their anxiety symptoms. In addressing this research question, initially, the correlations between all outcome measures, including mindfulness, were computed for each time interval: before intervention, mid-intervention, after intervention, and a one-month follow-up. The parent-reports of anxiety were also considered for the correlational analyses to see whether participants’ perceived growth in mindfulness had any relation to children’s fears, worries, and behaviours that they potentially exhibited during and after intervention that parents were thought to be referencing to in rating their child’s their anxiety symptoms at post-MBCT and a one-month follow-up. For example, Cotton et al. (2016) used a similar approach, in which the changes in their participants’ mindfulness were examined with the decreases in clinician- rated anxiety at pre- and post-MBCT.

According to the findings of the present study, before beginning MCBT, self-reports of mindfulness did not significantly correlate with either self- or parent-reports of anxiety symptoms reported at baseline screening. That is, the levels of mindfulness perceived by participants did not relate to the number or severity of anxiety symptoms endorsed by themselves or their parents. It is assumed that individuals with anxiety may engage in reduced mindfulness, so teaching them mindfulness may alleviate their distress with anxiety (Hoffman, Sawyer, Witt,

& Oh, 2010). However, in the present study, children’s perception of their mindfulness did not appear to be related to anxiety severity, as endorsed by themselves or their parents before

MBCT. Along with insufficient sampling, assessment issues with mindfulness could have contributed to this result. Goodman et al. (2017) cautioned researchers that children may not have accurate insights into their mindfulness before they learn what mindfulness really is, and

118 hence, the validity of their self-reports of mindfulness may be weak. This makes it challenging to conceptually examine the relationship between mindfulness and anxiety in children prior to any mindful training. In efforts to mitigate this assessment issue, mindfulness measures need to be tested for differential item understanding for different groups of raters (e.g., children with or without mindfulness training) and researchers should make appropriate changes with wording of items to enhance their validity.

At post-MBCT and a one-month follow-up, participants’ reports of mindfulness had a negative, significant correlation with their ratings of anxiety symptoms. That is, after completing the intervention, participants who reported higher levels of mindfulness, were also likely to report fewer number or less severe anxiety symptoms. This relationship between participants reported levels of mindfulness and anxiety symptoms was also maintained at a one-month follow-up. However, to further elucidate the relationship between mindfulness and anxiety for

MBCT in children, change scores for mindfulness and self-reports of anxiety were computed. To elaborate, as significant growth in mindfulness was only found between the pre- and mid-MBCT, change scores for mindfulness were calculated for this time interval. While significant improvements in anxiety on self-reports were not found in the analysis, nevertheless, the decreases in the levels of anxiety symptoms from baseline screening to post-MBCT was clinically meaningful for the “clinical group” (i.e., children who rated themselves to be having at least elevated levels of anxiety symptoms on the MASC-2 at baseline screening). Therefore, change scores were also computed for self-reports of anxiety symptoms from baseline screening to post-MBCT. The analysis with the change scores revealed that according to the perceptions of participants, growth in their mindfulness significantly correlated with decreases in their anxiety symptoms. In other words, some children decreased in their anxiety severity from baseline

119 screening to post-MBCT, and those who did also reported greater growth in their mindfulness from pre- to mid-MBCT. Cotton et al. (2016) found similar findings with respect to improvements in mindfulness and decreases in anxiety severity in their clinically anxious sample after completing MBCT (on both self-reports and clinician-rated anxiety). Cotton et al. also had a very small sample (n = 11), but they argued that a statistically significant correlation between the changes in mindfulness and decreases in anxiety in such a small sample is compelling and supports the notion that mindfulness training may be an important mechanism of action to reduce anxiety symptoms in MBCT.

Mindfulness was measured using the MAAS-C in the present study. The predominant focus of the MAAS-C is to measure the likelihood of a child’s present moment awareness and experience in children, which is an important component of mindfulness (Lawlor et al., 2014).

Hence intervention participants in the study specifically reported growth in their present moment awareness through participating in MBCT. Children with anxiety symptoms are thought to allocate increasing attentional resources scanning for stimuli perceived to be threatening

(Hadwin et al., 2006). Therefore, it is postulated that when participants in the intervention group who enhanced their present-moment awareness, their attention load was reduced that otherwise might have been occupied scanning or thinking about their anxiety-provoking stimuli.

Furthermore, enhanced present-moment awareness might have fostered detached self- observation (i.e., observing thoughts and de-centering with them) as well as reduced tendencies to engage in cognitive reactivity (Sears, 2015). Finally, it is probable that the mindfulness practices learned from MBCT helped the participants to better cope with the somatic symptoms associated with their anxiety symptoms (Kabat-Zinn, 2006). Cotton et al. (2016) reported that participants in their study found the mindfulness breathing techniques to be the most helpful

120 aspect of the MBCT program. Thus, the mindfulness practices taught in the MBCT program (Lee and Semple, 2014) might have also helped participants in the present study to relax their bodily sensations in tolerating the situations that evoked negative affect(s).

