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Vo DX, Tabi K, Bhullar M, Johnson A, Locke J, Wang S, Stewart SE, Marshall SK. Mindful awareness and resilience skills for adolescents (MARS-A): a mixed-methods study of a mindfulness-based intervention for a heterogeneous adolescent clinical population. Int J Adolesc Med Health 2024; 36:25-35. [PMID: 38298033 DOI: 10.1515/ijamh-2023-0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/15/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVES Mindful Awareness and Resilience Skills for Adolescents (MARS-A) is a mindfulness-based intervention adapted for the adolescent population. While previous studies have explored the benefits of MARS-A in various single-diagnosis populations, the aim of this study was to assess MARS-A for a heterogenous clinical adolescent population with mental health and/or chronic diagnoses, focusing on the underlying suffering present in all these conditions rather than its effects on a single diagnosis itself. METHODS Qualitative data was collected through interviews to understand post-intervention participant perspectives and experiences. Quantitative data was collected through measures to investigate preliminary secondary outcomes. RESULTS After participating in MARS-A, participants reported qualitative benefits in enhanced well-being, including coping with difficult emotions and managing sleep and/or pain. Quantitative results showed a reduction in functional disability, psychological distress, perceived stress, and depressive symptoms; increase in positive affect; and benefit in coping with pain and chronic conditions. CONCLUSIONS MARS-A shows great potential in a heterogeneous clinical adolescent population.
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Affiliation(s)
- Dzung X Vo
- Centre for Mindfulness, BC Children's Hospital, Vancouver, Canada
- BC Children's Hospital Research Institute, Vancouver, Canada
- BC Children's Hospital, Vancouver, Canada
- Division of Adolescent Health and Medicine, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Katarina Tabi
- Centre for Mindfulness, BC Children's Hospital, Vancouver, Canada
- BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, Vancouver, Canada
- Department of Psychiatry, The University of British Columbia, Vancouver, Canada
| | - Manreet Bhullar
- Centre for Mindfulness, BC Children's Hospital, Vancouver, Canada
- BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, Vancouver, Canada
| | - Andrea Johnson
- School of Social Work, The University of British Columbia, Vancouver, Canada
| | - Jake Locke
- BC Children's Hospital, Vancouver, Canada
| | - Sophia Wang
- Centre for Mindfulness, BC Children's Hospital, Vancouver, Canada
- BC Reproductive Mental Health Program, BC Women's Hospital and Health Centre, Vancouver, Canada
| | - S Evelyn Stewart
- Centre for Mindfulness, BC Children's Hospital, Vancouver, Canada
- BC Children's Hospital Research Institute, Vancouver, Canada
- Department of Psychiatry, The University of British Columbia, Vancouver, Canada
- BC Mental Health and Substance Use Research Institute, Vancouver, Canada
| | - Sheila K Marshall
- Division of Adolescent Health and Medicine, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- School of Social Work, The University of British Columbia, Vancouver, Canada
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Bluth K, Lathren C, Park J, Lynch C, Curry J, Harris-Britt A, Gaylord S. Feasibility, acceptability, and depression outcomes of a randomized controlled trial of Mindful Self-Compassion for Teens (MSC-T) for adolescents with subsyndromal depression. J Adolesc 2024; 96:322-336. [PMID: 38010232 PMCID: PMC10948004 DOI: 10.1002/jad.12277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/26/2023] [Accepted: 11/16/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Adolescents are experiencing high rates of depressive symptoms, with negative consequences to their long-term health. Group-based, mindful self-compassion programs show promise in mitigating the development of more significant depression in at-risk adolescents. However, the lack of well-designed, active control conditions has limited the ability to examine the efficacy of such interventions. METHODS Fifty-nine adolescents (Mage = 15.81, 70% female) with subsyndromal depressive symptoms from the Southeastern US were randomized to group-based Mindful Self-Compassion for Teens (N = 30) or a newly developed active control Healthy Lifestyles group (N = 29) during 2018 and 2019. Participants attended 8 weekly "main" sessions followed by 6 monthly continuation sessions. The feasibility and acceptability of participation in both groups were measured using attrition, attendance, credibility, and satisfaction data. Depression scores were collected weekly, and self-compassion scores were collected five times across 36 weeks. RESULTS Both groups were equally feasible and acceptable during the 8-week program period; however, monthly continuation sessions were poorly attended in both groups. The risk of developing clinically significant depression was 2.6 times higher in the control group compared with the self-compassion group (p = .037) across 36 weeks. Depression significantly decreased in the self-compassion group, while it significantly increased in the control group. Both groups increased significantly in reports of self-compassion. These findings are on par with results noting the efficacy of cognitive-based interventions for high-risk adolescents; follow-up studies with larger sample sizes should be conducted to confirm these findings. CONCLUSIONS Initial examination suggests Mindful Self-Compassion for Teens programming is feasible, acceptable, and efficacious in preventing the development of clinically significant depression in adolescents with subsyndromal depression. Future studies may benefit from refinements to the self-compassion measurement and/or the attention control condition; moreover, larger sample sizes are needed to confirm results.
