Mind-Body Therapies in Children and Youth SECTION on INTEGRATIVE MEDICINE

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Mind-Body Therapies in Children and Youth SECTION ON INTEGRATIVE MEDICINE

Mind-body therapies are popular and are ranked among the top 10 abstract complementary and integrative medicine practices reportedly used by adults and children in the 2007–2012 National Health Interview Survey. A growing body of evidence supports the effectiveness and safety of mind- body therapies in pediatrics. This clinical report outlines popular mind- body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The fi led confl ict of interest statements with the American Academy report is intended to help health care professionals guide their patients to of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of nonpharmacologic approaches to improve concentration, help decrease Pediatrics has neither solicited nor accepted any commercial pain, control discomfort, or ease anxiety. involvement in the development of the content of this publication. Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent. INTRODUCTION The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking Mind-body therapies and practices (eg, meditation and yoga) are among into account individual circumstances, may be appropriate. the top 10 complementary therapies reportedly used by adults and All clinical reports from the American Academy of Pediatrics 1 automatically expire 5 years after publication unless reaffi rmed, children in the 2007–2012 National Health Interview Survey. Mind-body revised, or retired at or before that time. therapies focus on the interaction between the mind and the body, with the intent to use the mind to influence physical functions and directly DOI: 10.1542/peds.2016-1896 affect health. Complementary therapies, such as yoga, meditation, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). mindfulness-based stress reduction (MBSR), hypnotherapy, guided Copyright © 2016 by the American Academy of Pediatrics imagery, and biofeedback, embrace this concept. Data from the 2012 FINANCIAL DISCLOSURE: The authors have indicated they do National Health Interview Survey show that 3.7% of US children 4 to 17 not have a fi nancial relationship relevant to this article to years of age used mind-body approaches. Mind-body therapies were used disclose. slightly more in older youth aged 13 to 17 years, more than twice as often FUNDING: No external funding. among females versus males (5.7% vs 1.7%), and less often in the South (2.4%). Children and youth were more likely to use mind-body therapies POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to if they experienced pain-related conditions or emotional, behavioral, or disclose. mental conditions and if they received specialty or mental health care. The most common reasons for the use of mind-body approaches were to improve overall health and feel better, to reduce stress level or relax, for To cite: AAP SECTION ON INTEGRATIVE MEDICINE. Mind-Body general wellness or disease prevention, and to feel better emotionally. 2 Therapies in Children and Youth. Pediatrics. 2016;138(3): e20161896 Children are very capable of engaging in self-care skills such as

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 :e 20161896 FROM THE AMERICAN ACADEMY OF PEDIATRICS mind-body therapies, 3 and there are Although direct clinical observation fingers), (2) heart rate variability many mind-body skills that children can provide clues to a patient’s (measuring the beat-to-beat and adolescents can learn and apply physiologic state and level of variation in heart rate patterns over throughout life. 4 autonomic nervous system (ANS) time), (3) electrodermal activity arousal, it is primarily subjective and, (measuring sweat gland activity), A growing body of evidence supports therefore, unreliable. In addition, (4) electromyography (measuring the effectiveness and safety of many patients (pediatric, adolescent, muscle activity), (5) EEG (measuring mind-body therapies in pediatrics. or adult) may subjectively state that brain wave activity), (6) capnometry In this clinical report, relevant they “feel relaxed,” but objectively (measuring exhaled carbon evidence regarding biofeedback, they may not be relaxed at all, at dioxide), and (7) pneumography clinical hypnosis, guided imagery, least as defined by measurable (measuring the movements of the meditation/MBSR, and yoga is physiologic phenomena, especially chest and stomach associated with reviewed so that pediatric health those that reflect the relative balance breathing). 