Research proposal: A Focus group interview of twelve year ...
Sixth-graders’ Perceptions about Mindfulness Meditation in the Context of Stress Management
Mark L. Anstadt
A thesis submitted in partial fulfillment
of the requirements for the degree of
Masters in Nursing
University of Washington
2007
Program Authorized to Offer Degree:
Department of Psychosocial & Community Health,
School of Nursing
University of Washington
Graduate School
This is to certify that I have examined this copy of a master’s thesis by
Mark L. Anstadt
and have found that it is complete and satisfactory in all respects, and that any
and all revisions required by the final examining committee have been made.
Committee members:
______________________________________________________
Elaine Adams Thompson, Thesis Committee Chairperson
_______________________________________________________
Cathryn Booth-LaForce, Thesis Committee Member
Date: 25 May 2007________
University of Washington
Abstract
Sixth-graders’ perceptions about mindfulness meditation in the context of stress management
Mark L. Anstadt
Chair of the Supervisory Committee:
Professor Elaine Adams Thompson
Psychosocial and Community Health Nursing
Chronic stress impacts the health of individuals and communities. This impact is widespread, increasing, and contributes to considerable suffering and expense. Children, due to their developmental and physiologic immaturity, are particularly vulnerable to the effects of chronic stress. Mindfulness meditation has been successfully used by adults for the purpose of stress management. Less is known about its application to children. Effective methods of reducing the experience and effects of stress during critical points in child development may prevent a great deal of chronic illness and psychological distress. To better understand the application of mindfulness meditation for stress reduction in this age group, the researcher conducted a focus group with a convenience sample of eight youth aged eleven to thirteen in Seattle, Washington. This research generated qualitative information regarding the perceptions of sixth-graders about mindfulness meditation in the context of stress management.
The data show that the participants have well developed vocabularies to describe stress. They worry most about school, extra-curricular activities, security of personal online information, and how they are viewed by their peers. Despite having significant daily stressors, they have received very little structured education regarding stress management. The majority of responses to the guided mindfulness meditation exercise were concrete. However, the participants made comments that suggested their views of meditation were expanded due to exposure to this exercise. They displayed a willingness to engage in mindfulness meditation, though they expressed fears about judgment from their peers. More research is needed to determine what types of meditation and what specific meditation exercises would be most accepted by this age group. It would also be helpful to study the relative effectiveness of a variety of methods of promoting meditation to this age group.
Table of Contents
Page
List of Tables iii
Chapter I: Problem and Purpose 1
Background 1
Stress 1
Stress and Children 1
Meditation 2
Focus group research 2
Significance 3
Specific Aims 3
Chapter II: Theoretical Framework and Review of the Literature 4
Theory 4
Types of meditation 4
Can children meditate? 4
Stages of development of school aged children 5
Developmental tasks of school aged children 5
Randomized Controlled Trials Studying Meditation for
Stress Management in Adult Populations 5
Search methods 5
Overview of findings 6
Detail of eight adult RCTs 8
Summary of adult RCTs 10
Knowledge Gaps in Meditation Research 11
Research Studying Meditation for Stress Management in Children 11
Chapter III: Methods 14
Design 14
Setting 14
Sample 14
Measures 14
Demographic data 14
Qualitative data 15
Process reliability 16
Content validity 16
Procedures 16
Recruitment 17
The Group 17
Role of the moderator 19
Data collection 19
Analysis Plan 19
Risks and Benefits 23
Chapter IV: Results 24
Characteristics of the Group 24
Category One: Conceptualization of Stressors and Stress Management
Strategies 24
What does it mean when you have stress? 24
What does it mean to manage stress? 25
What kind of things worry kids your age? 25
How does stress change the way you feel? 26
Do a lot of you have trouble sleeping at night? 26
Stress can be good or bad sometimes? 27
Category Two: Stress Management Strategies and Methods of Exposure 27