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Affiliation(s)
- Karen Bluth
- Department of Psychiatry, University of North Carolina School of Medicine, Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christine Lathren
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jinyoung Park
- Department of Psychology and Neuroscience, Duke University, Durham, North Carolina, USA
| | - Chanee Lynch
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - John Curry
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - April Harris-Britt
- AHB Center for Behavioral Health and Wellness, Durham, North Carolina, USA
| | - Susan Gaylord
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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France E, Uny I, Turley R, Thomson K, Noyes J, Jordan A, Forbat L, Caes L, Silveira Bianchim M. A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments. Cochrane Database Syst Rev 2023; 10:CD014873. [PMID: 37795766 PMCID: PMC10552070 DOI: 10.1002/14651858.cd014873.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them. OBJECTIVES 1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services? SEARCH METHODS Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022. SELECTION CRITERIA To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families. DATA COLLECTION AND ANALYSIS We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain. MAIN RESULTS We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work. AUTHORS' CONCLUSIONS We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.
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Affiliation(s)
- Emma France
- NMAHP Research Unit, University of Stirling, Stirling, UK
| | - Isabelle Uny
- Institute of Social Marketing, University of Stirling, Stirling, UK
| | - Ruth Turley
- Development Directorate, Cochrane Central Executive, Cochrane, London, UK
| | - Katie Thomson
- Occupational Therapy, Human Nutrition & Dietetics, Glasgow Caledonian University, Glasgow, UK
| | - Jane Noyes
- Centre for Health-Related Research, Fron Heulog, Bangor University, Bangor, UK
| | - Abbie Jordan
- Department of Psychology, University of Bath, Bath, UK
- Bath Centre for Pain Research, University of Bath, Bath, UK
| | - Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | - Line Caes
- Department of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, UK
| | - Mayara Silveira Bianchim
- NMAHP Research Unit, University of Stirling, Stirling, UK
- Centre for Population Health and Wellbeing Research, School of Medical and Health Sciences, Bangor University, Bangor, UK
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Ahola Kohut S, Keefer L. Building a Self-Management Toolkit for Patients with Pediatric Inflammatory Bowel Disease: Introducing the resilience 5. Gastroenterol Clin North Am 2023; 52:599-608. [PMID: 37543403 DOI: 10.1016/j.gtc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
Transition from pediatric to adult health care is a complex process that calls for complex interventions and collaboration between health care teams and families. However, many inflammatory bowel disease (IBD) clinical care teams do not have the resources to implement rigorous transition programs for youth. This review provides a description of the Resilience5: self-efficacy, disease acceptance, self-regulation, optimism, and social support. The Resilience5 represents teachable skills to support IBD self-management, offset disease interfering behaviors, and build resilience in adolescents and young adults transitioning to adult health care systems. These skills can also be encouraged and reinforced during routine IBD clinical care.
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Affiliation(s)
- Sara Ahola Kohut
- Department of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, 555 University Avenue, Toronto, Onatrio, Canada.
| | - Laurie Keefer
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, USA
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Peacefull: A French mindfulness-based intervention for adolescents with chronic pain a feasibility study. Arch Pediatr 2022; 29:581-587. [PMID: 36109288 DOI: 10.1016/j.arcped.2022.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/26/2022] [Accepted: 06/18/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Pediatric chronic pain can lead to serious consequences in terms of daily functioning and global quality of life. Mindfulness-based intervention (MBI) approaches that emphasize accepting rather than controlling pain have gained increasing attention in adults with chronic pain. The effectiveness of MBIs for chronic pain in the pediatric population remains unknown. The aim of the Peacefull program was to study the feasibility in France of a mindfulness program for adolescents with chronic pain, based on a program especially developed in Canada and Belgium. METHOD An MBI for adolescents consisting of eight 90-min sessions was provided. It focused on building skills and incorporated mindfulness meditation, exercises, and activities especially adapted to teenagers with chronic pain. RESULTS A total of 27 adolescents aged 12-17 years who were diagnosed with a chronic pain condition were enrolled in five cohorts from April 2018 to June 2021. The completion rate of the Peacefull program was 88.89 with no dropouts and good completion of outcome measures. Secondary outcomes were assessed before the program, at the end, and 3 months later. A trend toward an improvement was observed on the mean average score for the Visual Analog Scale (VAS), but it was not statistically significant. Scores increased significantly over time on the Functional Disability Inventory (FDI), and pain catastrophizing also improved. CONCLUSIONS Although the findings regarding the effectiveness of Peacefull programs were inconsistent and insufficient, they can be indicative of the benefits of mindfulness as an adjuvant treatment for adolescents with chronic pain.