34 care providers are better prepared to of sympathetic and parasympathetic Biofeedback technology has evolved answer parent questions and provide nervous system activity. Therefore, to the point that there are now patient-centered, evidence-based biofeedback can be an invaluable tool several low-cost, portable products care. For each therapy reviewed, for the pediatric health care provider available that allow for training recommendations regarding to help gauge what topics, thoughts, at home and school, thereby indications and precautions are and other phenomena trigger supporting greater generalization provided. The level of evidence based mind/body arousal in children of the skill into real-life settings. on data from published clinical trials and adolescents. The benefits for Enhancing an individual’s context and systematic reviews is described pediatric patients include allowing awareness in real-life settings by (Table 1). Key outcomes discussed in them to observe the immediate, using biomonitoring and providing association with mind-body therapies convincing, objective mind-body real-time feedback is an emerging and practices include focused interactions, literally seeing that a e-health trend. 38 Home biofeedback concentration, decreased pain, and “change in the mind (thoughts and/ systems with multimedia game reduced anxiety. or feelings) can immediately lead to formats are available for personal a change in the body’s physiological computers as well as for smart response.”4, 35 Interested clinicians phones and tablet devices. SUMMARIES OF RELEVANT EVIDENCE can be certified in biofeedback by the BY TOPIC Biofeedback Certification International The user-friendly technologies Alliance. 36, 37 The Biofeedback listed in Table 2 can make practice Biofeedback Certification International Alliance of these self-regulation skills more enjoyable and effective as they “Every change in the physiological certifies individuals who meet state is accompanied by an appropriate education and training standards measure a variety of physiologic change in the mental-emotional state, in biofeedback and progressively functions, such as heart rate conscious or unconscious, and conversely recertifies those who advance their variability, skin conductance, and every change in the mental-emotional knowledge through continuing peripheral temperature. Like other state is accompanied by a change in the mind-body skills, it is important that physiological state.”33 education. pediatric patients use these skills on Biofeedback is defined as the use Research over the past 30 years has a regular basis both for prevention of electronic or electromechanical shown that children and adolescents and for acute situational relief, as equipment to measure and then feed- are good at self-regulation 36 and they eventually learn to control and back information about physiologic capable of voluntarily modulating ultimately reset their ANS response processes to an individual. These physiologic processes, including patterns and master the mind-body physiologic processes can then be peripheral temperature, muscle connection. controlled by the individual for activity, breathing, brain electrical therapeutic purposes. Feedback activity, and certain aspects of Conclusions can be provided in auditory, visual, immune function, such as salivary Research suggests benefits of kinesthetic, or multimedia formats immunoglobulin A secretion. 35 The peripheral forms of biofeedback for and even now in the form of “video most common forms of biofeedback children and adolescents, particularly games for the body.” 34 This makes that reflect the balance of the ANS for headache (tension type and biofeedback, in its many forms, include the following: (1) peripheral migraine), asthma, enuresis, and particularly relevant as an option for temperature (measuring the rehabilitation applications, as well today’s tech-savvy youth. temperature change in hands or as EEG biofeedback (neurofeedback)

Downloaded from www.aappublications.org/news by guest on September 24, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Evidence Summary by Topic Study, year (design) Sample Age, y Study Goal Intervention Outcomes Size, N Biofeedback Knox et al, 2011 24 9–17 Examined changes in anxiety and Heart rate variability Biofeedback-assisted relaxation training (clinical trial)5 depression biofeedback based can be useful in decreasing anxiety and on a session-by- depressive symptoms session protocol Palermo et al, 2010 1247 (25 9–17 Quantify the effects of psychological Cognitive-behavioral Omnibus cognitive-behavioral therapy, (meta-analysis)6 studies) therapies for the management of therapy, relaxation relaxation therapy, and biofeedback all chronic pain in youth therapy, and produced signifi cant and positive effects biofeedback on pain reduction Monastra et al, N/A 6–19 Effects of EEG biofeedback on ADHD EEG biofeedback EEG biofeedback was determined to be 2005 (review)7 “probably effi cacious” for the treatment of ADHD Eccleston et al, 808 6–18 Effi cacy of psychological therapy of Variety of biofeedback Treatments examined are effective in 2002 (systematic children and adolescents with modalities reducing the severity and frequency of review)8 chronic pain chronic pain Clinical hypnosis Rutten et al, 2013 