What kind of things do you do to help with stress? 27
What things help with school stress? 28
How do kids your age learn about what to do about stress? 28
Category Three: Beliefs and Opinions about Meditation 28
What do you think meditation is? 28
Can you imagine yourself meditating? 28
Did the meditation exercise change at all how you felt? 29
Does anybody feel differently about meditation after this exercise than you did before? 29
What kind of things might make you want to meditate? 29
What kind of things would keep you from meditating? 30
What, if anything would make meditation more appealing to
kids your age? 30
Summary Questions 30
What questions didn’t I ask today that you think I should
have asked? 30
What was it like for all of you talking? 30
What would be helpful in leaving here today for you to know? 30
Chapter V: Discussion and Conclusion 31
Data Themes in the Context of Study Aims 31
Conceptualizations of personal stressors 31
Methods of managing stress 31
Thoughts about mindfulness meditation 32
Significant omissions 33
Limitations 34
Implications for Research 35
Substantive recommendations 35
Methodological recommendations 35
Implications for Practice 36
Concrete language 36
Incorporate movement 36
Seek and verify influential images and role models 36
Incorporate programs into structured daily activity 37
Stressors and loss of control 37
Summary 37
Conclusion 38
References 39
Appendix A: Demographic data 42
Appendix B: Mindfulness exercise 43
Appendix C: Assent form 44
Appendix D: Consent form 45
Appendix E: Mental health resources 48
Appendix F: Instant Meditation for Kids 49
List of tables
Table Number Page
1. Meditation Articles Compared 7
2. Measurement Categories and Corresponding Group Questions 15
3. Ground Rules Script 18
4. Proposed versus Actual Questions 21
5. Themes and Questions 22
Chapter I: Problem and Purpose
The physiological and emotional consequences of chronic stress impact the health of individuals and communities. This impact is widespread, increasing, and contributes to considerable suffering and health care expense (Kalia, 2002). Mindfulness meditation has been successfully used by adults for the purpose of stress reduction. Less is known about its application to children. The objective of this research is to generate qualitative information regarding the perceptions of sixth-graders about mindfulness meditation.
Background
Stress. Stress, an individual’s response to a real or perceived threat, can have a variety of negative physical and emotional consequences. Emotional consequences may include tension, strain, nervousness, loss of a sense of control, and decreased empathy (VanItallie, 2002). Physical consequences may include increased pain perception, immune dysfunction, and altered hormonal responses (VanItallie, 2002). All of these impact the health of the individual, and are implicated as a cause of or exacerbating factor in many diseases, including anxiety, depression, hypertension, atherosclerosis, osteoporosis, diabetes types I and II, peptic ulcer disease, arthritis, fibromyalgia, chronic fatigue syndrome, and substance abuse (VanItallie, 2002).
This widespread health problem has been increasing dramatically over recent years. Up to 90% of all doctor visits are now stress related, and up to one in four American workers suffers from a mental health problem that is stress related (Kalia, 2002). The total cost of this problem to the U.S., through increased utilization of health care resources and lost productivity, is estimated to be $42 billion yearly (Kalia, 2002). Given the extensive morbidity and ever-increasing expense resulting from stress, it is imperative that health care providers be able to offer evidence-based recommendations to individuals experiencing stress.
Stress and children. Children, due to their developmental and physiologic immaturity, are particularly vulnerable to the effects of chronic stress. This is also a period in life when lifelong patterns of stress response are developing (McEwen, 2003). In addition to the ill effects suffered by adults, research has shown that children who experience chronic stress are more likely to suffer from other psychological disorders such as depression, anxiety disorders, attention deficit disorder, and attention deficit hyperactivity disorder (Costello, Egger, & Angold, 2005). They may also experience more chronic health disorders as adults. These children are more vulnerable to participation in undesirable health and social behaviors such as joining gangs, avoiding school, and abusing tobacco, alcohol, and other substances (Andrews & Wilkinson, 2002).