It is promising to see that significant improvements in mindfulness were reported to be associated with MBCT in the present study. However, issues with mindfulness assessment could lead to Type-I error in interpreting these results. Goodman et al. (2017) also cautioned that children’s mindfulness ratings after intervention could be biased. During mindfulness interventions, children are essentially taught 1) how they should be engaging with themselves and their environment, 2) how they should be carrying out tasks and activities, and 3) how to be with their thoughts and emotions. In fact, mindfulness questionnaires and interventions tend to use consistent wording to describe the construct (Goodman et al., 2017). After intervention, children may then consequently report on their mindfulness as they deemed to be socially desirable or demanding (Nichols and Maner, 2008). On the other hand, it is also true that mindfulness learning was the central and explicit focus of the intervention (Lee and Semple,

2014). Along with session discussions and dedicated mindfulness activities and exercises, intervention participants were also assigned weekly mindfulness at home practice exercises.

Furthermore, each week, parents received communications as to how they can support their child in carrying out the at home practice exercises. Taken together, it probable that at least some children in the study did learn how to be more mindful. Nevertheless, it will be important to develop and validate second-person reports (e.g., parents, teachers, blind raters) of behaviours found to be associated with mindfulness (Goodman et al., 2017). The integration of multiple perspectives to assess mindfulness will enhance the validity of the data and researchers’ confidence to assert whether interventions such as MBCT truly improves children’s mindfulness.

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Mindfulness and parent-reports of anxiety. A significant correlation between participants’ reports of mindfulness and parents’ reports of anxiety symptoms was only found at a one-month follow-up. One month after completing MBCT, for parents who reported a lesser number or less severe anxiety symptoms, their child was likely to report higher levels of mindfulness. However, the changes reported in mindfulness by participants at mid-MBCT did not significantly correlate with the decreases in their anxiety symptoms that their parents reported at post-MBCT. In other words, decreases in parents’ ratings of their child’s anxiety severity did not relate much with improvements that their child was reporting in their mindfulness. For example, some parents reported a greater decrease in their child’s anxiety from baseline screening to post-MBCT, but that level of decrease was not consistent for how much the child perceived their mindfulness to have grown from pre- to mid-MBCT, and vice-versa. Hence, there might have been other variables that influenced parents’ perception in the study that their child’s anxiety symptoms decreased from baseline screening to post-MBCT. Haydicky, Wiener, and Shecter (2017) conducted qualitative interviews with parents of adolescents aged 13-17 with

ADHD to examine their experiences of having their adolescents undergo a mindfulness-based psychotherapy. According to the themes observed in the parents’ interview responses, parents saw increased self-awareness and self-regulation in their adolescents, and parents thought that these changes contributed to behavioural changes in their adolescents (e.g., showing empathy, improved communication and better conflict management skills with parents). Theoretically, it is assumed that present-moment awareness would also modulate improvements in self-regulation in children (Kaunhoven & Dorjee, 2017), and these are anchors, that parents may use to rate the severity of their child’s psychological concerns. However, use of only parent- and self-reports makes it uncertain as to how parents decided on the ratings of their child’s anxiety. Therefore,

122 integration of supplemental interviews with parents after intervention could provide a more comprehensive account of how and why they perceived their child benefited from MBCT. In addition, variables such as children’s self-regulation, and display of empathy and compassion could also be measured quantitatively by using parent-reports before, during, and after MBCT to see how the changes in those variables relate to the decreases in anxiety that parents report for their child. Integration of interviews and measurement of behavioural changes would enhance our understanding as to what influences parents’ perception about the effects of MBCT on their child, specifically on the child’s anxiety.

Emotional reactivity. The present study also investigated whether children with elevated to very elevated levels of anxiety symptoms reduced their emotional reactivity while and after completing MBCT. To do so, the subscales emotional sensitivity, recovery, and impairment making up the overarching construct of emotional reactivity, as measured on the REA Scale of the RSCA were examined. Contrary to what was hypothesized, intervention participants did not report significant changes with their emotional sensitivity, reactivity, or impairment from pre- to post-MBCT. Furthermore, no significant changes in emotional sensitivity, reactivity, and impairment were reported between post-MBCT and a one-month follow-up.

At pre-MBCT, the intervention group means for emotional sensitivity, recovery, and impairments for intervention participants fell in the “ average” range as classified by the RSCA developers (Prince-Embury, 2007). A scaled score between 8 to 12 is considered to be average.

Average mean scores endorsed for all the components of the emotional reactivity at pre-MBCT suggests that as a group, intervention participants did not perceive their emotional sensitivity, recovery, or impairment to be heightened before intervention. Hence, from measurement perspectives, there was not much room for the emotional reactivity variables to decrease as a

123 result of participation in MBCT, since they were not deemed to be a significant concern in the perception of intervention participants. Consistently, the group intervention averages for emotional sensitivity, recovery, and impairment remained in the average range at post-MBCT and a one-month follow-up. There may be two main reasons as to why no significant changes in emotional reactivity were found in the study: 1) participants’ anxiety was not severe enough to have accompanied heightened emotional reactivity, and 2) emotional reactivity was not measured comprehensively.

First, the study sample was not required to have a diagnosis of an anxiety disorder, but just elevated or very elevated levels of anxiety symptoms as endorsed by the child or the parent.

