Brief Report: Mindfulness Training for Chinese Adolescents with Autism Spectrum Disorder and Their Parents in Hong Kong

Studies have shown autism spectrum disorder (ASD) has an increasing prevalence in the last decade (Matson and Kozlowski 2011; Polanczyk et al. 2015). In the Chinese population, the pooled prevalence of ASD is 26.6 per 10,000 (95% Confidence Interval: 18.5, 34.6; Sun et al. 2013). ASD is one of the common neurodevelopmental disorders observed among adolescents. Besides impaired social communication and restricted, repetitive patterns of behaviour (American Psychiatric Association 2013), adolescents with ASD exhibit externalizing and internalizing problems (Bauminger et al. 2010), attention problems (Bauminger et al. 2010), as well as deficits in executive function (Margari et al. 2016). They experience difficulties in behavioural regulation (e.g. controlling impulses, shifting attention, and regulating emotion) and metacognition (e.g. implementing problem-solving strategies, working memory, planning events, organizing materials, and self-monitoring). As it concerns the many difficulties that adolescents with ASD have, treatments are needed to improve their competence and functions in daily life, as well as comorbid emotional problems.

Currently, applied behavioural analysis (ABA), social intervention, CBT, and medication are the most common treatments for adolescents with ASD. They are shown to have some positive impacts on social functioning, anxiety, and behavioural problems. However, there are certain limitations to each treatment. For example, ABA is intensive and requires long-term participation to optimize the outcomes. Also, most of the ABA effectiveness studies are conducted on young children with ASD, instead of adolescents with ASD (Reichow and Volkmar 2010). Social skill interventions are shown to have a small treatment effect (Gates et al. 2017) and might lead to increased anxiety after training (Swain et al. 2015). Cognitive behavioural therapy (CBT) is effective in treating comorbid anxiety of individuals with ASD (Sukhodolsky et al. 2013), but not ASD itself. Medications have adverse side-effects and similar effectiveness compared to placebo (Reddihough et al. 2019; Yatawara et al. 2015). As it concerns the shortcomings in current treatments, further research is required to explore new treatments.

Mindfulness training could be a potential treatment for adolescents with ASD. Recently, a mindfulness-based intervention (MBI), called the MYmind program, was developed for adolescents, who have ASD without having intellectual disability or borderline intelligence, and their parents. It consists of 9 weekly 1.5-h mindfulness-training sessions for adolescents and parents separately. There are several reasons to suggest the MYmind program has beneficial effects on adolescents with ASD. Firstly, in consideration of ASD symptoms, mindfulness involves focusing on the present moment, which includes moments of having interaction with others. It helps adolescents with ASD pay attention to social cues during interaction with others and give appropriate responses. Secondly, in consideration of executive function, mindfulness involves mind–body exercise, which allows adolescents with ASD to shift attention and monitor the interaction among mind, body, and behaviours, hence foster self-control of emotion and behaviour (Chan et al. 2013). Also, studies have shown practising mindfulness could protect against proactive interference and promote insightful thinking (Greenberg et al. 2019; Ren et al. 2011), which could in turn improve metacognition (e.g. working memory and problem-solving) of adolescents with ASD. Thirdly, in consideration of attention problems, mindfulness meditation helps adolescents with ASD stay present by bringing attention back to breath whenever get distracted. Fourthly, in consideration of externalizing and internalizing problems, mindfulness helps adolescents with ASD promote self-reflection (Marcovitch et al. 2008), which could facilitate positive behavioural changes. Moreover, long-term meditation training could reduce amygdala reactivity (Kral et al. 2018), which suggests improved emotional responses of adolescents with ASD toward stress. Fifthly, the MYmind program involves mindfulness training for parents. It allows parents to establish a positive parenting style by being thoughtful and empathic, which in turn decreases their children's problem behaviours (Singh et al. 2006, 2014). Also, previous studies have shown parents of children with ASD experience higher levels of stress, rumination, and poorer well-being than parents of children with typical development (Bonis 2016; Carpita et al. 2019; Giallo et al. 2013; Lai et al. 2015; Wang et al. 2013). Providing mindfulness training could help them alleviate these problems and reduce their burdens.

