School Based Mindfulness Interventions within a Response to Intervention Framework by Innovations2Solutions

School-Based Mindfulness Interventions within a Response to Intervention Framework Alexandra Bluell, BA, SSP (Specialist in School Psychology)

ACADEMIC AND SOCIAL-EMOTIONAL LEARNING STANDARDS no comparable measure for social-emotional learning standards despite the fact that approximately one in five children and adolescents either currently experience or will experience mental health issues that warrant intervention.3 These types of issues include both internalizing conditions such as anxiety and depression and externalizing conditions such as Attention Deficit Hyperactivity Disorder, Conduct Disorder, and Oppositional Defiant Disorder.3 These disorders present a wide variety of challenges and adverse side effects for individuals who suffer from them. Some of these negative side effects include lower academic achievement4,5,6,7, higher school dropout rates4,6, and negative peer relationships.4,5,6,7

Public education is continually evolving to best meet the academic and social-emotional needs of an increasingly diverse student population. A major driving force for this change is the No Child Left Behind Act (2001), which holds schools and teachers accountable for student performance on standardized tests in reading, math, and science.1 In order to academically prepare students for these high-stakes tests, 43 states have adopted the Common Core Standards.* These standards hold students to a high level of performance in language arts and math that is designed to prepare them for career and college readiness.2 While the Common Core Standards provide a universal framework for academic standards across the United States, there is

Figure 1: Negative Outcomes Associated with Clinically Significant Internalizing and Externalizing Conditions

INTERNALIZING CONDITIONS Anxiety Depression

NEGATIVE OUTCOMES ê Academic Achievement é Dropout Rates

COMORBIDITY OF DISORDERS

ê Peer Relationships

EXTERNALIZING CONDITIONS Attention Deficit Hyperactivity Disorder Conduct Disorder Oppositional Defiant Disorder

* All red terms are defined in the Glossary on page 8.

While one in five children or adolescents will at some point suffer from a condition requiring intervention, many will not seek out or receive the necessary treatment for various reasons. Schools have the potential to help intervene and potentially prevent some of these issues by promoting social-emotional learning standards. Social-emotional learning (SEL) emphasizes development of several critical skills that are often impaired in students with internalizing and externalizing disorders, including self-awareness, self-management, responsible decision making, social awareness, and relationship skills.8 In addition, these skills have documented relationships to academic achievement as well as to a number of other positive outcomes. For example, a meta-analysis of roughly 270,000 students from kindergarten to high school found statistically significant effect sizes indicating that students who received a universal curriculum emphasizing one or more SEL skill had improved SEL skills, more positive attitudes towards self and others, used more positive social behaviors, experienced higher academic performance, had fewer conduct problems, and less emotional distress than controls.9

3 The information and concepts contained in this document are the proprietary property of Sodexo. As such, they cannot be reproduced or utilized without permission. ÂŠ2015

While this example highlights the importance of universal SEL curriculum, current trends in education as well as federal legislation such as the Individuals with Disabilities Education Improvement Act (2004)10 emphasize a continuum of intervention intensity. This service delivery model is known as Response to Intervention (RtI), and it underscores the importance of early intervention and prevention. The RtI service delivery model categorizes evidence-based general education interventions into three tiers of intensity. Tier 1, or universal interventions, target the entire student population and include the general curriculum. Students identified as at-risk for academic or social-emotional concerns should receive Tier 2 interventions that are targeted at areas of concern and delivered in a small group format. Finally, those students with the most severe academic or behavioral deficits should receive intensive and individualized Tier 3 services which can be provided in a small group setting or individually.11 Figure 2: Response to Intervention Tiers

Target: Students with severe academic or behavioral problems (5% of all students) Delivery: Small groups or Individually

Target: Students at-risk for academic or social-emotional-behavioral concerns (15% of all students)

TIER THREE

TIER TWO

Delivery: Small Groups

Target: All students (80% of student needs should ideally be met here)

TIER ONE

Delivery: General curriculum or universal programs

4 The information and concepts contained in this document are the proprietary property of Sodexo. As such, they cannot be reproduced or utilized without permission. ÂŠ2015