Theoretical rationales, accompanied by empirical data, support the notion that heightened emotional reactivity can be an important clinical feature of anxiety disorders in children (e.g.,

Bogels & Zigterman, 2000; Carthy et al., 2010). Specifically, it is theorized that heightened emotional reactivity may predict the presence of behavioural problems associated with anxiety disorders: escape or avoidance (Carthy et al., 2010). The thought of encountering anxiety- provoking stimuli is so intense and prolonged, and it causes so much impairment, that it drives children to avoid or escape the stimuli. The avoidance or escape from the anxiety-provoking stimuli then reduces emotional reactivity. For the diagnosis of most anxiety disorders in children, escape, or avoidant behaviours are necessary to be present in them for a specified time interval

(APA, 2013). Although elevated or very elevated T-scores on the MASC-2 indicates that the child has a greater probability of having one or more anxiety disorders (March, 2012), participants or their parents in the study were not comprehensively assessed through a clinical interview to verify whether the participating children also had escape or avoidant behaviours relating to their anxiety symptoms to warrant a diagnosis of an anxiety disorder. Hence, it is

124 possible that the range and level of anxiety symptoms of participants in the study was not severe enough to manifest into escape or avoidant behaviours, explaining why they might not also have heightened emotional reactivity. Anxiety severity of children then likely influences whether improvements in emotional reactivity would be a secondary outcome in MBCT.

Second, emotional reactivity has been previously measured both objectively and subjectively in adults and children (Nock et al., 2008). In addition to using self-reports, many researchers have used neuroimaging and performance-based measures to assess emotional reactivity in children with anxiety symptoms or disorders (e.g., Killgore & Yurgelun-Todd,

2005; Weems et al., 2005). A different pattern of findings might have been seen for the present study if a performance-based measure (e.g., assessing participants’ emotional reactions in response to presentation of threatening stimuli) was used to monitor changes in emotional reactivity in participants while and after participating in MBCT. While they come with their own respective limitations (e.g., ecological validity), neuroimaging and performance-based measures reduce the demands of self-perceptive biases and development of emotional awareness that may influence responses on self-reports of emotional reactivity (Isquith, Roth, & Gioia, 2013).

In the literature for MBCT for childhood anxiety, so far, only Cotton et al. (2016) and

Strawn et al. (2016) so far have examined changes in participants’ emotional experience as they undergo MBCT. Cotton et al. (2016) used parent-reports rather than self-reports to assess changes in emotion regulation skills in participants from pre- to post-MBCT. They found that, according to parents, participants significantly improved their emotion regulation skills from pre- to post-MBCT. However, improvements in emotion regulation did not correlate with decreases reported in anxiety symptoms by participants or clinicians. Thus, they recommended integrating performance-based and neuroimaging measures to more fully understand how changes in

125 emotional regulation may influence changes in anxiety after participating in MBCT. In line with that, Strawn et al. (2016) recruited nine participants from the Cotton et al. (2016) study while they were undergoing MBCT. Strawn et al. (2016) found that after MBCT, decreases in participants’ anxiety were correlated with change in activation levels in the brain regions known for cognitive and emotional processing. In the same participants, there was inconsistency in how changes in parent-reported emotional regulation versus changes in neurological activation levels correlated with decreases in anxiety after MBCT. Findings seen in these two studies alone highlight the challenges in interpreting changes in emotional experience in children and adolescents. It is important to have extended analysis to compare the reliability and validity of each of these measurement approaches (e.g., neuroimaging, stress tasks, self-reports) to guide researchers and clinicians of the best practices to evaluate emotional reactivity and overall emotional experience in children and adolescents to make decisions about assessment, and intervention efficacy.

Theoretical, Empirical, and Clinical Implications

During the past two decades, the science of psychology saw an emergence of mindfulness psychology, a new field for research and practice. We saw an exponential surge in the development and evaluations of mindfulness-based interventions in clinical and community settings (Felver et al., 2013). However, research on the evaluations of mindfulness-based psychotherapeutic interventions has been predominantly focused on adult populations. Despite the paucity of research in child-focused mindfulness interventions, moderate to large effect sizes seen in clinical trials of mindfulness interventions with adults, as well as adaptation of adult- based mindfulness interventions for children and adolescents have led to enthusiasm among mental health practitioners, agencies, and schools to implement mindfulness-based interventions

126 with children and adolescents as well (Felver et al., 2013). This enthusiasm and efforts to do mindfulness with children faced criticisms – e.g., some researchers warning that the new mindfulness interventions are ahead of the research (Chadwick & Gelbar, 2016). In other words, according to some researchers, we might be raising ethical and clinical concerns by implementing interventions with children, even if lacking sufficient empirical evidence.

Therefore, studies such as the current one is important to extend the literature and provide empirical insights into a mindfulness-based intervention, such as MBCT, with children. Similar to the previous adult trials for mindfulness-based interventions (Hoffman et al., 2010), a large effect size was also found in this study when the effects of MBCT to reduce childhood anxiety symptoms was compared with waitlist controls, from the perspectives of parents. Therefore, this study adds to the body of literature, suggesting that MBCT may be a promising intervention to help children better manage their anxiety symptoms. At the same time, it is also important to acknowledge that the evidence for MBCT for use with children with anxiety symptoms is still emerging. Future evaluations of MBCT are highly encouraged to develop a stronger research base for the intervention.