108 5–18 Assess effi cacy of HT in pediatric Gut-directed HT Therapeutic effects of HT seem superior to (systematic patients with FAP and IBS standard medical care in children with review) 9 FAP or IBS Accardi and Milling, 528 3–19 Effectiveness of hypnosis in Hypnosis Hypnosis was more effective than standard 2009 (systematic reducing procedure-related pain medical care or control at relieving pain review) 10 in children during medical procedures Vlieger et al, 2007 53 8–18 Effectiveness of hypnosis for FAP 6 sessions of 50 min Gut-directed HT is highly effective in the (RCT) 11 and IBS over a 3-mo period treatment of children with longstanding of gut-directed HT FAP or IBS Richardson et al, 313 3–18 Effectiveness of hypnosis for Hypnosis Hypnosis has the potential to reduce 2006 (systematic procedure-related pain and procedure-related pain and distress in review) 12 distress in pediatric patients pediatric patients with cancer with cancer Butler et al, 2005 44 4–15 Examine whether hypnotic Hypnosis Results indicate signifi cant benefi ts for the (RCT) 13 relaxation could reduce distress hypnosis group for children who undergo VCUG Calipel et al, 2005 50 2–11 Effi cacy of hypnosis on anxiety Hypnosis Hypnosis alleviates preoperative anxiety (RCT) 14 and perioperative behavioral disorders Guided imagery Weigensberg et al, 35 14–17 Determine the effects of the mind- 12 weekly sessions of The IGI group showed signifi cant reductions 2014 (RCT)15 body modality of IGI in obese a lifestyle education in leisure sedentary behavior and Latino adolescents plus IGI program increases in moderate physical activity van Tilburg et 34 6–15 Test a home-based, guided imagery 2-mo guided imagery Guided imagery treatment plus medical care al, 2009 (pilot treatment protocol using audio treatment was superior to standard medical care study) 16 and video recordings only for the treatment of abdominal pain Weydert et al, 2006 22 5–18 Evaluated the therapeutic effect of 4 weekly sessions of Signifi cantly greater decrease in the number (RCT) 17 guided imagery for children with guided imagery of days with pain recurrent abdominal pain with progressive muscle relaxation Meditation and MBSR Britton et al, 2014 101 11.7 Effects of a nonelective, classroom- 6-wk program with Both control and intervention groups (RCT, pilot)18 (mean) based, teacher-implemented, daily mindfulness decreased signifi cantly on clinical mindfulness meditation meditation practice syndrome subscales and affect but intervention on standard clinical did not differ in the extent of their measures of mental health and improvements affect Sibinga et al, 2014 43 13–21 Explore the specifi c effects of MBSR 8 weekly 2-h MBSR MBSR did not result in statistically (RCT) 19 for urban youth sessions and a 3-h signifi cant differences in self-reported retreat survey outcomes of interest but was associated with qualitative outcomes of increased calm, confl ict avoidance, self-awareness, and self-regulation for urban youth

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e3 TABLE 1 Continued Study, year (design) Sample Age, y Study Goal Intervention Outcomes Size, N Sibinga et al, 2013 41 11–14 Effects of a school-based MBSR 12-session programs Results provide cautious support that MBSR (RCT)20 program for young urban males of MBSR enhances self-regulatory processes for urban male youth, including improved psychological symptoms and enhanced coping Sibinga et al, 201621 300 12 (mean) Ameliorate the negative effects of 12-wk program MBSR students had signifi cantly lower levels (RCT) stress and trauma among low- of somatization, depression, negative income, minority, middle-school affect, negative coping, rumination, public school students self-hostility, and posttraumatic symptom severity Barnes et al, 2012 62 15–17 Impact of TM on LVM in African- 15-min TM sessions TM decreased LVM index in prehypertensive (RCT) 22 American youth at increased twice/day for 4 mo African-American adolescents risk of development of cardiovascular disease Wright et al, 2011 121 14–15 Impact on ABP in African-American BAM each weekday, BAM participants showed signifi cant (RCT) 19 patients at increased risk 10-min sessions for reductions in self-reported hostility and of development of essential 3 mo 24-h systolic ABP hypertension Flook et al 2010 64 7–9 Evaluate school-based program 30-min MAPs, twice/ Stronger effect of MAPs on children with (RCT) 23 of MAPs week for 8 wk executive function diffi culties Biegel et al 2009 102 14–18 Assess the effect of the MBSR 8 weekly MBSR MBSR may be a benefi cial adjunct to (RCT) 24 program for adolescents with classes, meeting outpatient mental health treatment of heterogeneous diagnoses in an 2 h/wk adolescents outpatient psychiatric facility Barnes et al, 2004 100 15–17 Determine the impact of stress 15-min TM sessions, Benefi cial impact of the TM program in youth (RCT) 25 reduction on blood pressure in twice/day for 4 mo at risk