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Peris-Baquero Ó, Osma J, Gil-LaCruz M, Martínez-García L. Acceptability of and intention to use the Unified Protocol delivered in group format in the Spanish Public Health System. J Eval Clin Pract 2021; 27:1299-1309. [PMID: 33565231 DOI: 10.1111/jep.13546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/14/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The high prevalence of emotional disorders leads to a high demand for mental care which results in high costs and long waiting lists in public mental health settings. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a recent emotion-regulation-based intervention that can be a cost-effective solution in public mental health settings due its transdiagnostic approach and the possibility to apply it in group format. However, the acceptability by mental healthcare professionals (MHCPs) delivering the UP in group format has not been explored. METHODS Thirty-three MHCPs, grouped into MHCPs without previous experience and MHCPs with experience in delivering the UP, were asked about aspects of acceptability and intention to use. Quantitative analysis was carried out to explore MHCPs acceptability. Furthermore, qualitative opinion about UP were collected through a SWOT (strengths, weaknesses, opportunities, threats) analysis to explore MHCPs opinion of delivering the UP intervention in a group format, within the Spanish Public Mental Health System. RESULTS The results showed high scores in all acceptability dimensions and intention to use in the future. SWOT analysis showed strengths and opportunities focusing on its transdiagnostic nature and the cost-effective benefits of group treatment, and weaknesses and threats related to the limited material and human resources. CONCLUSIONS Findings indicate high acceptability of the UP by MHCPs working within the Spanish Public Mental Health System and also identified areas for improvements. In order to enhance the dissemination and implementation of the UP, it is essential to consider MHCPs' perceptions and to be open to their suggestions.
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Affiliation(s)
- Óscar Peris-Baquero
- Departamento de Psicología y Sociología, Facultad de Ciencias Sociales y Humanas, Universidad de Zaragoza, Teruel, Spain.,Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Jorge Osma
- Departamento de Psicología y Sociología, Facultad de Ciencias Sociales y Humanas, Universidad de Zaragoza, Teruel, Spain.,Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Marta Gil-LaCruz
- Departamento de Psicología y Sociología, Facultad de Ciencias de la Salud, Zaragoza, Spain
| | - Laura Martínez-García
- Departamento de Psicología y Sociología, Facultad de Ciencias Sociales y Humanas, Universidad de Zaragoza, Teruel, Spain.,Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
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Taşdelen Baş M, Çavuşoğlu H, Bükülmez A. Peer-Interactıon Group Support in Adolescents with Celiac Disease: A Randomized Controlled Study in Turkey. CHILD & YOUTH CARE FORUM 2021. [DOI: 10.1007/s10566-021-09664-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Influence of Standardized Nursing Intervention Combined with Mindfulness Stress Reduction Training on the Curative Effect, Negative Emotion, and Quality of Life in Patients with Chronic Gastritis and Gastric Ulcer. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:2131405. [PMID: 34691208 PMCID: PMC8531762 DOI: 10.1155/2021/2131405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/25/2021] [Indexed: 12/04/2022]
Abstract
Objective To explore the curative effect of standardized nursing intervention combined with mindfulness stress reduction training in patients with chronic gastritis and gastric ulcer and its influence on negative emotion and quality of life. Methods Total of 146 patients with chronic gastritis and gastric ulcer admitted to our hospital from August 2018 to February 2020 were collected and divided into the control group (n = 73) and study group (n = 73) according to patients' wishes and the random number method. The control group received traditional nursing measures. The study group received standardized nursing intervention combined with mindfulness stress reduction training. The general data, nursing efficiency, negative emotions, self-efficacy, quality of life, and nursing satisfaction of the two groups were recorded. Results The nursing effective rate of the study group (91.78%) was higher than the control group (79.45%) (P < 0.05). After intervention, the self-rating anxiety scale score and self-rating depressive scale score of the study group were lower than the control group (P < 0.05). After intervention, the general self-efficacy scale score and the generic quality of life inventory-74 scores of the study group were higher than the control group (P < 0.05). The nursing satisfaction rate of the study group (89.04%) was higher than the control group (75.34%) (P < 0.05). Conclusion Standardized nursing intervention combined with mindfulness stress reduction training has a good curative effect in patients with chronic gastritis and gastric ulcer, which is beneficial to reduce negative emotions, increase self-efficacy, improve quality of life, and improve nursing satisfaction.