The developmental consequences of stress on school-aged children include poor school performance and impaired growth, memory, and cognition (Murray & Zentner, 2001, p. 509-511). Physiologic consequences are similar to adults and include increased cardiovascular reactivity, elevated blood pressure, decreased immune factors, elevated cortisol levels, and exacerbation of chronic illness (McEwen; Barnes, Davis, Murzynowski, & Treiber, 2004). In children, three chronic illnesses have been shown to have a particularly notable relationship to stress: asthma, environmental allergies and eczema (Costello et al.).
Meditation. Once considered esoteric, meditation is now being embraced by both individuals and institutions as a way to manage stress and decrease the risk of chronic health problems. Meditation is one of the most common alternative therapies used by Americans. Its use in more than 100 stress-reduction programs at major medical centers around the U.S. demonstrates that it has also been embraced by mainstream science (Bonadonna, 2003). All forms of meditation involve training one’s attention and concentration. In mindfulness meditation, the focus of this heightened awareness may include sounds, thoughts, physical sensations, emotions, or the breath (Ott, 2004, p. 24).
Meditation is effective at moderating both psychological the physiological responses to stressors in adults. These benefits are thought to be related, in part, to a better understanding of one’s emotional responses and a decrease in stress hormones (Bonadonna, 2003). It is thought that the regular practice of meditation cultivates a greater ability to regulate one’s response to perceived stressors. This regulation of emotions may result in a more objective outlook on perceived stressors and quicker recovery from states of worry and anxiety. Quicker recovery from these psychological states may explain the reduction in stress hormones, such as cortisol, which, if chronically elevated, may contribute to a decline in physical health by negatively affecting the immune and cardiovascular systems (Kabat-Zinn, 1990).
Because of its effects on psychological and physical health, meditation, if successfully taught to school-aged children, could be of tremendous benefit in decreasing chronic illness. More research is needed, however, to determine the feasibility, usefulness, and practical applications of using meditation for stress management in children.
Focus group research. Focus groups have become increasingly popular as a method of collecting information on subjects about which little has been previously studied (Polit & Beck, 2004, p. 342). These groups have been successfully used in qualitative research with children (Wind, Bobelijn, DeBourdeaudhuij, Klepp, & Brug, 2005) and may hold promise in expanding the body of knowledge about the usefulness of meditation to decrease stress in children.
Significance. Stress is a significant and growing contributor to chronic illness. Effective methods of reducing the experience and effects of stress during critical points in child development may prevent a great deal of chronic illness and psychological distress. By promoting evidence-based coping techniques to school-aged children, the lifetime risk of chronic illness may be greatly reduced. This research was designed to better define the perceptions of sixth-graders about stress and mindfulness meditation. The information gained will help establish how the participants think and talk about mindfulness meditation in the context of stress reduction, which will contribute to understanding the potential for using meditation for stress reduction in sixth-graders.
Specific aims. The specific aims of this study are to gather information about sixth-graders’ conceptualizations of personal stressors, methods they use to manage stress, and their thoughts about meditation before and after a mindfulness meditation exercise. To gather data about the application of mindfulness meditation for stress reduction within this age group, the researcher conducted a focus group with children aged eleven to thirteen. This moderated discussion sought to elicit conversation about personal stressors, stress management strategies, and beliefs and opinions about mindfulness meditation before and after a short mindfulness meditation exercise.
In order to provide a foundation for this research, a discussion of relevant theory and a review of the available literature regarding meditation for stress reduction will be presented in chapter one, followed by a description of the methodology used for this study in chapter two. Chapter three will present the results of the focus group. A discussion will follow in chapter four. The discussion will elucidate themes, summarize the findings, and present the limitations of this study. The conclusions that follow will include implications of the findings for research and practice.
Chapter II: Theoretical Framework and Review of the Literature
Little research has been conducted to evaluate the effectiveness of meditation for stress management in children. This chapter, therefore, will present a review of the literature supporting the use of meditation for stress management in adults. That review will be followed by a discussion of what is known about the application of meditation in younger populations. In considering the use of meditation for stress management, however, it is helpful to first distinguish between the different types of meditation used in the reviewed studies and theories of child development that may affect the use of meditation for stress reduction in children.