of the development of hypertension adolescents by the TM program Barnes et al, 2003 45 15–18 Determine the effect of stress 15-min TM sessions, TM program conducted in the school setting (RCT) 26 reduction via the TM program twice/day for 4 mo has a benefi cial effect on absenteeism, on school rule infractions in rule infractions, and suspension rates adolescents Yoga Hagins et al, 2013 30 10–11 Effects of yoga on physiologic 50 min yoga, 3 times/ No signifi cant differences in physiologic (RCT) 27 response to behavioral stressor wk for 15 wk responses to behavioral stressors tasks between groups Telles et al, 2013 98 8–13 Effects of yoga on physical fi tness, 45 min yoga, 5 d/wk Social self-esteem higher in control versus (RCT) 28 cognitive performance, self- for 3 mo yoga group, whereas general and esteem parental self-esteem improved Khalsa et al, 2012 121 15–19 Evaluate potential mental health 30–40 min yoga, 2–3 Measures of anger, resilience and fatigue/ (RCT) 29 benefi ts of yoga for adolescents times/wk for 11 wk inertia signifi cantly improved in secondary school Nidhi et al, 2012 72 15–18 Effi cacy of yoga on glucose 60 min yoga, 7 d/wk Fasting insulin, fasting blood glucose, and (RCT) 30 metabolism and blood lipid for 12 wk insulin resistance were signifi cantly values in adolescent girls with improved PCOS White, 2012 (RCT)31 155 8–11 Effi cacy of yoga to reduce perceived 60 min yoga, 1 d/wk Self-esteem and self-regulation increased stress, enhance coping abilities, for 8 wk, as well in both groups, whereas the yoga group self-esteem, and self-regulation as 10 min yoga reported greater appraisal of stress and homework 6 d/wk greater frequency of coping Mendelson et al, 97 9.7 and Improve adjustment among 45 min yoga, 4 d/wk Signifi cant improvement in the RSQ 2010 (RCT)32 10.6 chronically stressed and for 12 wk Involuntary Engagement Scale and (mean) disadvantaged youth component subscales for rumination, intrusive thoughts, and emotional arousal ABP, ambulatory blood pressure; ADHD, attention-defi cit/ hyperactivity disorder; BAM, breathing awareness meditation; HT, hypnotherapy; IGI, Interactive Guided Imagery; LVM, left ventricular mass; MAP, mindful awareness practice; N/A, not available; PCOS, polycystic ovary syndrome; RSQ, Responses to Stress Questionnaire; VCUG, voiding cystourethrography. for attention-deficit/hyperactivity conclusive. Biofeedback applications attractive form of self-regulation for disorder. Positive evidence for for the treatment of functional today’s youth, given their interest in other indications (eg, insomnia, gastrointestinal tract disorders is and comfort with technology. There chronic pain syndromes, and an area of particular promise. 54 are no significant contraindications anxiety disorders) exists but is not Biofeedback offers a particularly to the use of biofeedback, and the

Downloaded from www.aappublications.org/news by guest on September 24, 2021 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 2 Demonstrated Safety and Effi cacy of Biofeedback-Based Treatments in a Variety of Childhood Conditions Biofeedback-Based Treatment Technique Condition Reference sEMG and peripheral temperature Migraine, muscle tension, headache Andrasik and Schwartz, 200639 ; Nestoriuc et al, 200840 Variety of biofeedback modalities Chronic pain syndromes Eccleston et al, 20028 ; Palermo et al, 20106 sEMG pelvic fl oor biofeedback; anorectal EMG Functional disorders of elimination Culbert and Banez 2007,41 200842 ; Palsson et al, 200443 ; biofeedback; manometric feedback Weydert et al, 200344 Sophisticated multichannel sEMG biofeedback Developmental disabilities and neuromuscular Bolek, 200645 ; Brütsch et al, 201146 ; Wang and Reid, 201147 ; challenges EEG biofeedback (also termed neurofeedback) Attention-defi cit/hyperactivity disorder Wang and Reid, 201147 ; Monastra et al, 20057 ; Vernon et al, 200448 Heart rate variability biofeedback Performance anxiety Knox et al, 20115 Bifrontal sEMG biofeedback Asthma Lehrer et al, 200249 sEMG biofeedback Various learning disorders Carter and Russell, 198550 ; Hoy et al 201151 Specifi c biofeedback training targeting lowered Sleep disorders Barowsky et al, 199052 ; Morin et al, 200653 sympathetic nervous system arousal sEMG, surface electromyography. only barrier may be financial in that inappropriate practice of hypnosis by characteristics of the patient. This both home and professional health entertainers. situation precludes a standardized care biofeedback hardware/software approach, and large randomized Clinical hypnosis, when provided by packages can be somewhat expensive studies of individualized approaches appropriately trained individuals, and third-party health care insurance are difficult to conduct. is an adjunctive therapy that can payers do not consistently cover be used by pediatric health care biofeedback treatment. A selection Functional Abdominal Pain providers to assist in managing of resources