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Ewais T, Begun J, Kenny M, Hay K, Houldin E, Chuang KH, Tefay M, Kisely S. Mindfulness based cognitive therapy for youth with inflammatory bowel disease and depression - Findings from a pilot randomised controlled trial. J Psychosom Res 2021; 149:110594. [PMID: 34399198 DOI: 10.1016/j.jpsychores.2021.110594] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/21/2021] [Accepted: 07/31/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Mindfulness-based cognitive therapy (MBCT) is a promising adjunctive treatment for adolescents and young adults (AYAs) with Inflammatory Bowel Disease (IBD) and comorbid depression. OBJECTIVES This pilot randomised controlled trial (RCT) aimed to evaluate feasibility and efficacy of an adapted MBCT program for AYA, aged 16-29, with IBD. METHODS Sixty-four AYAs were randomly allocated to MBCT (n = 33) or treatment as usual (TAU) (n = 31). Primary outcome measure was the depression score on Depression, Anxiety and Stress Scale. Secondary outcomes included anxiety, stress, IBD-related quality of life, coping, mindfulness, post-traumatic growth, medication adherence, IBD activity, inflammatory markers, microbiome characteristics and brain functional connectivity. RESULTS Study recruitment rate was 75%, retention rate 70%, and session attendance 92%. Intention to treat analyses revealed that, compared to TAU group, MBCT group had significantly lower depression (∆ = -6.0; 95%CI = -10.8 to -1.2; P = 0.015) and stress (∆ = -5.1; 95%CI = -10.1 to -0.0; P = 0.049), higher active coping (∆ = 1.0;95%CI = 0.1-1.9; P = 0.022), and total mindfulness scores (∆ = 10.9;95%CI = 1.1-20.8; P = 0.030) at 8 weeks (post-therapy), and improved coping by positive reframing (∆ = 1.1;95%CI = 0.0-2.2; P = 0.043) and planning (∆ = 0.9;95%CI = 0.0-1.9; P = 0.045), mindful awareness (∆ = 5.2.;95%CI = 2.0-8.5; P = 0.002) and total mindfulness scores (∆ = 10.8.;95%CI = 0.4-21.1; P = 0.042) at 20 weeks. On per protocol analysis, MBCT group had significantly lower depression (∆ = -6.3; 95%CI = -11.4 to -1.2; P = 0.015), stress (∆ = -6.0; 95%CI = -11.2 to -0.5; P = 0.032), increased active coping (∆ = 0.9;95%CI = 0-1.7; P = 0.05) at 8 weeks, and mindful awareness (∆ = 5.4; 95%CI = 2.1-8.6; P = 0.001) at 20 weeks. CONCLUSION In AYAs with IBD, MBCT is feasible and beneficial in improving depression, stress, mindfulness and adaptive coping. It holds promise as an important component of integrated IBD care. Trial registration number ACTRN12617000876392, U1111-1197-7370; Pre-results.
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Affiliation(s)
- T Ewais
- School of Medicine, Mater Clinical School and Princess Alexandra Clinical School, Raymond Terrace, The University of Queensland, South Brisbane, Queensland 4101, Australia; Mater Young Adult Health Centre, Mater Misericordiae Ltd, Raymond Terrace, South Brisbane, Queensland 4101, Australia; Mater Research Institute, Mater Misericordiae Ltd, Raymond Terrace, South Brisbane, Queensland 4101, Australia; School of Medicine, Griffith University, Gold Coast, Queensland 5005, Australia.
| | - J Begun
- School of Medicine, Mater Clinical School and Princess Alexandra Clinical School, Raymond Terrace, The University of Queensland, South Brisbane, Queensland 4101, Australia; Mater Young Adult Health Centre, Mater Misericordiae Ltd, Raymond Terrace, South Brisbane, Queensland 4101, Australia; Mater Research Institute, Mater Misericordiae Ltd, Raymond Terrace, South Brisbane, Queensland 4101, Australia.
| | - M Kenny
- The University of Adelaide, Adelaide, South Australia 5005, Australia.
| | - K Hay
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Queensland 4006, Australia.