The present evaluation of MBCT also pointed to certain considerations that practitioners, clinics, and agencies need to consider when deciding whether clinically anxious children should receive MBCT. First, fidelity of MBCT is largely dependent on how well the implementers are trained and have access to clinical supervision and consultation if needed. The intervention effects of MBCT can be misinterpreted if it is not implemented with appropriate fidelity, training, and experience. Hence, clinics, schools, and agencies need to consider their clinicians’ preparedness and resources first before deciding whether they can provide MBCT services for children.

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Second, child-specific factors must also be considered when deciding whether MBCT is appropriate for a clinically anxious child (Chadwick & Gelbar, 2016). There may be a subset of clinically anxious children who may benefit more from MBCT. Many intervention participants shared in sessions that they opted to use mindfulness-based practices to relax their physiological states in situations that they deemed to be stress-or-anxiety-provoking. A common mindfulness- based practice that participants indicated engaging in was the three-minute breathing space (Lee

& Semple, 2014). The researcher did not collect this information to address a study question.

That said, the shared experiences of participants shed light on a possible “active ingredient” that might have been driving the changes in anxiety severity through participation in MBCT. This observation and sharing align with previous research findings in MBCT. For example, previous

MBCT participants reported that they most enjoyed doing mindfulness breathing and related body-based sensory activities in sessions (Cotton et al., 2016). In the development of MBCT,

Kabat-Zinn (2006) argued that mindfulness activities engage and ground our senses. Grounding of our senses, coupled with slow and deep breathing, balance our sympathetic and parasympathetic responses arising from anxiety-provoking stimuli. Mindfulness practices likely then help to alleviate physiological symptoms and responses that manifest out of anxiety. Hence, children with anxiety-related issues who have more or severe physiological symptoms may particularly benefit from MBCT.

Furthermore, mindfulness activities taught and practiced in sessions may also be helpful coping strategies that children learn from participating in MBCT. In the present study, growth in mindfulness significantly correlated with decreases in anxiety symptoms. It is possible that being equipped with this coping strategy enhances children’s confidence and ability to face anxiety- provoking stimuli and reduce the severity of their anxiety. These body-based and sensory

128 activities are less cognitively demanding than cognitive coping strategies (e.g., cognitive restructuring) taught in traditional CBT interventions (Lee and Semple, 2014). As such, these mindfulness practices may also be more accessible to neuro-diverse children struggling with anxiety. However, we need future MBCT investigations that utilize multimodal approaches to test out these theoretical rationales. For example, it will be helpful to conduct interviews with

MBCT participants to evaluate how diverse children use their learned mindfulness strategies to cope with their anxiety. Research designs will be enhanced if children’s use of mindfulness to cope are also measured using self-reports and parent and teacher interviews. Such investigations will discern as to whether mindfulness is an active ingredient or a mechanism of action in MBCT with greater validity.

Another anxiety symptom that may have increased relevance for MBCT is excessive and uncontrollable worries, a central feature of GAD. MBCT aims to reduce cognitive reactivity

(Cladder-Micus et al., 2018; Raes, Dewulf, Van Heeringen. & Williams, 2009). MBCT participants learn to observe the flow of thoughts and decenter their relationship with them. In other words, thoughts are assumed to become objective rather than having subjective connotations attached to them (Sears, 2015). Wells (2006) argues that this mindfulness-based cognitive strategy allows MBCT participants to become aware that worries (a cognitive exercise) can also be controlled. Children with GAD believe that worries are uncontrollable, and this maladaptive belief further escalates their negative affect. Practicing mindfulness likely then help children also to become aware that thoughts and worries are not permanent (Sears, 2015).

Furthermore, as they learn more cognitive strategies to decenter the relationship with thoughts and worries, their negative affect may also reduce that arise from over-thinking and excessive worries. In the present study, participants expressed their excitement using some of the

129 metaphors taught in MBCT (Lee and Semple, 2014) to observe thoughts objectively and to decenter their relationship with thoughts. They shared that the metaphors helped them to better understand how to explore, navigate, and accept distressing thoughts about their anxiety.

However, to truly understand whether these cognitive strategies taught to children as metaphors are an active ingredient of MBCT for childhood anxiety, more systematic evaluations are warranted. Specifically, researchers should evaluate the acceptability, utility, and efficacy of these cognitive coping strategies with respect to intervention outcomes for MBCT. For example, conducting individual interviews with children during and after completing MBCT will provide further insights into how they were using their cognitive coping strategies to cope with their anxiety-related issues.

On the other hand, MBCT might not be appropriate for every child struggling with elevated anxiety symptoms. Mindfulness has been said to be a type of metacognitive strategy

(Satlof-Bedrick & Johnson, 2015). Developmental and cognitive capacities may vary children's ability to learn and integrate mindfulness into their daily lives. Thus, it will be important to assess children’s developmental milestones and cognitive functioning to decide their readiness to participate to gain optimized outcomes from MBCT.