A number of established curriculums exist to promote SEL standards; however, best practices in education indicate that schools should implement evidencebased practices or interventions with extensive research support demonstrating their efficacy. One type of intervention with growing empirical support is mindfulness which has been found to have positive effects on self-regulation, attention, promoting positive emotions, and improving math performance.12,13 This white paper provides information on the current research establishing the preliminary efficacy and effectiveness of school-based mindfulness interventions, at each of the three tiers in the RtI service delivery model.

of and focus on the present moment.14 Mindfulness can also be considered a type of contemplative practice sharing some similar central concepts as yoga and meditation. For example, contemplative practices encourage focused attention on one’s thoughts and awareness of one’s body and environment.15 Recent research has focused on adult outcomes of mindfulness interventions; however, there is a growing body of literature suggesting positive results of mindfulness interventions for children and adolescents. Contemplative practices not only focus on attention but also on self-regulation skills which require students to control or manage their thoughts, emotions, and behaviors.16 Self-regulation skills are exceedingly recognized as positively related to student’s later academic success.17 In addition, contemplative practices may also simultaneously focus on promoting physical fitness by strengthening muscles or encouraging movement. Research suggests that physical fitness itself is associated not only with positive physical effects but also with positive psychological outcomes including reduced depressive and anxiety symptoms.18

WHAT ARE MINDFULNESS INTERVENTIONS? Mindfulness interventions represent a relatively new field in the study of school-based interventions utilized to promote positive SEL outcomes. Mindfulness itself has been defined in numerous ways; however, most definitions include emphasis on individuals’ awareness

CASE STUDIES

a wait-list (n=107). ME is considered a universal and preventive classroom curriculum designed to promote social-emotional competence in all children. The ME lessons were implemented by the classroom teachers and consisted of at least 3 “mindful attention training” sessions daily for a 10-week period of time. The ME curriculum was developed into a user-friendly manual to facilitate implementation ease and integrity. The lessons focused on the development of the following four skills related to mindfulness: (1) quieting thoughts in the mind by focusing on one sound and one’s breathing, (2) “mindful attention” to thoughts, feelings, and body, (3) controlling negative thoughts, and (4) being aware of one’s self and of others. These skills were selected as targets of intervention due to hypothesized relationships with increased self-regulation, positive emotions, and use of goal setting.

The following case studies demonstrate the flexibility, utility, and acceptability of school-based mindfulness interventions to address a wide variety of student needs at each level of the Response to Intervention service delivery model.

Tier 1 Interventions Tier 1 practices, which include scientifically-based general education curriculum, screening procedures for all students to identify those at-risk for learning or behavioral difficulties, and other evidence-based group interventions implemented universally, are meant to meet the needs of approximately 80% of the student population at a school.19 The following case study describes the feasibility, acceptability, and effectiveness of a universal, preventative Mindfulness Education program implemented by classroom teachers to improve students’ social emotional competence.20

The results of this study indicate some very promising effects from the ME program. First, teachers valued the program, as evidenced by their ratings of the effectiveness of the program. Specifically, post intervention, teachers were asked to rate how effective the ME program was at helping their students demonstrate social-emotional skills in the classroom. On a scale of 1 (not at all) to 5 (significantly), the

This study consisted of six experimental groups of 4th-7th grade students who received the Mindfulness Education (ME) program daily in their regular classroom setting (n=139) and six control groups who were on

Tier 2 Interventions

average teacher rating was 4.6, indicating a strong belief that the ME program was effective at influencing social-emotional skills. Similarly, teachers reported implementing the core ME activities on average 87% of the time over the course of the study, which is a high implementation rate. These results indicate both the feasibility and acceptability of implementing a universal ME program in the classroom setting.