| | - Evan Houldin
- Queensland Brain Institute, St Lucia, Queensland 4072, Australia.
| | | | - M Tefay
- Mater Young Adult Health Centre, Mater Misericordiae Ltd, Raymond Terrace, South Brisbane, Queensland 4101, Australia.
| | - S Kisely
- School of Medicine, Mater Clinical School and Princess Alexandra Clinical School, Raymond Terrace, The University of Queensland, South Brisbane, Queensland 4101, Australia; Metro South Health Service, Wooloongabba, Queensland 4102, Australia; Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
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Muse K, Johnson E, David AL. A Feeling of Otherness: A Qualitative Research Synthesis Exploring the Lived Experiences of Stigma in Individuals with Inflammatory Bowel Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18158038. [PMID: 34360327 PMCID: PMC8345596 DOI: 10.3390/ijerph18158038] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 12/18/2022]
Abstract
Inflammatory bowel disease (IBD) consists of Crohn’s disease and ulcerative colitis, chronic conditions involving inflammation and ulceration of the gastrointestinal tract. Individuals with IBD may be susceptible to experiencing health-related stigma: experienced, perceived, or internalised social exclusion, rejection, blame, or devaluation resulting from negative social judgements based on the disease. This qualitative research synthesis draws together findings from 38 studies describing lived experiences to develop a unified interpretative account of the experience of stigma in IBD. Analysis developed two categories: ‘The IBD journey’ explores the dynamic ways in which having IBD impacted on individuals’ self-identity and ‘a need to be understood’ examines the tension between wanting to be understood whilst feeling their true experiences needed to be hidden from or were misjudged by the social sphere. The overarching concept ‘feeling of otherness’ highlights that, rather than a static, binary experience, individuals moved across a continuum ranging from the excluding experience of feeling stigmatised and othered, to the inclusive experience of integration. Individuals fluctuated along this continuum across different physical, social, and health contexts. Psychological adjustment to IBD, drawing on experience of adaptive coping, and reconnecting with valued others through illness disclosure strengthened stigma resistance during more challenging times.
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Affiliation(s)
- Kate Muse
- School of Psychology, University of Worcester, Worcester WR2 6AJ, UK
- Correspondence:
| | - Emma Johnson
- Children’s Psychological Medicine, Oxford Children’s Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK; (E.J.); (A.L.D.)
| | - Annabel L. David
- Children’s Psychological Medicine, Oxford Children’s Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK; (E.J.); (A.L.D.)
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Mindfulness-Based Virtual Reality Intervention for Children and Young Adults with Inflammatory Bowel Disease: A Pilot Feasibility and Acceptability Study. CHILDREN-BASEL 2021; 8:children8050368. [PMID: 34063034 PMCID: PMC8147916 DOI: 10.3390/children8050368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 02/08/2023]
Abstract
The aim of this pilot study was to assess: (1) the feasibility and acceptability of a Mindfulness-Based Virtual Reality (MBVR) intervention among children and young adults with Inflammatory Bowel Disease (IBD), and (2) the preliminary efficacy of MBVR on key psychological (anxiety) and physical (pain) outcomes. Participants were 62 children to young adults with IBD (M = 15.6 years; 69.4% Crohn's disease; 58% male) recruited from an outpatient pediatric IBD clinic. Participants completed a baseline assessment, underwent the 6-min MBVR intervention, completed a post-intervention assessment and study satisfaction survey, and provided qualitative feedback. Results suggest strong feasibility and acceptability. Participants reported high levels of satisfaction with MBVR including high levels of enjoyment (M = 4.38; range 1-5) and relaxation (M = 4.35; range 1-5). Qualitative data revealed several key themes including participants interest in using MBVR in IBD medical settings (e.g., hospitalizations, IBD procedures, IBD treatments), as well as in their daily lives to support stress and symptom management. Preliminary analyses demonstrated improvements in anxiety (t = 4.79, p = 0.001) and pain (t = 3.72, p < 0.001) following MBVR. These findings provide initial support for the feasibility and acceptability of MBVR among children and young adults with IBD. Results also suggest MBVR may improve key IBD outcomes (e.g., anxiety, pain) and highlight the importance of conducting a randomized controlled trial and more rigorous research to determine intervention efficacy.
