Authors
- Townshend, Kishani BSocSc Hons (Psych), Grap Dip (Psych), BSocSc
Abstract
Review question/objective: The primary objective of this review is to systematically evaluate the effectiveness of Mindful Parenting programs in promoting children's, adolescents' and parents' wellbeing, particularly in relation to the intensity of symptoms associated with internalizing (depression, anxiety, stress) and externalizing (conduct) disorders. The secondary objective is to evaluate how effective Mindful Parenting programs are in improving emotional regulation, quality of the parent-child relationship, resilience and mindfulness of the children, adolescents and parents. The comparator is the control or waitlist conditions. The population of interest in this study is children aged between 0 to 18 years and their parents who have completed a Mindful Parenting program.
Background: There is a growing consensus that a paradigm shift is needed to address the profound impact of mental illness, the delayed diagnosis and long waiting lists. Depression is the leading cause of disability with 350 million people affected across the world.1 The cost of mental health disorders to the Australian community is approximately $20 billion per annum which includes loss of productivity and labour force participation.2 The initial onset of anxiety, depression and conduct disorders tends to occur in childhood and adolescence.3 However they are not detected until later in life due to gaps in the efficacy and effectiveness of mental health services to young people.4 Mental illness has complex, multifaceted etiologies. The dominant view is that parenting and the quality of the parent-child relationship significantly influence early brain development and the development of mental health disorders.5 Mindful Parenting has been defined as the ability to pay attention to your child and your parenting in a particular way, that is intentionally, non-judgementally whilst being in the here and now.6 This study aims to investigate whether Mindful Parenting programs could be added to the repertoire of tools used in the prevention and early intervention of mental illness.
Epidemiological evidence shows that half of all lifetime mental health disorders commence by the age of 14 years, with anxiety and impulse control disorders having a median age of onset at 11 years for clinical diagnoses.3 The primary mental health disorders in childhood tend to be internalizing (anxiety, depression) and externalizing (aggression, oppositional defiance) disorders.7 Internalizing disorders represent disorders associated with depression, anxiety and somatic symptoms.8 Externalizing disorders refer to disorders characterized by impulsive, disruptive conduct and substance use symptoms.8 Approximately 25% of youth in Australian and international populations present with these disorders which continue to adolescence and adulthood.9-11 Furthermore there are higher rates of mental health conditions amongst Indigenous, migrant and African American children. Yet, due to the stigma associated with mental illness and gaps in services, these children are even less likely to receive a timely diagnosis or treatment.4, 12 Childhood mental health problems that are not effectively treated can result in significant health costs to society, protracted psychological distress, learning difficulties, school dropout, poor employment outcomes, social isolation, substance abuse, family violence and suicide.13
The term "Mindful Parenting" was coined by John and Myla Kabat-Zinn in 1997 in their book, Everyday Blessings: The inner work of mindful parenting.14 It originates from the Eastern and Western concept of mindfulness. Mindfulness is defined as the ability to be attentive to the present.6, 14 It is an attention process that focuses on clarity of thinking, flexibility of thinking and being present in the moment rather than running on automatic pilot. Over the last three decades, studies have indicated that mindfulness-based interventions have positive outcomes in relation to mental health issues, weight loss, cancer, parenting stress and the parent-child relationship.15-17 Integrating mindfulness with parenting, "Mindful Parenting" is one of the newer applications of mindfulness in mental health contexts.17 Although mindfulness-based psychotherapies are becoming increasingly popular in promoting mental health, there is a scarcity of literature on whether Mindful Parenting programs can promote children's wellbeing. However the definition of wellbeing is just as controversial as its measurement.18 This paper will refer to the definition of wellbeing provided by Dodge, Daly, Huyton & Sanders18, that is, wellbeing as the state of equilibrium or balance that can be affected by life events or challenges. In the absence of studies with validated wellbeing measures, this review will measure wellbeing in terms of the reduction in the intensity of symptoms associated with internalizing and externalizing disorders.