for pediatric health care conditions that they are already A few studies have evaluated providers is provided in Table 3. otherwise licensed to treat. For the effectiveness of hypnosis for example, a pediatrician may use functional abdominal pain (FAP) and Clinical Hypnosis 11 clinical hypnosis to help a child IBS. Vlieger et al randomly assigned Clinical hypnosis in children and dealing with enuresis, irritable 52 children to either hypnosis adolescents has seen a surge in both bowel syndrome (IBS), or anxiety. with an experienced clinician or research and clinical application A licensed mental health practitioner standard care, which included dietary in the past 30 years, although its may use clinical hypnosis to help guidance, medication as needed, use in children dates back >200 children with anxiety, depression, and supportive counseling. Twelve years.55 Hypnosis is defined or posttraumatic stress disorder sessions over 3 months led to marked variably by several professional (PTSD). However, a mental health improvement in pain frequency and societies.56 Perhaps best stated, practitioner should not use clinical severity in patients in the hypnosis “when we are in hypnosis, we hypnosis for a child with IBS group compared with control intensify our attention, decrease our without physician comanagement, patients at the end of the intervention 11 peripheral awareness and become and pediatricians should not use and at 1-year follow-up. A later more receptive to new ideas and this technique for PTSD without follow-up study at 5 years showed a associations whenever we reinforce, collaborating with a mental health significantly higher remission rate in rewire, reframe or otherwise alter practitioner. the hypnosis group compared with the neurophysiological networks the control group (68% vs 20%; 60 we call ‘experience.’ Trance is Case series and clinical trials of P = .005). A systematic review of 3 what happens when we engage in clinical hypnosis first appeared trials for FAP and IBS in children and changing our minds…. Hypnosis is in the 1970s and 1980s. Since adolescents showed superior efficacy 9 a skill set involving interpersonal then, the literature has grown and over standard care. communication designed to includes clinical trials, Cochrane facilitate therapeutic change in reviews, and neuroimaging Pain Management maladaptive psycho-physiological studies. 55 –59 However, high-quality Numerous small trials have shown reflexes.” 56 Pediatric health care randomized controlled trials (RCTs) the efficacy of clinical hypnosis for providers should understand that with clear methodologies remain procedural as well as for chronic hypnotherapy in children is a lacking. Clinical hypnosis involves pain. Butler et al 13 compared well-established therapeutic establishing a strong rapport with hypnosis with breathing and modality, and it should not be patients and individualizing the relaxation techniques for procedure- confused with or misperceived as the therapy to the specific goals and related pain and anxiety during

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e5 TABLE 3 Resources by Topic Resources Web Sites, Books, DVDs, etc Biofeedback Biofeedback Certiﬁ cation International Alliance www. bcia. org Inner Balance www.heartmath. com Interactive games (Healing Rhythms, Journey to www.wilddivine. com Wild Divine) “eSense” temperature and sweat gland activity http://www. mindﬁ eld.de/ en/ biofeedback/ products/ esense/ esense- skin- response (electrodermal activity) sensors Tinke http://www. zensorium. com/ tinke/ Hypnosis Video: “magic glove” technique, performed by Dr http://www. youtube. com/ watch? v= cyApK8Z_ SQQ Leora Kuttnera Dr Laurence Sugarman’s 70-minute DVDa Sugarman L. Hypnosis in Pediatric Practice: Imaginative Medicine in Action [DVD and booklet]. Carmarthen, United Kingdom: Crown House Publishing; 2006 National Pediatric Hypnosis Training Institute www. nphti. org American Society of Clinical Hypnosis www. asch. net Society for Clinical and Experimental Hypnosis www. sceh. us Guided imagery Health Journeys: Guided Meditation and Imagery http:// www. healthjourneys. com Kaiser Permanente: Guided Imagery (podcasts) https://healthy. kaiserpermanente. org/ health/ care/ !ut/ p/ a0/ FchBDoMgEADAt_ iAzYZEYfFmhH6hhds GiZIIGELt99seZ9DjC33hO- 3cUy18_ uxCLD22md9bqnCnLV Z8okd_ Nd4zoysVAocj_ o9bT- GM6IzVap2MBamlBCG sgEWPBohoUkKp8UErXjnTZxmGL2IKPpI!