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Murphy LK, de la Vega R, Kohut SA, Kawamura JS, Levy RL, Palermo TM. Systematic Review: Psychosocial Correlates of Pain in Pediatric Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:697-710. [PMID: 32458966 DOI: 10.1093/ibd/izaa115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pain is a common symptom in pediatric inflammatory bowel disease (IBD) and is associated with poor health outcomes, yet additional knowledge about the psychosocial correlates of pain is needed to optimize clinical care. The purpose of this study is to systematically review the psychosocial factors associated with pain and pain impact in youth diagnosed with IBD within a developmentally informed framework. METHODS Manual and electronic searches yielded 2641 references. Two authors conducted screening (98% agreement), and data extraction was performed in duplicate. Average study quality was rated using the National Institutes of Health Quality Assessment Tool. RESULTS Ten studies (N = 763 patients; N = 563 Crohn disease, N = 200 ulcerative/ indeterminate colitis) met the inclusion criteria. Findings showed consistent evidence that higher levels of child depression symptoms and child pain catastrophizing were associated with significantly greater pain and pain impact (magnitude of association ranged from small to large across studies). Greater pain and pain impact were also associated with higher levels of child anxiety symptoms, child pain threat, child pain worry, and parent pain catastrophizing. Within the included studies, female sex and disease severity were both significantly associated with pain and pain impact. Study quality was moderate on average. CONCLUSIONS There is evidence that child psychosocial factors are associated with pain and pain impact in pediatric IBD; more studies are needed to examine parent- and family-level psychosocial factors. Youth with IBD should be routinely screened for pain severity, pain impact, and psychosocial risk factors such as anxiety/depression.
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Affiliation(s)
- Lexa K Murphy
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Rocio de la Vega
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Sara Ahola Kohut
- Department of Psychology and Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Joy S Kawamura
- Department of Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Psychiatry, University of Washington, Seattle, Washington, USA
| | - Rona L Levy
- Department of Social Work, University of Washington, Seattle, Washington, USA
| | - Tonya M Palermo
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
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March-Luján VA, Prado-Gascó V, Huguet JM, Cortés X, Arquiola JMP, Capilla-Igual M, Josefa-Rodríguez-Morales M, Monzó-Gallego A, Armero JLP, Ortí JEDLR. Impact of BMGIM Music Therapy on Emotional State in Patients with Inflammatory Bowel Disease: A Randomized Controlled Trial. J Clin Med 2021; 10:1591. [PMID: 33918724 PMCID: PMC8069074 DOI: 10.3390/jcm10081591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have a high prevalence of emotional disturbances which worsen the symptoms of the disease. As a therapeutic alternative that is part of a comprehensive care alongside medication, the Bonny Method of Guided Imagery and Music (BMGIM) music-assisted therapy has achieved promising emotional improvements in patients with chronic diseases. The objective of the study was to determine the impact of a treatment based on a BMGIM group adaptation on patients with inflammatory bowel disease (IBD) and their emotional state, therefore analyzing state of mind, quality of life, anxiety, depression, immunocompetence as a marker of well-being, and levels of acute and chronic stress. METHODS Longitudinal, prospective, quantitative, and experimental study including 43 patients with IBD divided into an intervention group (22 patients), who received eight sessions over eight weeks, and a control group (21 patients). A saliva sample was taken from each patient before and after each session in order to determine cortisol and IgA levels. Similarly, a hair sample was taken before the first and after the last session to determine the cumulative cortisol level. All molecules were quantified using the ELISA immunoassay technique. In addition, patients completed several emotional state questionnaires: HADS, MOOD, and CCVEII. RESULTS An improvement was observed in the following states of mind: sadness, fear, anger, and depression. No significant effect was observed in state of mind in terms of happiness or anxiety, in the levels of cortisol in hair, and in patients' perceived quality of life. A reduction in cortisol was observed in saliva, although this did not significantly affect the IgA titer. CONCLUSIONS BMGIM seems to improve the emotional state of patients with IBD.
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Affiliation(s)
- Vicente Alejandro March-Luján
- Department of Teaching and Learning of Physical, Plastic and Musical Education, Catholic University San Vicente Martir, 46110 Valencia, Spain
| | - Vicente Prado-Gascó
- Department of Social Psychology, University of Valencia, 46010 Valencia, Spain;
| | - José María Huguet
- Digestive Disease Department, General University Hospital of Valencia, 46014 Valencia, Spain; (J.M.H.); (A.M.-G.)
| | - Xavier Cortés
- Digestive Disease Department, Hospital of Sagunto, 46520 Valencia, Spain; (X.C.); (M.J.-R.-M.)