Third, findings from this study also highlight important implications for the measurement of emotional reactivity in clinical research designs. Previous researchers (e.g., Cotton et al.,

2016; Nock et al., 2008; Strawn et al., 2016) have discussed the challenges of measuring emotional reactivity in children, and these researchers have also highlighted the inconsistency in its severity across raters and measures. Therefore, there is an increasing need for clinical research designs to incorporate multiple perspectives and approaches to measure emotional reactivity in children and to compare their strengths and weaknesses. Along with self-reports of emotional

130 reactivity, researchers are recommended to incorporate objective tasks to measure emotional reactivity in children. For example, children could be exposed to their anxiety-provoking stimuli and then asked to rate their emotional reaction and experience multiple times before, during, and after the exposure. Britton et al. (2012) took a similar approach to measure emotional reactivity in adults struggling with anxiety and depression. Furthermore, parent, teacher, and clinician observations of children’s emotional experiences should be incorporated in research designs to strengthen the validity of emotional reactivity measurement in children. For example, researchers can provide to parents and teachers scenarios that are known to provoke anxiety in the child.

Then parents and teachers can report how the child overly respond to those situations to get a better sense of the child’s emotional reactivity. The same scenario can also be presented with the child to examine how they perceive to emotionally react to the stressor. Furthermore, such approaches to measure emotional reactivity are to be conducted longitudinally and with different age groups. Longitudinal and developmental designs will enhance our understanding as to when

(i.e., developmental stage) reporting of emotional reactivity between the observer (e.g., the parent) and the child become more consistent. Along with allowing to measure emotional reactivity with increased validity, such longitudinal and developmental research designs will provide additional insights into emotional awareness and development in children across childhood and adolescence.

Implications for mindfulness programming in schools. The findings from this study provide further empirical support that mindfulness could be a helpful practice for children to use in better managing their anxiety symptoms. Based on the study design, we can only acknowledge that an at-risk sample (i.e., only elevated anxiety symptoms, no confirmation of a disorder)

131 received MBCT. Therefore, these findings provide some support for the argument as to why mindfulness-based programming may benefit at-risk students in schools.

One in five children and adolescents report significant mental health difficulties during their school years (Alberta Education, 2017). Mental health difficulties may cause significant interference in the child’s ability to regularly attend to and actively engage in the learning process. Therefore, a focus for schools in recent years has been to address mental health difficulties in students (Carsley et al., 2018). It is a well-accepted notion that it is not feasible or practical to provide intensive, mental health care in schools. Intensive mental health programming requires individual planning and treatment. A student who is responsible for full- time learning at school may not have adequate opportunities or for the time to participate in intensive mental health care at school. Intensive care is then limited to tertiary settings (Reynolds

& Gutkin, 2009). However, many school mental health researchers and clinicians argue that schools present an ideal setting to provide universal and targeted mental health care and prevention with students (School Mental Health Ontario, 2019).

Within the past decade, many studies have evaluated the impact of mindfulness programming with typical and at-risk student populations (e.g., Felver et al., 2016; McKeering &

Hwang, 2019). These evaluations highlight the potential of mindfulness programming to improve mental health outcomes including decreases in anxiety and emotional regulation. As we move towards scaling up mindfulness programming in schools, different stakeholders need to consider the supports that schools need to sustain the implementation of these programs (Carsley et al., 2018). To support stakeholders who make these decisions, research on school-based mindfulness programming needs to shift its focus as well. Specifically, research now needs to focus on school and student factors that moderate outcomes of school-based MBIs as well as

132 system-level evaluations to map out successes, challenges, and barriers to implementing these interventions in schools.

Carsley et al. (2018) published one of the first studies to answer some of the abovementioned questions regarding moderators and system-level challenges of MBIs in schools. In their meta-analysis, their findings revealed that mental health outcomes from the mindfulness programs differed according to whether the intervention was provided by a trained teacher or an external mindfulness practitioner. To elaborate, their findings suggested that there were significant effects at follow-up evaluations when trained teachers implemented the MBI instead of external facilitators. This finding is critical to understanding the structure of delivering

MBIs in schools. Teachers remain in the classroom upon completion of the program (the external facilitator does not), and hence, teachers probably provide more opportunities for students to practice mindfulness activities. It is important to note that this effect was only seen for teachers who underwent training for the specific MBI. This finding has two implications. One, even if an external facilitator (e.g., school psychologist) implements a targeted MBI with at-risk students in schools, the intervention would likely have more sustaining effect if they continue to have booster sessions with students after program completion. Second, teachers who received structured training are likely to enhance the outcomes of MBIs in students. Trained teachers are more familiar with the MBI. They are likely to integrate components of the MBI in students’ daily classroom routines after program completion, thus, leading to continued benefits for students (Britton et al., 2014). Therefore, schools need to invest in structured teacher training for the MBIs that they would like to implement. In line with that, continuous consultation and booster training will also likely enhance teachers’ capacity to augment and sustain the outcomes of MBIs in students. From a feasibility stand-point then, implementation of MBIs will require

133 more funds and resources for schools. For example, teachers need time off from their teaching to attend training, consultations, and booster sessions (e.g., substitute teachers will be needed).

Additionally, schools need to hire trainers and consultants to support teachers.

Targeted MBIs, like the one conducted in this study, are usually provided by licensed mental health clinicians in schools (e.g., school psychologists). While mindfulness training has been embedded in clinical and counselling psychology training programs in North America, it has received less attention in school psychology programs (Felver et al., 2013). As such, school psychologists implementing targeted MBIs in schools may also need specific training, supervision, and consultation. School boards will then need to consider whether this structure of service delivery is feasible due to increased costs and resources associated with providing supervisions to clinicians. That said, the popularity of MBIs should encourage school psychology graduate programs to train their students in mindfulness, MBCT, and related interventions

(Felver et al., 2013). Clinical training and experiences with mindfulness will well position school psychologists to support the implementation of MBIs in schools and, ultimately, enhance students’ mental health outcomes.