The growing interest by clinicians and researchers in the field of mindfulness is fuelled by the promise of a new tool to alleviate the suffering associated with physical, psychological and psychosomatic disorders. Whilst mindfulness is an ancient concept, its application in modern healthcare, education, employment and prison systems is becoming increasingly popular. The key active ingredient of mindfulness is thought to be the improved self-observation that promotes better coping skills.19 Two broad approaches of mindfulness that have been integrated into psychotherapy include mindfulness-based and mindfulness-oriented.5 Mindfulness-based psychotherapy includes Mindfulness Based Stress Reduction (MBSR), Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Cognitive Behavior Therapy (MBCBT).5 Mindfulness-oriented models include Acceptance Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT).20, 21 A comprehensive meta-analysis found Mindfulness Based Therapy is an effective treatment for a variety of psychological disorders, especially for reducing anxiety, depression and stress.20
Although an initial search found no systematic reviews on Mindful Parenting, it found several systematic reviews on the burgeoning field of mindfulness. A recent systematic review of randomized controlled trials (RCTs) using MBSR and MBCT found that MBSR improves mental health and MBCT prevents depressive relapse with medium effect sizes.19 From the 21 studies included in this study, 11 studies found MBSR improved mental health compared to the waitlist control or treatment as usual (TAU) and was as efficacious in the active control group in three studies.19 Mindfulness Based Cognitive Therapy was found to reduce the risk of relapse in two studies and was found to be as efficacious as TAU on the active control group in two studies.19 The literature however does acknowledge the limitations with "mindfulness". One limitation is that the results are only generalizable to individuals who have an interest in mindfulness and the ability to participate in such programs.19 This is because mindfulness studies are not double-blinded as participants actively chose the program and know they are participating. So bias is inherent in self-selected samples. Publication bias may be another limitation as most studies report positive results.19 Regardless of these limitations, the studies tend to concur that attention is one of the mechanisms of change. Future research needs to clarify how attention is therapeutic.
Over the last 17 years since Myla and Jon Kabat-Zinn's first significant application of mindfulness in 1997, there have been several primary studies on Mindful Parenting. Whilst some of these are RCT22, 23 the majority of the study designs tend to be descriptive case series.24-27 The sample sizes are generally small. The settings tend to be mostly home-based with parents attending two to two-and-a-half hours per week for eight to twelve weeks. The studies are usually conducted in America, Australia or Europe. While all the participants are parents, the target group of parents tends to vary from pregnant mothers, parents with children presenting with autism, parents with children diagnosed with conduct disorders and parents of children from the age 10-14, to parents on a the methadone program with pre-schoolers. Both experimental and descriptive studies indicate that Mindful Parenting programs can improve the parent-child relationship, parenting skills and the child's wellbeing with regard to social and emotional competence.17 Mindful Parenting programs have also been used to prevent the transmission of mental health disorders from parent to child.17 The results from these primary studies indicate some consistency of positive effects.
A preliminary search in the major bibliographical databases identified no completed systematic review or review protocol on the topic of interest for this proposal. The databases that were searched included the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), EMBASE, PsycINFO and PROSPERO, the international database of prospectively registered systematic reviews in health and social care. A systematic review evaluating the effectiveness of Mindful Parenting Programs on children's and parents' outcomes is the first step in establishing whether there is sufficient empirical support to justify the promotion of Mindful Parenting as a prevention intervention.
Article Content
Inclusion criteria
Types of participants
This review will consider studies that include all children aged 0 to 18 years old, whose parents have completed a Mindful Parenting program. The participants are the children or adolescents and their parents. Most countries across the world consider a child to be an adult when they become 18 years old. This study will consider participants under 18 years of age, as a child. Mindful parenting is the same regardless of age. It is the ability to be attentive to a child's changing needs from birth to adulthood and beyond. Given the large developmental differences between the ages of 0 to 18, a sub-group analysis will be conducted according to the following age groups: 0 to18 months; 2 to 3 years; 3 to 5 years; 6 to 11 years; and 12 to 18 years, if there are sufficient studies. The bracketing of these age groups are consistent with Erikson's psychosocial developmental stages of infancy (0 to 18 months), early childhood (2 to 3 years), preschool (3 to 5 years), school age (6 to 11 years) and adolescence (12 to 18 years).28
Children and adolescents with or without a mental health diagnosis from culturally diverse backgrounds, from adopted or fostered backgrounds or children living with their family of origin will be included in this review, as long as their parents have completed a Mindful Parenting program. For all children whose parents have completed a Mindful Parenting program, a piori subgroup analysis will be conducted for Indigenous children, migrant children and African American children in addition to children diagnosed with mental health conditions, if there are sufficient studies. This is to account for any confounding factors, cultural differences and mental illness that may affect the children's outcomes.