- Universidad Cardenal Herrera-CEU, CEU Universities, 46113 Valencia, Spain
| | | | - María Capilla-Igual
- Research Foundation of the General Hospital of Valencia, 46014 Valencia, Spain;
| | | | - Ana Monzó-Gallego
- Digestive Disease Department, General University Hospital of Valencia, 46014 Valencia, Spain; (J.M.H.); (A.M.-G.)
| | - José Luis Platero Armero
- Department of Nursing, Catholic University San Vicente Martir, 46001 Valencia, Spain; (J.L.P.A.); (J.E.d.l.R.O.)
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Ewais T, Begun J, Kenny M, Headey A, Tefay M, Kisely S. Mindfulness-based cognitive therapy experiences in youth with inflammatory bowel disease and depression: findings from a mixed methods qualitative study. BMJ Open 2020; 10:e041140. [PMID: 33148766 PMCID: PMC7643511 DOI: 10.1136/bmjopen-2020-041140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Mindfulness-based cognitive therapy (MBCT) is effective in treating psychosocial comorbidities in inflammatory bowel disease (IBD); however, there have been no qualitative studies of MBCT experiences among youth with IBD. We aimed to examine the experiences of youth with IBD and depression who completed an adapted MBCT group programme, and the impact of common psychotherapy and group factors. DESIGN This mixed method qualitative study, nested within a randomised controlled trial (RCT) of MBCT for youth with IBD, employed thematic analysis of qualitative data from three focus groups and open-ended survey questions. SETTING The study was conducted in the outpatient department of a tertiary hospital for young adults in Brisbane, Australia. PARTICIPANTS Out of sixty-four adolescents and young adults recruited to the RCT of MBCT for youth with IBD and depression, 29 completed the MBCT evaluation survey and 19 attended the focus groups. RESULTS Four key themes emerged: 'connectedness and shared understanding', 'growing in wisdom', 'therapeutic alliance' and 'barriers to mindfulness practice'. Participants described MBCT experiences as healing and transformative with the themes of connectedness, growing in wisdom and therapeutic alliance laying the foundation for therapeutic change. Main barriers included fatigue, depression, time and travel constraints. CONCLUSIONS The study identified key themes facilitating the process of therapeutic change within the MBCT programme for youth with IBD and elucidated common and group psychotherapy factors underlying the key themes. Participants perceived connecting with peers as essential for learning mindfulness skills which in turn strengthened the connection. Study findings will facilitate interpretation of the results of the RCT of MBCT in youth with IBD and inform the design of future studies of MBCT in this cohort. TRIAL REGISTRATION NUMBER ACTRN12617000876392; Results.
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Affiliation(s)
- Tatjana Ewais
- Mater Clinical School and Princess Alexandra Clinical School, School of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
- Faculty of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Mater Young Adult Health Centre, Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
| | - Jake Begun
- Mater Clinical School and Princess Alexandra Clinical School, School of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
- Mater Young Adult Health Centre, Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
| | - Maura Kenny
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Alan Headey
- Mater Young Adult Health Centre, Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
| | - Merilyn Tefay
- Mater Young Adult Health Centre, Mater Misericordiae Ltd, South Brisbane, Queensland, Australia
| | - Steve Kisely
- Mater Clinical School and Princess Alexandra Clinical School, School of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
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Murphy LK, Rights JD, Ricciuto A, Church PC, Ahola Kohut S. Biopsychosocial Correlates of Presence and Intensity of Pain in Adolescents With Inflammatory Bowel Disease. Front Pediatr 2020; 8:559. [PMID: 33014942 PMCID: PMC7506075 DOI: 10.3389/fped.2020.00559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022] Open
Abstract
Background: There is growing consensus that pain in pediatric inflammatory bowel disease (IBD) is not fully explained by disease-related processes. However, previous studies have largely measured individual biological, psychological, or social risk factors for pain in isolation. Further, not all youth with IBD presenting to clinic will report presence of pain, and those who do vary in their reports of pain intensity. This study therefore extends prior research by determining biopsychosocial correlates of both presence and intensity of pain in adolescents with IBD, in order to inform targeted pain management intervention approaches. Methods: Adolescents with IBD followed at SickKids, Toronto, and their parents were consecutively enrolled from outpatient clinic. IBD characteristics (diagnosis, time since diagnosis, patient-reported disease activity) were collected. Adolescents reported on current pain (NRS-10), internalizing symptoms (Strengths and Difficulties Questionnaire), and pain catastrophizing (Pain Catastrophizing Scale-Child). Parents reported on protective responses to child pain (Adult Responses to Child Pain) and pain catastrophizing (Pain Catastrophizing Scale-Child). Hurdle models were conducted to examine predictors of presence and intensity of pain in the same model. Biological (patient-reported disease activity, IBD diagnosis subtype, illness duration), psychological (internalizing symptoms, pain catastrophizing), and social (parent pain catastrophizing, parent protective responses) factors were entered as predictors, adjusting for age and sex. Results: Participants included 100 adolescents (12-18; Mean = 15 years) with IBD (60% Crohn's Disease, 40% Ulcerative Colitis or IBD-unclassified) and 76 parents. The majority of the sample was in clinical remission or reported minimal symptoms. Half of participants reported no current pain; for those reporting pain, intensity ranged 1-7 (M = 3.43, SD = 1.98). Disease activity (OR = 53.91, p < 0.001) and adolescent internalizing symptoms (OR = 7.62, p = 0.03) were significant predictors of presence of pain. Disease activity (RR = 1.37, p = 0.03) and parent protective responses (RR = 1.45, p = 0.02) were significant predictors of intensity of pain. Conclusions: Results suggest that the experience of pain in pediatric IBD is biopsychosocially determined. Patient-reported disease activity and internalizing symptoms predicted presence of pain, while disease activity and parent protective responses predicted intensity of pain. While medical intervention in pediatric IBD is focused on disease management, results suggest that depression/anxiety symptoms as well as parent protective responses may be important targets of pain management interventions in pediatric IBD.