Strengths

The present study has some strengths that warrant discussion. Research in the area of

MBCT for childhood anxiety is its infancy, evident by the fact that only four studies have been published in the literature thus far. Hence, this study strengthens the research base of MBCT for childhood anxiety and provides additional insights of MBCT’s effects on decreasing anxiety symptoms in children. The study compared the efficacy of MBCT in comparison to another group of children with similar levels of anxiety symptoms as reported by parents. Then, the study attempted to move the field forward in understanding whether mindfulness and emotional

134 reactivity could be possible mechanisms of action for MBCT to reduce childhood anxiety. In his criteria to identify mechanisms of action for interventions, Kazdin (2007, 2009) recommends that the proposed mechanisms be measured at multiple time intervals during the intervention period to establish that change in the mechanisms precedes the change in the outcome. In line with

Kazdin’s recommendation, the proposed mechanisms were measured at mid-MBCT, along with being measured at pre-MBCT, post-MBCT, and a one-month follow-up. Furthermore, measuring mindfulness during MBCT provided very preliminary evidence about the benefits of specific therapeutic activities of the MBCT-C program (Lee and Semple, 2014) to improve mindfulness in children.

Limitations and their Implications

With respect to this study’s limitations, there are four notable limitations to mention.

First, the study had a small sample size. While efforts were made to recruit a larger sample (by contacting several schools in the Calgary area to disseminate information about the research intervention), the response rate from schools was only about 21%. Nonetheless, a larger sample size would have allowed the researcher to conduct mediational analysis to examine whether the improvements in the secondary outcomes predicted the decreases in childhood anxiety symptoms in the study, thus strengthening the rigor of the results. A larger sample also would have allowed to have control for additional covariates when creating the intervention and the waitlist groups for randomization. If additional covariates were incorporated to create matched pairs, then we would have had greater confidence in concluding that the differences seen between the two groups in this study were due to the effects of MBCT. Taken together, findings obtained with a larger sample size would have enhanced the reliability and validity of the current findings and

135 improved their applicability of implementing MBCT for childhood anxiety in clinical and community settings.

Second, it is important to highlight that the researcher did not collect any demographic information from participants. Examples of common demographic variables include socioeconomic status (SES) of participating families, marital status of participants’ parents, as well as parents’ education. Demographic information is important in describing study samples, as well as in discerning how generalizable the research findings are for diverse child and family populations. To elaborate, demographic variables could influence parental engagement (e.g., having time to bring their child to intervention session, working with the child to do home practices). Parental engagement could impact children’s participation and intervention outcomes

(Kazdin et al., 1997).

In the present study, the attendance rate was high. It might have been easier for families of certain socio-economic statuses and marital statuses to commit to bringing their child to the intervention regularly. Furthermore, families of certain educational background or SES could also be drawn to interventions for their children, that if those interventions received increased public and media attention in recent times (Kazdin & Nock, 2001). Parents of certain educational and socio-economical privileges may be better equipped to navigate and be aware of existing and emerging resources to help their child with anxiety-related issues. Therefore, demographic information is important to collect to analyze the barriers that may be associated with intervention accessibility and acceptability, as they can moderate intervention effects in children

(Sekhon, Cartwright, & Francis, 2017). Hence, future researchers are advised to measure participant demographics in future evaluations of MBCT with children.

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Third, the study did not incorporate clinician-rated anxiety to determine intervention eligibility or efficacy. Considering the inconsistencies seen between the parent- and self reports of anxiety symptoms on the MASC-2 at baseline screening, a trained clinician could have assessed participants’ severity and range of anxiety symptoms using a clinician-rated scale (e.g.,

PARS; RUPP., 2002) at different time intervals of the study. Typically, in an RCT design, the clinician (i.e., the assessor) assessing for symptom severity is recommended to be ‘blinded.’ That is, the assessor is not to be aware of the participant's group allocation, and the assessor is not to provide the study intervention (Portney & Watkins, 2000). Having access to participant’s group allocation information and being involved in the implementation of the intervention could explicitly or implicitly bias the assessor’s judgement on interpreting the information received during interviews, ˗ e.g., as the assessor completes rating scales (Page & Persch, 2013). In the present study, the researcher conducted baseline screenings as well as implemented the intervention. Additionally, the researcher was not affiliated with any pediatric or mental health clinics and did not have access or support of secondary, well-trained clinicians to perform clinician-rating scales to identify participants presenting with anxiety symptoms. Therefore, self- reports were used to assess symptom severity. Nevertheless, this an important limitation to highlight for the study.