/ Shambala Kids: Guided Imagery and Relaxation http://shambalakids. com/ index. php? option= com_ content& view= category& id= 40& Itemid= 419& lang= us Audio CDs Stress Free Kids Indigo Dreams Audio CDs http://www. stressfreekids. com/ category/ cds/ children- cds Academy for Guided Imagery http:// acadgi.com Meditation and MBSR For health professionals: Mind-Body STREAM program https://mind- bodyhealth. osu. edu For parents: Everyday Blessings: The Inner Work of Mindful Kabat-Zinn M, Kabat-Zinn J. Everyday Blessings: The Inner Work of Mindful Parenting. New York, NY: Parenting Hyperion; 1998 Growing Happiness http://growing- happiness. com/ mindfulness- training- for- parents/ Meditation for children http://www. freemeditation. com/ online- meditation/ meditation- for- children/ For teens: Mindfulness for Teens http://mindfulnessfortee ns. com Mindfulness Retreats http://ibme. info/ Learning to Breathe http://learning2breathe. org/ UCSD Center for Mindfulness Professional Training http:// mbpti.org/ UCSD Center for Mindfulness blog https://ucsdcfm. wordpress.com/ tag/ron- epstein/ UMass Medical School Center for Mindfulness http:// www. umassmed. edu/ cfm/ training/ UCLA Mindful Awareness Research Center http:// marc.ucla. edu/ Yoga Global Family Yoga http:// globalfamilyyoga.com/ International Association of Yoga Therapists http:// iayt.org/ Kripalu Yoga in the Schools http:// nccam.nih. gov/health/ yoga Yoga Alliance http://www. yogaalliance. org/ Yoga Calm http://www. yogacalm. org/ Yoga for the Special Child http:// www. specialyoga. com/ Yoga in Schools http:// yogainschools. org YogaKids http://yogakids. com/ STREAM, Skills Training for Resilience, Effectiveness, and Mindfulness; UCLA, University of California, Los Angeles; UCSD, University of California, San Diego; UMass, University of Massachusetts. a The technique should never be used for entertainment, should only be used by appropriately trained providers, and should only be used in clinical situations for which the provider already has competence in treating. voiding cystourethrography. hypnosis with midazolam for concluded that there is promising Moderate effect sizes for symptom anesthesia for abdominal surgery evidence for hypnosis for acute reduction were noted by parents, showed reduced anxiety at the time procedure-related pain. 10, 12 medical staff, and research observers; of induction as well as improved and procedure length was reduced behavior outcomes at 1 and 7 days Conclusions by 14 minutes in the hypnosis group. after surgery for the hypnosis Research suggests benefits of A trial comparing preprocedure group. 14 Two systematic reviews clinical hypnosis for children and

Downloaded from www.aappublications.org/news by guest on September 24, 2021 e6 FROM THE AMERICAN ACADEMY OF PEDIATRICS adolescents, particularly for FAP, IBS, and an evidence base in children therapies, such as biofeedback, to and pain management. Promising is growing. In 1 adult RCT, guided enhance relaxation.68 Regulated evidence for its application for imagery in 96 patients with newly training for guided imagery does not other indications (eg, enuresis, diagnosed breast cancer showed exist at this time. tics/Tourette syndrome, migraine, significant correlation with improved Conclusions and anxiety) exists but is not mood and quality of life. 62 For conclusive. There are few absolute example, a second adult RCT that Guided imagery appears to be a contraindications to the use of used guided imagery was correlated promising complementary therapy hypnosis. The technique should be with an increase in numbers and for children and adolescents, with used only by appropriately trained activity of beneficial immune function very low reports of adverse effects. providers and in clinical situations (T helper cells, natural killer cells, Guided imagery as a therapeutic in which the provider already is lymphokine-activated killer cells, intervention has been shown to have competent managing without the and favorable interleukin-1β levels) positive effects on psychological inclusion of hypnosis. A selection of in 80 patients with breast cancer functioning, stress reduction, and practical resources (eg, videos) for in active treatment. 63 An example pain management. Caution is advised pediatric health care providers is of a pediatric RCT that used guided in patients with a history of previous provided in Table 3. imagery involved a 12-week lifestyle emotional, sexual, or physical abuse intervention trial in 29 Latino to avoid an unintended triggering Guided Imagery adolescents with obesity, in which of posttraumatic stress symptoms. Consultation with a mental health Guided imagery is a powerful mind- weekly interactive guided imagery practitioner is advised if questions body technique that invokes all sessions were associated with a about appropriateness of use exist in of the senses (sight, sound, taste, statistically significant reduction in this context. More RCTs in children touch, smell, and movement). salivary cortisol, improved physical are needed for this noninvasive Imagery has a rich history in activity, and promotion of health therapy in the pediatric clinical healing traditions throughout the behavior change in the treatment setting. A selection of guided imagery world. Guided imagery and clinical group. 