Those students whose needs are not met solely by universal practices progress along the continuum to targeted, Tier 2 interventions based on broad areas of concern. Students receiving Tier 2 interventions continue to receive the general curriculum in addition to more targeted interventions. Tier 2 services are meant to meet the needs of approximately 15% of students for whom Tier 1 practices are insufficient to make adequate academic or behavioral progress.19 Students in this category may have deficits in specific academic areas, difficulty sustaining attention in the classroom, or poor work completion rates. The following case study documents the effectiveness of a Mindfulness-Based Kindness Curriculum on promoting prosocial behavior and self-regulation skills in preschool children.16

Additionally, students who participated in the ME program reported significantly higher levels of optimism post-study than students in the control group. Similarly, pre-adolescents in the ME group reported higher levels of self-concept following the intervention; however, this effect was not found for older students included in the study. Perhaps the most promising finding is that teachers reported significantly higher levels of attention, emotion-regulation, and social-emotional skill competence for students in the classrooms that received the ME program when compared to those students in the control classrooms.

In this study, 68 children were randomly assigned to one of three intervention classrooms (n=30) or one of four control classrooms (n=38). The students in the intervention classrooms received two 20–30 minute lessons over the course of 12 weeks from a trained mindfulness instructor. The lessons incorporated music, stories, and movement activities that promoted prosocial behaviors (e.g., kindness, empathy, and sharing) and self-regulation skills.

Summary of Outcomes for the Mindfulness Education (ME) Program

Tier 1 Outcomes: »» Students reported increased optimism »» Pre-adolescents reported improved selfconcept »» Teachers reported increased levels of attention, emotion-regulation, and social-emotional skills for their students »» Teachers valued the program and acknowledged the feasibility of universal implementation

The results of the study indicated statistically significant improvements in teacher ratings of selfregulation skills and prosocial behaviors for students who participated in the Mindfulness-Based Kindness Curriculum as compared to the controls. Similarly, students in the control group performed more selfishly on a sticker-sharing task, as they kept more stickers

Tier 3 Interventions

for themselves than students in the intervention group. Students in the intervention group also earned higher grades in the following areas: approaches to learning, health and physical development, and social emotional development. These grades were provided three months after the end of the intervention, therefore they serve as a type of follow-up measure indicating the program continued to impact student performance even after the end of implementation. Additionally, students in the experimental group did not earn higher scores in all areas assessed on the report card providing further evidence that the intervention, at least partially, led to increased grades. No statistically significant results for improvements in self-regulation skills as measured by executive functioning tasks (e.g., flanker task) were found in this study; however, a positive trend (based on effect sizes) for improved executive functioning for students in the intervention group was noted. One possible reason for the lack of statistical significance is the small sample size of the study.

The remaining 5% of students whose academic or behavioral needs are not met through either Tier 1 or Tier 2 services receive the most intensive, individualized interventions based on specific areas of deficit.19 The following case study demonstrates the preliminary efficacy of a mindfulness-based cognitive therapy for children (MBCT-C) targeted at reducing anxiety and minimizing attention and behavioral problems.21 The study included children ages 9–13 who were predominantly from families of low socioeconomic status in an urban environment. The children were referred to the study for displaying academic difficulties, particularly in reading. The sample consisted of 25 children, 6 of whom entered with clinically significant levels of anxiety and 5 of whom showed attention problems consistent with Attention Deficit Hyperactivity Disorder. The MBCT-C was delivered in a group format with no more than 8 students in a group. The groups met once a week for 90 minutes for a 12-week period. The MBCT-C was developed by Semple and Lee as a developmentally appropriate intervention based on a MBCT used to treat adults with depressive symptoms. MBCT-C actively engaged the participants by utilizing games, activities, and various sensory activities. These types of “mindful movement” activities were incorporated into the study because of children’s documented need for physical activity. The students also had the opportunity to engage in mindful meditation for shorter periods of time (i.e., 3–9 minutes). Parents were invited to participate in the intervention by practicing mindfulness practices at home and completing daily logs of their child’s progress.