While the MASC-2 has shown to have good psychometrics to measure anxiety symptoms in children, it does not measure the degree of impairments relating to experiencing the rated anxiety symptoms (Fraccaro et al., 2015). That said, this is not unique to MASC-2 but applies to, most, if not all, symptom inventories for childhood anxiety symptoms. In line with that, the

MASC-2 and other anxiety symptom inventories do not also measure children’s coping styles or efficacy to manage their anxiety symptoms. In anxiety disorders, avoidance or escape is the most

137 common maladaptive coping strategy to manage distress manifesting from excessive fears or worries. On the other hand, some children may engage in more adaptive coping, including problem-solving and positive self-talk. Children’s ability to cope with their anxiety symptoms predict the degree of impairments they would have relative to interferences in their daily functioning (Kendall et al., 2016). Therefore, the degree of impairment relating to anxiety symptoms is critical to measure in order to evaluate whether the anxiety is pathological (APA,

2013). In future research designs, it will be helpful to collect information about children’s coping styles and efficacy and degree of impairments to assess anxiety symptoms with increased validity. Variables such as coping efficacy and impairments can be measured using self-reports and structured or semi-structured interviews. For example, Kendall (1994) developed the measure, Coping Questionnaire to evaluate youth’s perceptions of their abilities to cope with anxiety-provoking situations. The Coping Questionnaire has both self- and parent-reports.

The fourth limitation of this study concerns the research design and sample characteristics. The design of the study relied on the parents to recognize or perceive that their child might be having anxiety or related social-emotional issues to seek out the opportunity to participate in the study. Previously, child anxiety researchers have documented low-service use for anxious children and youth (Chavira, Stein, Bailey, & Stein, 2004). Low-service use suggests that at many times, anxiety symptoms maybe under-detected by parents and teachers. The current sample consisted of children whose anxiety symptoms were detected by the adults in their lives (or the adults thought the child might be having anxiety concerns). Plus, parents or caregivers had accessible means (e.g., affording transportation to travel to the University of

Calgary campus) to bring them to the intervention and the related appointments. Hence, the

138 research design excluded children whose anxiety problems were under-detected, and/or families who had barriers to accessing the intervention.

Recently, Reardon, Harvey, & Creswell (2019) surveyed parents with respect to their help-seeking for anxiety support in the community. Their findings revealed that almost two- thirds of parents of children with anxiety disorder reported seeking help from a professional, but less than 3% of children received evidence-based intervention for anxiety. Findings such as this emphasize the increasing need to promote help-seeking and access to professional support for child anxiety, as well as the need for intervention researchers and mental health professionals to explore more innovative means to reach diverse samples of children. Schools, in particular, are well-positioned and equipped with the skills and resources to support parents and caregivers to recognize anxiety in children (Reardon et al., 2019). In addition, schools can guide families on evidence-based resources, strategies, and interventions for child anxiety.

Concerning the role of intervention researchers specifically, intervention researchers are recommended to explore more ways to partner with schools to reach a more diverse sample of participants. For example, researchers can support schools in implementing universal screening of anxiety-related issues and anxiety disorders to identify students who may need professional support or intervention. Universal screenings can also mitigate help-seeking issues that may result from personal barriers that parents experience in accessing mental health care for their children. For example, parents’ negative attitudes and stigma surrounding help-seeking and their lack of personal experience of using mental health services could reduce their likelihood of accessing mental health care for their children (Reardon et al., 2019). Hence, screenings conducted in schools may reduce some barriers that children with anxiety have in accessing mental health services.

139

Furthermore, researchers should continue to partner with schools and communities to explore the feasibility of implementing interventions such as MBCT in spaces that are more accessible to children (e.g., schools, local community centres). Implementing and evaluating

MBCT in schools and community centres can reduce barriers related to transportation, finances, and time (e.g., parents finding the time to bring their child to intervention sessions). As such, implementation and evaluation of MBCT in more accessible settings will allow researchers to reach more diverse and well-representative samples, and to strengthen knowledge about its generalizability and applicability.

Future Directions for Research

Suggestions are presented here to direct future research for MBCT and childhood anxiety. First, RCTs of MCBT for childhood anxiety is recommended to be conducted with larger samples. Larger samples will not only improve the reliability and the validity of the RCT findings, but will also allow researchers to examine whether factors such as the child's intersectionality, session attendance, and completion of home practices (i.e., how well the child is integrating and practicing mindfulness outside the interventions) moderate the efficacy of

MBCT. Furthermore, researchers should explore and systematically examine mechanisms of action for MBCT to reduce childhood anxiety symptoms with larger sample sizes. In line with that, along with examining variables such as mindfulness and emotional reactivity, researchers should also analyze changes in other potential mechanisms of action, such as cognitive reactivity with respect to anxiety. Such comprehensive evaluations of MBCT are needed to understand the

1) strengths and limitations of MBCT for specific population characteristics and 2) what specific

MBCT components optimize and mediate intervention outcomes.

140

Second, it will be important to have long-term follow-up evaluations of MBCT to analyze the maintenance of its effects on children’s anxiety. Along with that, future RCTs of MBCT for childhood anxiety should compare its efficacy with active controls. Evaluations with active controls will shed light into whether participation in MBCT leads to better and more sustained outcomes in children having anxiety issues compared to other interventions and community resources.

