Gender differences in response to a school-based mindfulness training intervention for early adolescents

Abstract

Mindfulness training has been used to improve emotional wellbeing in early adolescents. However, little is known about treatment outcome moderators, or individual differences that may differentially impact responses to treatment. The current study focused on gender as a potential moderator for affective outcomes in response to school-based mindfulness training. Sixth grade students (N = 100) were randomly assigned to either the six weeks of mindfulness meditation or the active control group as part of a history class curriculum. Participants in the mindfulness meditation group completed short mindfulness meditation sessions four to five times per week, in addition to didactic instruction (Asian history). The control group received matched experiential activity in addition to didactic instruction (African history) from the same teacher with no meditation component. Self-reported measures of emotional wellbeing/affect, mindfulness, and self-compassion were obtained at pre and post intervention. Meditators reported greater improvement in emotional wellbeing compared to those in the control group. Importantly, gender differences were detected, such that female meditators reported greater increases in positive affect compared to females in the control group, whereas male meditators and control males displayed equivalent gains. Uniquely among females but not males, increases in self-reported self-compassion were associated with improvements in affect. These findings support the efficacy of school-based mindfulness interventions, and interventions tailored to accommodate distinct developmental needs of female and male adolescents.

Introduction

Early adolescence presents unique developmental challenges and opportunities for implementing mental health intervention strategies. Early symptoms of emotional disturbance, such as depression or context-inappropriate behaviors or feelings (Code of Federal Regulations, Title 34, §300.8(c)(4)(ii), 2004) tend to emerge during early adolescence (Paus, Keshavan, & Giedd, 2008) with the prevalence rate of 11% to 50% of school-age children experiencing emotional problems severe enough to warrant the use of mental health services (Carter et al., 2010; Kessler et al., 2012; Romano, Tremblay, Vitaro, Zoccolillo, & Pagani, 2001; U.S. Department of Health and Human Services, and Centers for Disease Control and Prevention, 2013). Given the prevalence of pathology and wide need for prevention, development of cost-effective and generalizable interventions that aim to improve emotional wellbeing of adolescents is critical. One emerging strategy that has shown promising effects among the adolescent populations is mindfulness training (Biegel, Brown, Shapiro, & Schubert, 2009; Bögels, Hoogstad, Dun, Schutter, & Restifo, 2008; Broderick & Metz, 2009; Napoli, Krech, & Holley, 2005; Saltzman & Goldin, 2008; Schonert-Reichl & Lawlor, 2010; for a review, see Burke, 2010). However, less is known about moderators of treatment outcomes or factors that influence treatment efficacy that are necessary to inform successful development of evidence-based intervention strategies (Ospina et al., 2007). The current study addressed gender, a critically relevant risk factor for emotional wellbeing/affect among adolescents (for meta-analyses, see Else-Quest, Hyde, Goldsmith, & Van Hulle, 2006; Hofmann, Sawyer, Witt, & Oh, 2010), as a potential treatment outcome moderator for mindfulness intervention success among early adolescents.

Mindfulness training aims to cultivate mindful awareness with nonjudgmental approaches to thoughts, sensations, and feelings, and greater compassion toward one's thoughts and actions (Kabat-Zinn, 1990). Mindfulness training was previously shown to increase self-reported mindfulness (Chambers, Lo, & Allen, 2008; Zeidan, Johnson, Diamond, David, & Goolkasian, 2010) and self-compassion (Birnie, Speca, & Carlson, 2010; Neff, 2003), and positive affect was associated with increases in mindfulness (Baer, 2003) and self-compassion (Hollis-Walker & Colosimo, 2011; Van Dam, Sheppard, Forsyth, & Earleywine, 2011). Therefore, improvements in mindfulness and self-compassion in meditators may predict enhanced affective wellbeing.

Mindfulness training aims to cultivate moment-to-moment non-elaborative attention to and awareness of external and internal events, such as thoughts, emotions and body sensations (Kabat-Zinn, 1990). In practice, individuals maintain awareness of and attention to the present moment, whenever mind wanders, gently but firmly bring back the focus of attention to the initial target object. The goal of such practice is to train the mind to be stable and disengage from habitual mental processes, such as emotional reactivity (Kang et al., 2013, Kang et al., 2014). Mindful attention may allow individuals to identify secondary elaboration of thought processes at the moment they enter the mind. For example, when a student fails an exam, her mind may generate condemnatory self-evaluations (e.g., “I am a failure.”). Mindful attitude may either prevent such secondary evaluations from occurring, or help individuals to embrace already occurred evaluative thoughts as they are, without suppression or distortion (e.g., “I am feeling as though I am a failure.”). Maintaining a subtle distance from mental experiences and observing thoughts as mental events that do not necessarily reflect facts of reality, or de-centering through mindful attention (Segal, Williams, & Teasdale, 2002), can in turn lead to healthy coping strategies to social and academic challenges unique to school environments.