Theory
Types of meditation. Meditation in the broadest sense is any activity characterized by a heightened state of awareness. The many types of meditation vary in the method used to achieve this state. Yoga, for example, uses movement, body poses and breathing techniques that have evolved out of ancient spiritual teachings. Tai Chi uses many of the same techniques, but has its roots in the martial arts. The two other forms of meditation applied in the research reviewed for this study include Transcendental Meditation (TM) and Mindfulness Meditation (MM).
TM and MM are similar in that they both employ strategies to focus attention. In TM, this is accomplished by concentrating on one narrow point, such as a sound or phrase. The goal of this sustained concentration is to transcend, or rise above, any other thoughts or feelings. MM, on the other hand, may use thoughts, sensations and emotions themselves as the focus of attention. The goal of MM is to cultivate a new relationship to these common experiences. This new relationship is characterized by curiosity, acceptance and empathy (Ott, 2004).
Can children meditate? Meditation of all types often employs imagery and imagination as vehicles through which to increase awareness of oneself. This raises a question about whether or not children, based on their cognitive ability, can realize benefits from meditation. The cognitive ability to think abstractly, a characteristic of the formal operational stage of development, seems like a logical prerequisite to meditation, which utilizes imagery. While this question has not been specifically addressed by currently available research, works by Rozman (1989) and Desmond (2004) describe implementation and benefits of meditation for children as young as eighteen months. For sixth-graders, who may lie within a wide range between concrete operational and formal operational cognitive development (Murray & Zentner, 2001), determining the developmental level may be more relevant to determining appropriate teaching methods than determining the appropriateness of meditation per se.
Stages of development of school aged children. According to Piaget’s theory of cognitive development, school-aged children progress along a continuum from the concrete operational stage (beginning around age seven) to the formal operational stage (beginning around age twelve) (Murray & Zentner, 2001, chpts 10 & 11). The concrete operational stage is characterized by systematic reasoning regarding tangible or familiar situations and the use of logic to analyze relationships (Murray & Zentner, 2001, p. 489). As children progress to the formal operational stage, they demonstrate increasing use of symbolism, imagination, memory and logic. It is the formal operational stage that is associated with abstract thought (Murray & Zentner, pp. 539-540). Factors that affect the advancement of children along the operational continuum include safety needs and educational style. Suggested ways to meet the safety needs of children in this stage include working collaboratively with schools, parents, and community organizations to minimize possible threats of violence, both real and perceived (Murray & Zentner, p. 540). Group work has been shown to encourage operational advancement because it encourages brainstorming and the sharing of creative ideas. Other educational approaches that encourage advancement include the use of both divergent and convergent questions to stimulate children in reflective thought.
Developmental tasks of school-aged children. Developmental tasks of the school-aged child that are relevant to this research include developing increasing complexity of reasoning and communication, discovering healthy ways of becoming acceptable as a person, and learning how to handle strong feelings appropriately (Murray & Zentner, 2001, p. 518). Supporting children in their progression through these tasks can help give them a strong foundation for entering adolescence, a period characterized by dramatic physical, psychological, and emotional changes (Murray & Zentner, 2001, p. 518). If meditation is helpful in regards to stress management, it may also help school-aged children progress in regards to their developmental tasks. Offering effective strategies of stress management to children may be particularly important at this stage in their development, in that it precedes adolescence, a period associated with the stress of significant changes.