Third, researchers are recommended to evaluate the efficacy of MBCT to reduce anxiety symptoms in children with co-morbid psychological concerns. Anxiety disorders are often referred to as the “gateway” disorder. That is, having one anxiety disorder puts the child in increasing risks to develop another anxiety disorder and/or other co-morbid psychological disorders such as depression, substance abuse, and eating disorders later in life (Dozois et al.,

2015; Ginsburg et al., 2014). Additionally, anxiety disorders are often a common, secondary problem coinciding with childhood neurodevelopmental disorders (e.g., ADHD, specific learning disorders; Elia, Ambrosini, & Berrettini, 2008; Jarrett & Ollendick, 2008). Therefore, to expand the scopes and applicability of MBCT for childhood anxiety, increased enhancements, and evaluations of MBCT to support children with anxiety and co-morbid neurodevelopmental and psychological concerns are warranted. To this end, currently available manualized MBCT programs should be reviewed in order to identify modifications that are to be made to support children with diverse neurological and psychological needs, and then evaluations of enhanced

MBCT programs should be systematically conducted.

Conclusion

Anxiety issues are highly prevalent in childhood and could severely disrupt the developmental course of affected children and youth (Ginsburg et al., 2014). Thus, there is a

141 continuous need to examine and evaluate various interventions that may be efficacious to support children with anxiety issues. One intervention that needed further empirical investigation was

MBCT. This study conducted an RCT to compare the efficacy of MBCT to reduce childhood anxiety symptoms with waitlist controls. Despite the limitations, this study extends the current literature and provides empirical support that MBCT appears to be associated with lower levels of childhood anxiety symptoms as perceived by parents. Some children also reported decreased levels of anxiety after completing MBCT, and those who did also reported greater growth in their mindfulness at mid-MBCT. Continued research with MBCT for childhood anxiety is needed to expand our knowledge about MBCT’s applicability, generalizability, and long-term efficacy.

142

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Appendix A

Session Outlines of MBCT-C (Lee and Semple, 2014) Session and Theme Key Points

1. Being on • We live much of our lives on automatic pilot Automatic • Mindfulness exists, and it is a different, more helpful way of Pilot being in the world 2. Being • Living with awareness isn’t easy, so why are we doing this Mindful is anyway? Simple, but It • We give attention to the barriers in practice Is Not Easy • Understanding the importance of practice • Bringing awareness to the breadth and body 3. Who Am I? • Thoughts arise in the present, but are often about past or future • Thoughts may not be accurate to the present reality • Thoughts are not facts 4. A Taste of • We have thoughts, feelings, and body sensations, but these are Mindfulness not who we are • Thoughts, feelings, and body sensations are not exactly the same as the events they describe 5. Music to Our • Thoughts, feelings, and body sensations often color how we Ears experience the world • Without thoughts, we create individual and unique relationships and experiences • Awareness holds it all 6. Sound • Practicing mindfulness awareness helps us to recognize that Expressions thoughts, feelings, and body sensations influence how we express ourselves • We can choose to express ourselves with mindful awareness 7. Practice • Judging is not the same as noting Looking • If we simply observe experience rather than judge them, the experience may change • We can choose to observe or note our experiences instead of judge them 8. Strengthening • Judging often changes how we experience the world the Muscle of • Becoming more aware of judgements may change how we Attention relate to thoughts and feelings • Discovering “choice points" 9. Touching the • We have little control over most events that occur World with • We have choices in how we respond to events Mindfulness • Choice points exist only in the present moment • Bringing greater awareness to this moment, we may see choice points

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10. What the • We often react to events by moving toward things we like or Nose Knows judge as “good” and moving away from things we don’t like or judge as “bad” • Judging an experience may interfere with seeing clearly what is present in each moment • We have choices in how we respond to events 11. Life Is Not a • Mindfulness is available in everyday life Rehearsal • We can practice mindful awareness using all our senses 12. Living with • Mindful awareness can be helpful in our daily lives Presence, • Bringing greater awareness to our lives is a personal choice Compassion, • Living with awareness requires commitment, compassion, and and continued daily practice Awareness 13. Follow-Up • No session • Therapist mails Letter to Myself and Daily Practice Calendar to each child

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Appendix B

Research Recruitment Letter for Schools

Dear Parents, Guardians, and Caregivers,

Researchers at the University of Calgary is currently conducting a study to evaluate whether a mindfulness-based group intervention could reduce anxiety challenges, in children ages 9-12. Specifically, the group intervention that will be evaluated is called Mindfulness-based Cognitive Therapy.

We are currently recruiting participants to see if they will be eligible for the intervention. If a child is found eligible, their name will be entered into a draw to determine whether they will participate in the intervention after recruitment period or will have to wait for 3 months to receive the intervention.

The 12-week intervention will be free of cost. A senior Ph.D. student from the University of Calgary will be facilitating the intervention. The student has received training and experience in the intervention, and will be supervised by a Registered Psychologist of Alberta. The research ethics board of the University of Calgary has approved this study.

Please note that XXX School is not a stakeholder of the research, and the research will run independently from the school.

If you think that your child is having challenges with anxiety, and you might be interested in having your child participate in the study, please contact the researchers at [email protected] or call (587) 896-7521.

Sincerely, Maisha M. Syeda, MSc., Ph.D. Student School and Applied Child Psychology Werklund School of Education University of Calgary

Dr. Jac J. W. Andrews, PhD Supervisor Chair and Professor, School and Applied Child Psychology Werklund School of Education University of Calgary

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Appendix C

Consent Form for Baseline Screening

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Appendix D

Consent Form for Intervention Participation

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