Mindful skills may be particularly beneficial in the midst of increasing demands and challenges students face in their academic and social life. Currently, an increasing number of youths are experiencing clinical disorders and stress-related behavioral problems (e.g., Card & Hodges, 2008; Currie et al., 2002; Lohaus & Ball, 2006): It is estimated that 22.2% of the youths in United States currently have or will have a severe mental disorder (Merikangas et al., 2010), with affect-related disorders such as anxiety and depression being among the most prevalent diagnoses (World Health Organization, 2002). Thus, considering the mental health of students is increasingly imperative to successful formal education, and the vital function of contemporary schools should include not only propagating knowledge, but also cultivating cognitive and affective skills to prevent psychological disorders and adaptively manage social and academic stressors.

School-based mindfulness training can be a powerful addition to existing school programs and can effectively function to meet students' psychological needs. First, mindfulness practice explicitly aims to enhance positive qualities of mind including self-discipline, emotion awareness and regulation, prosocial orientation such as compassion and empathy, and ethical decision making (e.g., Zenner, Herrnleben-Kurz, & Walach, 2014). These qualities might in turn help students to adaptively respond to increasing challenges and flourish in stressful environments (e.g., Shapiro, Brown, & Astin, 2008). Second, school is the primary foundation of most children's social life outside family, and what they have learned through mindfulness training can be directly applied among their peers. Continuous feedback loops can motivate students and provide an ideal ground to monitor their progress. Third, the preventative nature of mindfulness training may provide additional benefits to nonclinical groups before problematic behaviors reach a clinical severity (e.g., Britton et al., 2014). It can also help avoid social stigma associated with traditional clinical treatment programs for clinical groups. Fourth, mindfulness-based programs are often administered in groups, akin to classroom settings, and with standardized intervention modules at a relatively low cost (Weare & Nind, 2011). Mindfulness training may be especially effective for the schools in low income and underserved communities, where the need for general and preventative mental health resources is greatest (Mendelson et al., 2010). These unique features collectively position mindfulness training feasible for school-based group interventions.

For these reasons, mindfulness is especially suitable for integration into school psychology practice (Felver, Doerner, Jones, Kaye, & Merrell, 2013); however, mindfulness research is yet to be centrally established in school psychology. Theories and practice available in mindfulness can offer new and effective school-based interventions to help maintain and enhance affective health of students. Mindfulness intervention could be implemented by school psychologists with foundational training in mindfulness intervention via classroom-based small group interventions, and school psychology programs can prepare clinicians who can provide mindfulness-based consultative services in school. Given their specific training and major roles in addressing mental health needs of adolescents, school psychologists can provide insights into the mindfulness-based intervention research for children, and more generally, the development of preventative interventions that focus on using inherent individual strengths of the child.

Given the gender difference in affect and affect processing, different genders may respond to mindfulness interventions through potentially divergent affect-related mechanisms. Specifically, affect-related gender differences may lead not only to divergent outcomes but also through different pathways, that is, female and male participants may both show improvements in affect outcomes but through distinctive mechanisms. Consistent with this idea, improvements in affective health in female adults as a function of mindfulness training was associated with increases in self-compassion, whereas for male counterparts, self-compassion was not associated with changes in affect (Rojiani, Santoyo, Rahrig, Roth, & Britton, 2017). Because of the greater risk and need for prevention/treatment of affective disturbance among female adolescents compared to males, we focused on the mechanisms that may explain positive affect changes in females. Changes in self-compassion and mindfulness as a function of mindfulness training were examined, and whether they differ in predicting outcomes by gender. In particular, we tested whether more affective (vs. cognitive) pathway through increases in compassion (vs. mindfulness) may lead to greater changes in emotional wellbeing among females.

Mindfulness research among early adolescents is still in its infancy and more extensive studies are warranted to test its suitability and efficacy in this population; however, initial findings seem promising. Preliminary evidence supports general benefits of mindfulness training among youths across a wide range of domains including academic performance (Sibinga et al., 2011), social skills (Beauchemin, Hutchins, & Patterson, 2008), aggressive behavior (Singh et al., 2011; Singh et al., 2011), and sleep quality (Bootzin & Stevens, 2005; Britton et al., 2010), among various other outcomes (for a review, see Burke, 2010; c.f., Maynard, Solis, Miller, & Brendel, 2017).