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Affiliation(s)
- Lexa K Murphy
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Jason D Rights
- Department of Psychology, University of British Columbia, Vancouver, BC, United States
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,SickKids Research Institute, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Peter C Church
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Sara Ahola Kohut
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,SickKids Research Institute, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Chadi N, Weisbaum E, Vo DX, Ahola Kohut S. Mindfulness-Based Interventions for Adolescents: Time to Consider Telehealth. J Altern Complement Med 2019; 26:172-175. [PMID: 31765222 DOI: 10.1089/acm.2019.0302] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Nicholas Chadi
- Division of Adolescent Medicine, Department of Pediatrics, Sainte-Justine University Hospital Centre, Sainte-Justine Hospital Pediatric Research Centre, University of Montreal, Montreal, Canada
| | - Elli Weisbaum
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Dzung X Vo
- Division of Adolescent Health and Medicine, Department of Pediatrics, University of British Columbia, British Columbia Children's Hospital, Vancouver, Canada
| | - Sara Ahola Kohut
- Division of Gastro-Enterology, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada.,Department of Psychiatry, Institute of Medical Sciences, University of Toronto, Toronto, Canada
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Ma Y, Fang S. Adolescents' Mindfulness and Psychological Distress: The Mediating Role of Emotion Regulation. Front Psychol 2019; 10:1358. [PMID: 31231292 PMCID: PMC6567674 DOI: 10.3389/fpsyg.2019.01358] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 05/24/2019] [Indexed: 01/30/2023] Open
Abstract
Mindfulness has been widely linked with psychological well-being in general population. There are emerging studies supporting the relationship between adolescents' mindfulness and their mental health. However, the mechanisms through which mindfulness may influence adolescents' psychological distress have only recently been explored, and more related research is still needed. This study investigated the relationship between adolescents' dispositional mindfulness and psychological symptoms of depression, anxiety and stress. The mediating variables were also explored in perspective of two common emotion regulation theories, which were measured through Difficulties in Emotion Regulation Scale (DERS) and Emotion Regulation Questionnaire (ERQ). DERS has been used as a comprehensive assessment of emotion regulation difficulties. ERQ is also widely accepted to measure the emotion regulation process including dimensions of cognitive reappraisal and expressive suppression. Measures assessing mindfulness, emotion regulation, and psychological distress were administered to 1067 adolescents in mainland China. The results confirmed that adolescents' dispositional mindfulness was negatively associated with depression, anxiety, and stress. DERS, especially the sub-dimensions of Acceptance and Strategies, significantly mediated the relationship between mindfulness and symptoms of depression, anxiety and stress. Whereas, ERQ including subscales of cognitive reappraisal and expressive suppression exerted limited mediating effect. These findings provided insights for the potential underlying mechanism between adolescents' mindfulness and psychological distress, demonstrating that DERS might be more pervasive than ERQ. Further research was suggested to explore other mediating variables underlying mindfulness and psychological distress among adolescents and develop mindfulness-based programs to improve adolescents' mindfulness and emotion regulation ability.
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Affiliation(s)
- Ying Ma
- School of Education, Shaanxi Normal University, Xi’an, China
| | - Siqi Fang
- Faculty of Education, The Chinese University of Hong Kong, Sha Tin, Hong Kong
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