This study was implemented as a universal program, such as those used in Tier 1; however, the results indicated that those students who demonstrated the greatest improvements were the individuals who began with the lowest levels of self-regulation and socialemotional competence. In other words, students likely to benefit most from this type of intervention are those who would likely be identified as at risk and in need of Tier 2 services. The intervention described in this study could easily be modified to be delivered in a smaller group format for students identified as needing more support than the universal curriculum alone can provide. Summary of Outcomes for the Mindfulness-Based Kindness Curriculum

Tier 2 Outcomes: »» Teachers indicated increased selfregulation skills and prosocial behaviors for their students »» Students who did not receive the intervention demonstrated more selfish behaviors on a sharing task »» Students in the intervention earned higher grades in several areas »» The students most likely to benefit were those who started with the lowest levels of self-regulation and social-emotional competence

SUMMARY

The results of the study indicated that participants were reported to experience fewer attention problems than the control group and that these improvements in attention were maintained at a 3-month follow-up. Of the six children who entered the study with clinically significant levels of anxiety, there was a clinically significant reduction in both anxiety and behavioral problems. Due to the small sample size, future research with larger samples, specifically of students with severe anxiety or attention problems, is necessary to provide more empirical support. Although limited by the sample, the preliminary results indicate the efficacy of mindfulness-based cognitive therapies in helping children with anxiety and attention problems.

The Common Core Standards highlight the importance of high levels of academic achievement for today’s students. While traditional teaching methods are essential for meeting these standards, social-emotional learning can also positively impact and support attainment of academic goals when appropriately addressed. In fact, there is a growing trend that acknowledges and values the use of preventive and early intervention services to help resolve students’ academic and social-emotional concerns. Response to Intervention is a service delivery model recognized by federal law as a means to address student concerns prior to a referral to special education services. The model involves the use of screening measures that help identify at-risk and struggling students, and then the provision of high-quality, researchbased interventions to address their needs.

The application of this type of intensive and targeted intervention to schools would likely involve breaking down each of the 90-minute lessons into 20- to 30-minute sessions that could be delivered over the course of a school week. As the results indicated, use of MBCT-C may produce the best results for children with clinically significant levels of attention disorders or anxiety concerns prior to starting treatment. In other words, the children who have not benefited from Tier 1 and Tier 2 services would be ideal candidates for this type of targeted intervention.

Although a variety of methods to target and build social-emotional competence is available, a growing body of empirical research supports the effectiveness of mindfulness-based interventions at improving attention, self-regulation, and emotion-regulation among school children. Activities included in these interventions not only focus on mindful attention but also on movement and therefore may promote physical fitness. Some research even suggests that mindfulness interventions can improve students’ academic outcomes, such as their math grades. Mindfulness-based interventions are relatively simple to implement, as evidenced by teacher reports of acceptability and feasibility. Additionally, they use resources already readily available at most schools, saving time and money. Continued rigorous and controlled studies will help to further substantiate the current empirical evidence supporting schoolbased mindfulness interventions for children; however, the current findings are promising and reinforce the important role that such programs can play in today’s education system.

Summary of Outcomes for Mindfulness-Based Cognitive Therapy for Children (MBCT-C)

Tier 3 Outcomes: »» Participants reported fewer attention problems »» Improvements in attention were maintained at a 3-month follow-up »» Students with the highest levels of anxiety experienced clinically significant reductions in anxiety and behavioral problems

GLOSSARY OF KEY TERMS Social-Emotional Learning: emphasizes development of several critical skills, including self-awareness, selfmanagement, responsible decision making, social awareness, and relationship skills8

Self-Regulation Skills: skills that enable students to control or manage their thoughts, emotions, and behaviors; often positively associated with later academic achievement16

Common Core Standards: Career and college readiness standards in the areas of English/Language Arts and Mathematics for students in grades kindergarten through 8th grade; students in high school have grade-based standards for 9–10th and 11–12th grades

Social-Emotional Competence: Students’ demonstration of social-emotional learning standards in the classroom environment

Anxiety: A broad type of psychological disorder that is characterized by excessive fear or worry which can lead to disturbances in behavior4

Emotion-Regulation: The ability to identify and label one’s emotions and the emotions of others and use this knowledge to appropriately manage feelings