In regard to previous MBI studies to adolescents with ASD and their parents, many of them focused on providing mindfulness training to parents, and a few of them focused on providing mindfulness training to adolescents with ASD. To our knowledge, only a limited number of studies had examined the use of MBI on both adolescents with ASD and parents at the same time. For the MYmind program, three prior studies explored its effectiveness on adolescents with ASD and parents with pre-post-follow up design (de Bruin et al. 2015; Ridderinkhof et al. 2017; Salem-Guirgis et al. 2019). Various measurements were used among the studies and consistent findings were found that adolescents with ASD had improved social responsiveness, while parents had improved mindful parenting skills after the program. Other positive findings among the studies showed that mindfulness training had beneficial effects on adolescents with ASD (in terms of attention problems, externalizing and internalizing problems) and parents (in terms of parenting style, well-being, and parenting stress) (de Bruin et al. 2015; Ridderinkhof et al. 2017; Salem-Guirgis et al. 2019). Apart from quantitative studies, a qualitative study was conducted to interview adolescents with ASD and their parents about the experience of participating in the MYmind program (Ridderinkhof et al. 2019). Results showed the program was positively rated and both adolescents with ASD and parents reported positive self-changes in social and emotional aspects, such as attuning to others and being calm.

Despite the positive results found in the previous MYmind studies, the effects of mindfulness on adolescents with ASD and their parents need to be further investigated because none of the previous studies has a control group to compare with the intervention group (de Bruin et al. 2015; Ridderinkhof et al. 2017; Salem-Guirgis et al. 2019). Since there is a lack of studies investigating the effectiveness of MBI on families of adolescents with ASD in the Chinese context, the current study represents the first pilot randomized controlled trial to evaluate the feasibility and preliminary effectiveness of the MBI (MYmind program) on Chinese adolescents with ASD and their parents in Hong Kong, China. In light of the prior findings (de Bruin et al. 2015; Ridderinkhof et al. 2017; Salem-Guirgis et al. 2019), we not only aim to explore the effectiveness of mindfulness training on Chinese adolescents with ASD (in terms of social responsiveness, attention problems, externalizing and internalizing problems) and their parents (in terms of parenting stress, parenting style, mindful parenting, and mental well-being), but also to examine whether mindfulness training could improve executive function of adolescents with ASD and reduce rumination of parents. We hypothesized that the MYmind program was feasible and effective to adolescents with ASD (reduced attention problems, externalizing and internalizing problems, and improved social responsiveness and executive function) and parents (reduced rumination and parenting stress, and improved mindful parenting skills, mental well-being, and parenting style) when compared to a waitlist control group.

A total of 133 families registered for the study (See Fig. 1). In the screening process, 90 (68%) families were not eligible for the study. The major reasons were parents were unable to provide a diagnostic report of their child, and adolescents either did not have a diagnosis of ASD or were too young to join the program. There was 1 family excluded from the study because the adolescent had both ASD and oppositional defiant disorder (ODD). In the end, 37 out of 42 (88%) eligible families were included in the study; 19 families were randomised to the MYmind group and 18 families were randomised to the waitlist control group. Seventeen (89%) parents in the MYmind group and 14 (78%) parents in the waitlist control group completed the post-assessment.

According to the compliance rate, the retention rate, and the recruitment rate, the study showed the feasibility of launching the MYmind program for Chinese adolescents with ASD and their parents. The MYmind program in the study achieved an attendance rate of 80%, which was consistent with the findings of 70–100% attendance rate in other MBI studies for ASD individuals and their caregivers (de Bruin et al. 2015; Hartley et al. 2019; Ridderinkhof et al. 2017; Salem-Guirgis et al. 2019). For retention rate, there was no dropout in the MYmind group and the response rate in the post-assessment was 89%. The results were aligned with other MBI studies, which showed a range of 0–40% dropout rates and a range of 60–100% response rates (de Bruin et al. 2015; Hartley et al. 2019; Ridderinkhof et al. 2017; Salem-Guirgis et al. 2019). Apart from the compliance rate and the retention rate, the recruitment rate was adequate and about one-third of the families who registered for the study met our selection criteria. Among the eligible families, nearly 90% of them participated in the study. The majority of the applicants were excluded from the study because they did not meet the inclusion criteria (eg. Age, ASD diagnosis). To conduct a larger RCT in the future, it was suggested to recruit participants from clinics and NGO organizations, which provide service for adolescents with ASD and have a long-term good relationship with the families. Overall, the MYmind program was regarded as comprehensible and acceptable to Chinese adolescents with ASD and their parents, in terms of the easiness of program contents, the helpfulness to parents, and the satisfaction of the program. However, parents perceived the program was helpful to their children to a small extent. To examine the helpfulness of the program in detail, it was suggested to ask both adolescents and parents to rate the usefulness of each training session theme and mindfulness exercises in future studies.