In our previous report (the same sample as in the current study), mindfulness training improved emotional wellbeing among early adolescents (Britton et al., 2014). Other preliminary evidence supports overall efficacy of mindfulness intervention on emotional wellbeing in youths (for reviews, see Felver, Celis-de Hoyos, Tezanos, & Singh, 2016; Greenberg & Harris, 2012): Among K-12 grades, mindfulness training was associated with decreased negative affect and increased positive affect (Broderick & Metz, 2009), decreased emotional reactivity (Saltzman & Goldin, 2008) and emotional discomfort (Sibinga et al., 2011), improved teacher-reported socio-emotional competence (Schonert-Reichl & Lawlor, 2010), improved self-reported emotion regulation/stress coping (Broderick & Metz, 2009), increased subjective happiness (Bögels et al., 2008), and reduced symptoms of affect disorders such as anxiety (Biegel et al., 2009; Napoli et al., 2005), depression (Biegel et al., 2009; Liehr & Diaz, 2010; Tan & Martin, 2012), and rumination (Mendelson et al., 2010). Finally, four meta-analyses results (Black, Milam, & Sussman, 2009; Kallapiran, Koo, Kirubakaran, & Hancock, 2015; Zenner et al., 2014; Zoogman, Goldberg, Hoyt, & Miller, 2015) support that mindfulness training programs may be promising interventions designed to benefit affective health of children and early adolescents. However, several studies also report null or mixed effects (for a review, see Maynard et al., 2017), highlighting the complexity of mindfulness as an intervention strategy and the importance of examining potential moderators of the outcomes.

We propose that a critical next step is to examine individual difference variables among youths that may lead to divergent suitability and efficacy outcomes. Specifically, we focus on gender as a potential variable that may moderate the effects of meditation training (e.g., Desbordes et al., 2012). Data from our own lab (Rojiani et al., 2017) and others (de Vibe et al., 2013) showed gender at as an outcome moderator in adults (for a review, see Katz & Toner, 2013), such that female adults were generally shown to respond to meditation intervention favorably whereas male counterparts did not. In youth populations, it is still unknown if gender also serves as a moderator. Examining potential gender effects is especially important given the prevalence of gender difference in affective disturbances and treatment outcomes among adolescents (Table 1), and can help refine and enhance existing programs and critically inform future development of school-based mindfulness programs. Therefore, we re-analyzed our pre-existing dataset (Britton et al., 2014) to test whether gender served as a moderator in youths as well.

In early childhood, no apparent gender difference exists in most affect-related disorders such as depression (Brooks-Gunn & Petersen, 1991; Nolen-Hoeksema, 1987; Rutter, Izard, & Read, 1986), and anxiety disorders (Lewinsohn, Gotlib, Lewinsohn, Seeley, & Allen, 1998). Around the onset of puberty, however, a marked gender difference emerges such that by late adolescence, females are about twice as likely to experience symptoms of depression (for reviews, see McGrath, Keita, Strickland, & Russo, 1990; Nolen-Hoeksema, 1987), and anxiety (Lewinsohn et al., 1998) than their male counterparts.

Researchers argue that this gender-moderated emergence of affective illness is due to the increased affect-related risk factors among females compared to males during early adolescence (e.g., Nolen-Hoeksema & Girgus, 1994). Such risk factors that unfavorably impact females include negative affectivity (Lewinsohn et al., 1998), which describes increased sensitivity to negative stimuli that leads to a broad range of negative moods (Clark, Watson, & Mineka, 1994), and maladaptive coping strategies that lead to negative affect (e.g., self-criticism, rumination; Nolen-Hoeksema & Girgus, 1994). As summarized in Table 1, several studies have found gender-based differences in affective disorder and intervention outcomes. Given the consistent evidence on gender-based differences in affect processing, interventions that aim to modify affect and affect-related coping strategies may differentially impact males and females during early adolescence (Table 1). Consistent with this prediction, cognitive behavioral therapy (CBT) may lead to diverging coping styles among male and female adolescents, such that females endorsed greater use of affective support seeking as a coping strategy compared to males (Mendlowitz et al., 1999). Mindfulness training specifically targets risk factors that are unique to female adolescents such as positive affectivity (Anderson, Lau, Segal, & Bishop, 2007; Nyklíček & Kuijpers, 2008; Ortner, Kilner, & Zelazo, 2007) and adaptive coping strategies (Birnie et al., 2010). Therefore, females may demonstrate greater improvements in their emotional wellbeing as a result of mindfulness training compared to their male counterparts.

Consistent with previous findings on the psychological benefits of mindfulness training among youths (Black et al., 2009; Shapiro, Astin, Bishop, & Cordova, 2005), we predicted and previously reported using the same sample, that mindfulness training can increase emotional wellbeing among early adolescents (Britton et al., 2014). The current study further examined gender as a potential moderator for affective outcomes in response to school-based mindfulness training among early adolescents.

Q1. Given the risk factors that place female students at greater disadvantage in terms of affect and affect-related coping styles, and based on the evidence of mindfulness training improving these outcomes, we tested whether mindfulness training would bring greater benefits in affective symptoms for female than for male students.

Q2. We examined whether increases in mindfulness and self-compassion would be associated with improvements of affect outcomes, and tested potential gender difference in these relations.