Depression: A psychological disorder in which an individual suffers from symptoms such as depressed mood (can be displayed as irritability in children and adolescents), a loss of interest or pleasure in activities, sleep problems, and/or feelings of worthlessness for a marked period of time (at least two weeks)5

Prosocial Behavior: Behaviors that benefit others based on social responsibility instead of the desire for individual gain

Self-Concept: an individual’s thoughts, perceptions, and evaluations of themselves

Executive Functioning: An umbrella term for several cognitive processes, including planning, focusing attention on relevant information, using working memory to complete tasks, and self-regulation

Attention Deficit Hyperactivity Disorder (ADHD): A childhood disorder that can persist into adolescence and adulthood. The main symptoms include difficulty focusing attention, impulsivity, and hyperactivity. There are three subtypes: Predominantly hyperactiveimpulsive, Predominantly inattentive, and Combined hyperactive-impulsive and inattentive6

Flanker Task: Task that requires individuals to selectively attend to a target stimulus while simultaneously ignoring irrelevant stimuli Example: Look in the direction the center arrow is pointing: èèèèè ççèçç

Conduct Disorder: A disorder in which the basic rights of others or age-appropriate societal norms are violated which can be evidenced by a number of behaviors including, aggression to people or animals, destruction of property, deceitfulness or theft, and serious violations of rules7 Oppositional Defiant Disorder: A disorder characterized by angry/irritable mood, argumentative/defiant behavior, or vindictiveness that lasts for at least six months7 Effect Size: A statistical measure of the strength of the relationship between two variables; it is a standard measure that can be used across studies Mindfulness Interventions: contemplative practices (like yoga or meditation) which emphasis focused attention and awareness of the present moment

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19. RTI Action Network: A Program of the National Center for Learning Disabilities. (2014). Considering tier 3 within a responseto-intervention model. Retrieved from http://www.rtinetwork.org/essential/tieredinstruction/tier3/consideringtier3 20. Schonert-Reichl, K. A., & Lawlor, M. S. (2010). The effects of a mindfulness-based education program on pre- and early adolescents’ well-being and social emotional competence. Mindfulness, 3, 137-151.doi: 10.1007/s12671-010-0011-8 21. Semple, R. J., Lee, J., Rosa, D., & Miller, L. F. (2010). A randomized trial of mindfulness-based cognitive therapy for children: Promoting mindful attention to enhance social-emotional resiliency in children. Journal of Child and Family Studies, 18, 218229. doi: 10.1007/s10826-009-9301-y 22. Common Core State Standards Initiative: Preparing America’s Students for College & Career. (2015). Read the standards. Retrieved from http://www.corestandards.org/read-the-standards/ 23. McLeod, S. A. (2008). Self concept. Retrieved from http://www.simplypsychology.org/self-concept.html 24. Learning to Breathe. (2015). Why is emotion regulation important? Retrieved from http://learning2breathe.org/about/purpose 25. Kidron, Y., & Fleischman, S. (2006, April). Research matters: promoting adolescents’ prosocial behavior. Teaching the Tweens, 63, 90-91. 26. Center on the Developing Child: Harvard University. (2015). Key concepts: Executive function. Retrieved from http:// developingchild.harvard.edu/key_concepts/executive_function/ 27. National Institutes of Health Toolbox. (2012). NIH toolbox flanker inhibitory control and attention test. Retrieved from http:// www.nihtoolbox.org/WhatAndWhy/Cognition/Attention/Pages/NIH-Toolbox-Flanker-Inhibitory-Control-and-Attention-Test.aspx

About the Author Alexandra Bluell holds a Bachelor of Arts in Psychology and Spanish from Bradley University. She was published as the first author on an article in The Journal of Development and Cognition for her work on her senior honor’s thesis, which focused on executive functioning in preschoolers. She recently completed a three year graduate program at Illinois State University, earning a Specialist degree in School Psychology. In Fall of 2015, Alexandra will begin her career as a school psychologist working for a district serving students from preschool through 12th grade.