The Holm–Bonferroni sequential correction was used for the analysis of the secondary outcomes. No statistically significant difference was found in within-group or between-group comparison. In the within-group comparison of adolescent’s outcomes, both the MYmind group and the waitlist control group showed improvement in social responsiveness and internalizing problems. The possible explanation for the unexpected improvement in the waitlist control group could be due to the time arrangement of the intervention. As the intervention was arranged during summer vacation, adolescents with ASD did not need to go to school (stress-inducing environment) and therefore might have a lower level of stress, which was associated with improved social functioning and reduced internalizing problems (Bishop-Fitzpatrick et al. 2015; Sheidow et al. 2014). As adolescents with ASD were not under stress, it could be possible that mindfulness demonstrated little effect on the outcomes in the MYmind group. An additional follow-up assessment might be able to see the beneficial effect of mindfulness on adolescents with ASD when school resumed. Furthermore, in the measure of executive function, it was noted that adolescents in the MYmind group had little improvement. It seemed mindfulness had no beneficial effects on executive function of adolescents with ASD. However, as the results were based on parents’ reports and the sample size was small, further investigation of the effectiveness of mindfulness on executive function was suggested. In future studies, self-reported questionnaires and task-based tools are recommended to use as alternative measures of executive function.

In the within-group comparison of parent’s outcomes, the MYmind group had an overall greater improvement than the waitlist control group. However, an increase in laxness parenting was found among parents in the MYmind group, which meant parents tended to act permissively and had fewer demands on their children’s behaviours. This result was in contrast to the previous finding that mindful parenting was negatively associated with laxness parenting (de Bruin et al. 2015; Gouveia et al. 2016). The possible explanation could be due to the cultural difference. As Chinese culture emphasizes order and discipline in parenting, parents in Hong Kong are more demanding and stricter to their children (Shek 1997). They often set high standards and expect their children to follow. As a result, children often suffer from stress and have a lower level of psychosocial well-being (Yip et al. 2019). In the MYmind program, parents were taught to put themselves in their children’s shoes. They learned to accept the limitations of their children, and hence adjusted their expectations and made fewer demands on their children’s behaviours. In future studies, interviews can be included to further understand the effect of mindfulness on parenting style.

In the between-group comparison of adolescent’s and parent’s outcomes, no statistically significant difference was found between the MYmind group and the waitlist control group. Nevertheless, a big between-group effect size was found in the measure of rumination. This suggested that mindfulness might have beneficial effects on reducing the rumination of parents of adolescents with ASD. In regard to prior studies (Deyo et al. 2009; Jury and Jose 2018; Svendsen et al. 2016), positive results were also found that mindfulness was associated with a lower level of rumination. The mechanism could be mindfulness helped individuals acknowledge their thoughts with a non-judgemental attitude, which allowed them to better cope with emotional distress and let go of obsessive thoughts. In addition to rumination, medium between-group effect sizes were found in the measure of mindful parenting (IM-P’s total scale and emotional awareness subscale), parenting stress (parent–child dysfunctional interaction subscale), and parenting style (over-reactivity subscale). Compared to previous studies (Chaplin et al. 2018; Coatsworth et al. 2010; Lo et al. 2017a, b; Potharst et al. 2019), the current results were in alignment; previous results showed there was strong statistical evidence indicating mindfulness might benefit parents of adolescents with ASD by improving these aspects. The mechanism could be explained by the mindful parenting model (Duncan et al. 2009), which proposed that mindfulness helped parents bring emotional awareness to parenting interaction. Parents were therefore able to avoid over-reactive responses to their children and improve the parent–child relationship.

Due to the increase in ASD prevalence, innovative interventions are needed to support families of children with ASD. This study is the first RCT to investigate the effectiveness of a mindfulness-based intervention (MYmind) on Chinese adolescents with ASD and their parents in Hong Kong, China. Results showed the MYmind program was feasible in the Chinese context. Although the secondary outcomes were not statistically significant, there were some notable findings in parent’s rumination, mindful parenting, parenting style, and parenting stress. Future study with larger sample size and longer follow-up period is suggested to better examine the effectiveness of mindfulness training on adolescents with ASD and their parents.