Maric, Willard, Wrzesien, & Bögels (2019). Innovations in the treatment of childhood anxiety disorders: Mindfulness and self-compassion approaches." - Article summary

The most cost-effective treatment for childhood anxiety disorders (CAD) is cognitive behavioural therapy (CBT). It typically includes elements of cognitive restructuring and exposure activities aimed at targeting common anxiety symptoms. Involving the parents or family in CBT for CAD is only beneficial under certain conditions. However, about a third of the children do not respond to treatment and children with social anxiety disorder benefit less well than children with other disorders.

Attention problems play an important role in anxiety disorders (e.g. attentional bias). Mindfulness may affect attention as it is related to focusing one’s attention. Mindfulness implies welcoming daily hassles with acceptance, calmness, self-compassion and gratefulness. Mindfulness refers to awareness that arises by paying attention on purpose (1), focusing on the present moment (2) and non-judgementally (3). It is a mental state achieved by focusing on one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, bodily sensations, and action tendencies. Beginner’s mind refers to opening oneself to an experience as if it were the first experience.

The primary goal of mindfulness-based treatment include helping the child and system recognize triggers for anxiety and identify skills to use in those situations while simultaneously working to reduce heightened physiological arousal. Mindfulness-based therapy should begin with interviewing the child and the caregivers. Identifying symptoms and triggers of anxiety offers clinicians insight in the best ways and times to help the child integrate mindfulness skills into daily life and anxiety-provoking situations. Engaging caregivers an educators will reinforce practice and progress in the child.

One goal of mindfulness is to have the child practicing mindfulness on his own to regulate anxiety and avoidance independently. However, anxious children need systemic support and reinforcement for this. Relevant adults need to help children recognize and understand the triggers of anxiety and reinforce using mindfulness skills. Parents suffer from high stress when their child has severe anxiety disorders. Developing mindfulness in the parents can reduce this stress and facilitate progress in the child. This allows the parents to become a model for their child in how to apply mindfulness skills in stressful situations.

Mindfulness based cognitive therapy for anxious children (MBCT-C) refers to a manualized treatment that consists of 6 weekly 45-minute sessions and aims to train the children’s attention by focusing on bodily sensations and perceptions. Mindfulness is integrated in breathing exercises, walking and sensory experiences. The emphasis is on learning through experience, describing experiences and not judging them or labelling them. There are group activities and parents are engaged by using psychotherapy (1), having therapist-conducted mindfulness sessions for the parents (2), teaching parents about different mindfulness exercises (3), having parents participate in homework activities of children (4) and having parents participate in post-training qualitative interviews (5).

UvA minds refers to a treatment with 8 weekly two-hour group sessions. The aim is to teach adolescents to cope with difficult and worrisome thoughts, learning how to relax, sleep and concentrate better. It consists of outdoor activities (1), yoga exercises (2) and practicing mindfulness (3). The adolescents learn to know their inner world and learn strategies how to engage in difficult feelings and thoughts. ABC schemes and writing exercises are implemented to make adolescents more aware.

Mindfulness techniques are easily combined with cognitive-behavioural and other systemic approaches. Self-compassion is an integral part of mindfulness interventions. This has a protective function against psychopathology. Self-compassion consists of three components:

1. Self-kindness (i.e. treating oneself with care and compassion when experiencing challenges as opposed to self-judgement).
2. Sense of common humanity (i.e. understanding that our struggles are part of the human experience as opposed to isolation).
3. Mindfulness (i.e. maintaining a balanced perspective when faced with difficulties as opposed to over-identification).

Self-compassion exercises (e.g. guided meditation; compassionate letter writing) can be integrated into traditional therapies. Self-compassion skills work best when all individuals with whom the patient interacts on a daily basis are involved and engaged in the treatment. However, people who are high in self-criticism may experience fear of compassion, which refers to intense pain that is released because the unconditional love that is practiced reveals the conditions under which was unloved in the past.

Mindfulness self-compassion (MSC) and compassion focused therapy (CFT) are two self-compassion interventions. In a similar 8-week intervention of 1.5 hours for teens, youth learn self-compassion across themes of definitions of mindfulness and self-compassion (1), paying attention on purpose (2), loving kindness (3), self-compassion (4), self-esteem/self-compassion (5), living deeply (6), working with difficult emotions (7) and embracing your life with gratitude (8).

The effectiveness of mindfulness training in anxious children is understudied and there are no clear results of the effectiveness. Self-compassion is strongly associated with anxiety symptom reductions in adults. Higher levels of self-compassion are accompanied by lower levels of anxiety symptoms. However, results are not replicated for youth. Nonetheless, self-compassion interventions seem promising for interventions for youth anxiety disorders.  

Attentional processes may be a mediator of mindfulness training outcomes, though this is not clear. Acceptance and awareness could also be important processes underlying mindfulness training outcomes in children.

The severity of anxiety problems (1), type of childhood anxiety disorder (2), comorbid externalizing problems (3) and comorbid depression (4) may be moderators of effectiveness of mindfulness interventions for childhood anxiety disorders.

Self-compassion may be a mediator in mindfulness interventions. Self-compassion could decrease rumination and emotion suppression and increase positive psychological qualities as self-compassion increases the ability to deal with negative emotions and influence an enhancement in positive emotions. Gender may be a moderator of self-compassion interventions as self-compassion levels are slightly lower for women than men with the difference being larger in populations with higher level of ethnic minorities.

During the intake phase of treatment, assessments of mindfulness, self-compassion and other-related constructs (e.g. self-criticism) should be obtained as well as interest and possibilities in practicing mindfulness. Mindfulness can best be implemented in a manualized manner and in combination with cognitive-behavioural strategies. Homework is essential as mindfulness requires daily practice.