Types of intervention(s)
This review will consider studies that evaluate Mindful Parenting interventions with a minimum duration of two hours per week for eight weeks provided by a registered health practitioner including but not limited to a psychologist, social worker or nurse. The duration of Mindful Parenting programs generally range from eight to 12 weeks with parents attending a group workshop for two to two-and-a-half hours each week. This systematic review will select studies where there is a consistency in the variables such as program duration, timing, frequency, intensity and the qualifications of the program facilitator. It could include parenting programs that draw upon MBSR, MBCT, MBCBT, ACT or DBT. The focus will be on interventions that combine mindfulness and parenting.
Comparator
The Mindful Parenting programs will be compared with the control group of standard care as usual.
Types of outcomes
This review will include studies that report on outcomes for children, adolescents and parents which are measured with validated instruments. The primary outcomes will be the wellbeing in addition to the intensity of symptoms associated with internalizing disorders (depression, anxiety, stress) and externalizing disorders (conduct disorders) of the children, adolescents and parents. Secondary outcomes include emotional regulation, quality of the parent-child relationship, resilience and mindfulness of the children, adolescents and parents. These outcomes could be measured on validated tools with known psychometric properties such as Depression, Anxiety and Stress Scale (DASS)29, Resilience Scale,30 Emotional Regulation of Self and Others (EROS),31 Langer's Mindfulness Scale (LMS),32 and other relevant scales. Time points of measurements such as pre-, post and follow-up are also relevant to the durability of the outcomes.
Types of studies
This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. In the absence of randomized controlled trials, this study will consider quasi-experimental, observational and descriptive study designs. It will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies.
Search strategy
The search strategy aims to find published and unpublished studies from 1997 to November 2014. The term "Mindful Parenting"' started to appear in the literature from 1997, with Myla and Jon Kabat-Zinn's publication on the topic.14 A three-step search strategy will be utilized in this review. An initial search of PubMed, PsycINFO, EMBASE, Scopus, Psychology and Behavioral Sciences Collection, CINAHL and Cochrane Library will be undertaken followed by an analysis of the text words contained in the title, abstract and index terms used to describe the articles.
A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. In the absence of high quality published studies, the search for grey literature will only focus on searching ProQuest Dissertations and Theses Database.
Initial keywords to be used will be "mindful" and "parenting". Key words associated with "mindful" include mindfulness, Mindfulness Based Stress Reduction (MBSR), Mindfulness Based Cognitive Therapy, Mindfulness Based Cognitive Behavior Therapy (MCBT), Dialectical Behavior Therapy (DBT) or Acceptance Commitment Therapy (ACT). Some key words associated with "parenting" include, parent, parent-child relationship, father, mother, parental, maternal, paternal, perinatal and antenatal. Key words associated with wellbeing include resilience, emotional regulation, internalizing disorders (depression, anxiety, stress) and externalizing disorders (conduct disorders). The search for studies with different sub-groups of children will include key words pre-schoolers, adolescents, Indigenous, migrant and African American children
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MASTARI) (Appendix I ). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data collection
The authors will extract and analyze the data from the studies that meet the inclusion criteria. Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MASTARI (Appendix II ). The data extracted will include specific details about the interventions, populations, study methods in addition to the outcomes of significance to the review question and specific objectives.
Data synthesis
Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MASTARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Odds ratio will be analyzed for RCTs and relative risks will be calculated for cohort case series. Means and standard deviations will be analyzed for continuous scales items. Standard error will be analyzed for older studies.
Heterogeneity will be assessed statistically using the standard Chi-square homogeneity significance test and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation if appropriate. Finally enough papers will be required to support the line of inquiry. Given the large developmental differences between the ages of 0 to 18, a sub-group analysis will be conducted according to the following age groups: 0 to18 months; 2 to 3 years; 3 to 5 years; 6 to11 years; and 12 to18 years; if there are sufficient studies. Similarly a subgroup analysis will be conducted for Indigenous children, migrant children, African American children in addition to children diagnosed with internalizing and externalizing disorders if sufficient studies are found.
Conflict of interest
There are no conflicts of interest.
Acknowledgements
I am grateful for the advice on systematic review protocols provided by Dr Catalin Tufanaru.
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Appendix I: Appraisal instruments
MASTARI appraisal instrument [Context Link]
Appendix II: Data extraction instruments
MASTARI data extraction instrument [Context Link]
Keywords: Mindful parenting; children's wellbeing; adolescent wellbeing; mindfulness; Indigenous children; migrant children; African-American children; parenting and Mindfulness Based Stress Reduction (MBSR); Mindfulness Based Cognitive Therapy; Mindfulness Based