15 A second RCT combined Web resources is provided in Table 3. hypnosis have significant overlap, guided imagery with progressive and many studies combine these muscle relaxation in 22 children modalities. Strengths of guided ages 5 to 18 years with a diagnosis Meditation and MBSR imagery treatment include that it is of recurrent abdominal pain. Guided Meditation not invasive and has flexibility of use imagery with progressive muscle Meditation practices for children in different age ranges (preschool- relaxation in 4 weekly sessions and youth have become increasingly aged through adolescents and adults) was associated with a statistically popular in schools and medical and in various settings (outpatient, significant reduction in days with settings alike. Meditation is the inpatient, and acute care). The use pain throughout the 2-month practice of intentional attention of guided imagery has been shown follow-up period. 17 Home-based training and consists of a number to produce measurable physiologic audio-recorded guided imagery also of different specific approaches. changes in stress and immune has been shown to be effective in the Research on meditation in children biomarkers. 61 Challenges in the reduction of recurrent abdominal and youth consists primarily of 2 use of imagery include variable pain in a treatment group of 34 types of meditation: mindfulness training, acceptance of a novel children ages 6 to 15 years who meditation and concentration therapy by patient and practitioner, were randomly assigned to receive meditation. familiarity with and access to high- guided imagery versus standard care. quality resources, and relative lack Results were maintained throughout Research on meditation in of randomized controlled outcome the 6-month follow-up period.16 diverse populations of adults studies in children. Due caution is has accumulated sufficiently to indicated in patients with a history of In addition to these RCTs, other provide convincing high-level physical, sexual, or emotional abuse small studies that showed efficacy of evidence for reproducible benefits or those with PTSD, in which case guided imagery have been conducted of meditation in mental health and coordination of care with a qualified for a variety of medical conditions, pain management. 69 – 71 In addition, mental health expert is strongly including asthma, 64 sickle cell data suggest that greater levels advisable. disease,65 procedural anxiety, 66 and of mindfulness in adulthood may posttraumatic stress. 67 Both imagery mitigate some of the negative An evidence base for the use of and hypnosis may be combined health effects of adverse childhood guided imagery in adults is present, successfully with other mind-body experiences. 72 The literature in

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e7 children and youth, however, is less hyperactivity disorder and suggested yoga was the fifth most commonly developed and, although suggestive additional trials. 81 Active-controlled used complementary therapy of benefit, is just beginning to RCTs and active-control programs practice among all children ages 2 to emerge.73 – 76 To provide the highest of concentration meditation in 17 years, with ∼1.5 million children level of available evidence regarding children and youth have included practicing yoga in the previous the specific effect(s) attributable to both transcendental meditation year. In a survey of children and meditation instruction for children (TM) and the relaxation response. adolescents with chronic pain, yoga and youth, conclusions in this report Compared with active-control was preferred by 32% as their first are based on findings from RCTs with programs, TM has been shown to choice of complementary therapy. 85 active control conditions. lead to decreases in blood pressure Therapeutic yoga is the practice and left ventricular hypertrophy of uniting the mind, the body, and Mindfulness Meditation among African-American adolescents the spirit through mindfulness Mindfulness meditation is aimed with prehypertension 22, 25 as well of breathing and body postures at enhancing individuals’ innate as fewer negative school behaviors, to improve stress coping, lessen capacity to be purposefully aware such as absenteeism.26 Relaxation pain, and improve specific health of their present-moment emotional, response has been associated with conditions. Although not completely cognitive, and sensory experiences. improvements in self-esteem. 82 understood, yoga effects changes Through instruction in formal and in the parasympathetic nervous informal meditation techniques, this Conclusions system, positively affecting heart rate capacity for purposeful, moment-by- variability. 