Editorials for Clinical Practice
CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.
Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.
Mindfulness and child health
If you are struggling to figure out how you, as an individual pediatrician, can make a significant impact on the most common current issues in child health of anxiety, depression, sleep problems, stress, and even adverse childhood experiences, you are not alone. Many of the problems we see in the office appear to stem so much from the culture in which we live that the medical interventions we have to offer seem paltry. Yet we strive to identify and attempt to ameliorate the child’s and family’s distress.
Real physical danger aside, a lot of personal distress is due to negative thoughts about one’s past or fears for one’s future. These thoughts are very important in restraining us from repeating mistakes and preparing us for action to prevent future harm. But the thoughts themselves can be stressful; they may paralyze us with anxiety, take away pleasure, interrupt our sleep, stimulate physiologic stress responses, and have adverse impacts on health. All these effects can occur without actually changing the course of events! How can we advise our patients and their parents to work to balance the protective function of our thoughts against the cost to our well-being?
One promising method you can confidently recommend to both children and their parents to manage stressful thinking is to learn and practice mindfulness. Mindfulness refers to a state of nonreactivity, awareness, focus, attention, and nonjudgment. Noticing thoughts and feelings passing through us with a neutral mind, as if we were watching a movie, rather than taking them personally, is the goal. Jon Kabat-Zinn, Ph.D., learned from Buddhists, then developed and disseminated a formal program to teach this skill called mindfulness-based stress reduction; it has yielded significant benefits to the emotions and health of adult participants. While everyone can be mindful at times, the ability to enter this state at will and maintain it for a few minutes can be learned, even by preschool children.
Structured mindfulness programs for children have been shown to help reduce symptoms of depression, PTSD, anxiety, and negative affect; change maladaptive ways of coping with stress; improve sleep and self-confidence, and improve classroom behavior as well as social and academic performance in school. Some effect on improving attention, even at the EEG level, also has been found. Mindfulness in high-risk populations even has been shown to reduce some of the negative effects of exposure to adverse childhood experiences. Significant increases in telomerase in white blood cells thought to have an impact on immune function and aging also have been reported in preliminary studies. Mindfulness training usually involves 4-20 days of instruction and practice, but as little as 5 minutes per day has been found helpful.
How am I going to refer my patients to mindfulness programs, I can hear you saying, when I can’t even get them to standard therapies? Mindfulness in a less-structured format is often part of yoga or Tai Chi, meditation, art therapy, group therapy, or even religious services. Fortunately, parents and educators also can teach children mindfulness. But the first way you can start making this life skill available to your patients is by recommending it to their parents (“The Family ADHD Solution” by Mark Bertin [New York: Palgrave MacMillan, 2011]).
You know that child emotional or behavior problems can cause adult stress. But adult stress also can cause or exacerbate a child’s emotional or behavior problems. Adult caregivers modeling meltdowns are shaping the minds of their children. Studies of teaching mindfulness to parents of children with developmental disabilities, autism, and ADHD, without touching the underlying disorder, show significant reductions in both adult stress and child behavior problems. Parents who can suspend emotion, take some breaths,deep
and be thoughtful about the response they want to make instead of reacting impulsively act more reasonably, appear warmer and more compassionate to their children, and are often rewarded with better behavior. Such parents may feel better about themselves and their parenting, may experience less stress, and may themselves sleep better at night!
For children, having an adult simply declare moments to stop, take deep breaths, and notice the sounds, sights, feelings, and smells around them is a good start. Making a routine of taking an “awareness walk” around the block can be another lesson. Eating a food, such as a strawberry, mindfully – observing and savoring every bite – is another natural opportunity to practice increased awareness. One of my favorite tools, having a child shake a glitter globe (like a snow globe that can be made at home) and silently wait for the chaos to subside, “just like their feelings inside,” is soothing and a great metaphor! Abdominal breathing, part of many relaxation exercises, may be hard for young children to master. A parent might try having the child lie down with a stuffed animal on his or her belly and focus on watching it rise and fall while breathing as a way to learn this. For older children, keeping a “gratitude journal” helps focus on the positive, and also has some proven efficacy in relieving depression. Using the “1 Second Everyday” app to video a special moment daily may have a similar effect on sharpening awareness.
The goal of mindfulness is to listen to one’s own feelings and thoughts as “just thoughts.” Being aware that feelings, both pleasant and unpleasant, tend to rise and subside like the weather beyond your control is a form of “emotion education,” teaching you to wait them out rather than scream, panic, freeze up, or act out. One theory of how mindfulness helps with resilience to trauma is by helping individuals learn to tolerate unpleasant feelings without “dissociating” (going blank) so that processes such as memory can be maintained, and the traumatic events can become cognitively understood. This skill may allow teens or adults to avoid methods they might otherwise use to dull strong feelings such as excessive eating, drinking, smoking, sex, or drugs. These maladaptive methods of coping are perhaps the main way in which adverse childhood experiences produce long-term morbidity. Recommending mindfulness as one path to healthier coping strategies is one way you can make a difference in your patients’ lives (and your own)!
Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical
Communications. E-mail her at firstname.lastname@example.org.