86 Research on structured meditation moment, nonjudgmental awareness programs for children and youth is develops, along with the ability to Fourteen controlled studies 27 – 32, 87 – 94 suggestive of benefits, particularly shift attention. Several RCTs in youth and 4 systematic reviews95 – 98 were related to improvements in mental have evaluated the MBSR program, identified, and all uncontrolled trials health, coping, and self-regulation as which has established instructor and those in which yoga was not the well as decreasing hypertension and training through the University of sole treatment intervention 99 were negative school behaviors. Although Massachusetts School of Medicine’s eliminated from consideration. The there are structured training and Center for Mindfulness and has been conclusions of the systematic reviews certification programs for a number well researched in adults. 77 Youth- can be summarized as follows: of meditation programs (including adapted MBSR programs have been yoga appears to be a promising MBSR, TM, and mindfulness-based found to be beneficial in improving complementary therapy for children cognitive therapy), there is no mental health symptoms, coping, and adolescents, especially for those formal credentialing or licensure and self-regulatory processes with pain and emotional, mental, and for meditation instruction. Costs and decreasing blood pressure behavioral conditions, with very few vary depending on the format of when used in both primary reported adverse effects. However, a instruction and are increasingly, prevention 18 –21, 78, 79 and treatment lack of methodologic and statistical but not universally, covered by settings. 80 In children 7 to 9 years of rigor, including small sample sizes, insurance. Although these results age, an RCT of school-based mindful absence of randomization, and a are encouraging, careful attention awareness practice instruction high degree of variability between should be paid to elements of versus a reading program did not intervention methods, limits the implementation and dissemination show differences by treatment group ability to recommend yoga as to maintain high-quality, effective overall but did reveal improvements a primary intervention for any meditation instruction for children in mindful awareness practice particular population. On the basis of and youth. participants in executive function the 14 individual controlled studies, among children with lower executive yoga appears to be a promising function skills at baseline. 24 Yoga complementary therapy and stress- management tool for children Concentration Meditation The word yoga is derived from the and adolescents, with very low Sanskrit word yuj meaning “union.” reports of adverse effects. Yoga as a Concentration meditation involves An ancient Indian practice, yoga has therapeutic intervention has positive focusing attention on 1 specific thing, been classified by the National Center effects on psychological functioning, such as a word, phrase, or object. 23 for Complementary and Integrative especially in children coping with A Cochrane review found current Health as a mind-body medicine emotional, mental, and behavioral research inadequate to suggest modality. 83 According to the 2007 health problems. Specifically, meditation for attention-deficit/ National Health Interview Survey, 84 research has shown that educational

Downloaded from www.aappublications.org/news by guest on September 24, 2021 e8 FROM THE AMERICAN ACADEMY OF PEDIATRICS curricula incorporating stress- community-established standards. STAFF 100 management programs improve The Yoga Alliance sets guidelines Teri Salus, MPA, CPC academic performance, self-esteem, for yoga teacher certification in the classroom behaviors, concentration, United States. A selection of yoga ABBREVIATIONS and emotional balance, 98 suggesting Web resources is provided in Table 3. that schools may be an ideal setting ANS: autonomic nervous system to bring yoga to a heterogeneous, FAP: functional abdominal pain socioeconomically diverse sample CONCLUSIONS AND IBS: irritable bowel syndrome of children. In addition, in 4 RECOMMENDATIONS MBSR: mindfulness-based stress controlled trials, yoga was shown This report examines the best- reduction to positively influence metabolic available evidence for a variety of PTSD: posttraumatic stress and hormonal variables. Given the mind-body therapies and practices disorder increasing prevalence of obesity and in children and youth, including RCT: randomized controlled trial metabolic dysfunction in children, biofeedback, clinical hypnosis, TM: transcendental meditation coupled with the relative safety guided imagery, meditation, and and cost-effectiveness of yoga as an yoga. The evidence varies in intervention, more research in this terms of quantity and quality but REFERENCES population is needed. Limitations generally is supportive of mind-body 1. Black LI, Clarke TC, Barnes PM, of reviewed studies include small therapies and practices as safe and Stussman BJ, Nahin RL. Use of sample sizes, high attrition rates, lack potentially effective in common and complementary health approaches of evaluator blinding, reliance on self- debilitating conditions, including among children aged 4-17 years in report measures, and heterogeneity pain and anxiety. 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