Randomized Controlled Trials Studying Meditation for Stress Management in Adult Populations
Search methods. Before exploring the use of meditation for children, it is first necessary to gain an understanding of the state of knowledge regarding the use of meditation to treat stress in adults. To this end, a review of the literature was conducted using the Cochrane, Medline, and Cinahl electronic databases to determine the current evidence base for the use of meditation to decrease the experience and effects of stress in adults. Searches were limited to research performed on humans and published in English between January 1, 1990 and March 1, 2006. There has been a great deal of controlled research regarding meditation to alter disease outcomes. Much of the research on meditation for general stress reduction, however, appears to be focused on process and implementation. In order to better evaluate the strength of the evidence supporting the use of meditation for stress-reduction, this review was additionally limited to randomized controlled trials (RCT’s). The search terms “meditation AND stress reduction” were entered after setting search limits. Additional searches using the terms “meditation AND emotions” also yielded results. Adding “NOT cancer” to the search criteria eliminated most of the research on persons with a current illness. The search was then restricted to items containing the search terms in the title or abstract. A review of the remaining results yielded ten articles that met the criteria and limits selected. Two of these were eliminated due to inadequate information about the sample size and intervention, making comparisons difficult. No Cochrane Review articles were found regarding the use of meditation for stress reduction, but there was one article meeting the search criteria found from the Cochrane database. Medline searches produced the remaining seven articles used in this review. The Cinahl database search duplicated one article found in the Medline search with no other articles meeting the search criteria.
Overview of Findings. The eight relevant research articles studied different types of meditation interventions and used a wide variety of subjective and objective measures. Treatment time was between eight weeks and six months, with eight weeks being the most common. In all but one, results favored meditation as having a statistically significant desirable effect in comparison to the control groups. The strength, clinical relevance, and generalizability of the results varied widely between studies, however. See Table 1.
INSERT TABLE 1
Detail of eight adult RCTs. The oldest study included in this review was a comparative study of the differences between participating in Tai Chi, walking, meditating, or reading (Jin, 1992). The outcome measures, as well as the study groups, were numerous. Researchers studied a huge array of biochemical markers and psychological assessment tools. While information comparing meditation to other forms of stress reduction is an area where more research is needed, the design of this study included too many variables to be useful. The interpretation of objective measures such as blood pressure and heart rate, for example, was confounded by the use of walking as a comparison group, since normal variations occur in these measures while walking (Jin, 1992). There were no favorable results for meditation in this study outside of the results that were also favorable for other comparative groups (Jin, 1992). For example, a decrease in salivary cortisol after exposure to a stressor was reported as being “evident after all treatments.” This trend was “equivalent between groups” (Jin, 1992, p.366).
Pearl and Carlozzi, on the other hand, conducted a study that was highly specific to meditation (1994). This eight-week study had a sample size of sixty and used standardized psychological assessment tools (see Table 1) to determine that there was a significant decrease in anxiety in the treatment group in comparison to the control group. The study did not, however, support the researcher’s hypothesis that meditation increases empathy (Pearl & Carlozzi, 1994).
In a 1997 study of 49 healthy male subjects, MacLean and colleagues also used a specific, well described meditation technique. In this study, however, transcendental meditation (TM) was the treatment, and the outcome measures were biochemical markers rather than psychological tool results (MacLean et al., 1997). The significant result in this study was a drop in baseline serum cortisol levels from 13.9 to 11.1 micrograms/deciliter for the treatment group, while the control group demonstrated a rise in cortisol levels (MacLean et al., 1997). In the summary, the researchers took an expanded view when they reported that their results support previous findings that suggest “repeated practice of the TM technique reverses effects of chronic stress significant for health” (MacLean et al., 1997, p.277). Nonetheless, the external validity of this study is limited by the characteristics of the sample, a self-selected group of young men. This National Institutes of Health-funded study was the only one in this review that disclosed its financial source.
Another 1997 study with positive results but limited application to the general public was a study by Astin using a mindfulness meditation (MM) program to treat stress. Along with TM, MM is one of the most frequently researched style-specific meditation techniques (Bonadonna, 2003). Astin, like other researchers, based his eight-week intervention on a stress-reduction meditation program designed by Kabat-Zinn. This popular program, entitled Mindfulness-Based Stress Reduction (MBSR), is described in detail in a training manual by the same name (Kabat-Zinn & Santorelli, 1993). In Astin’s study, assessment tools with well documented validity (see Table 1) showed the main results of decreased somatic complaints, increased sense of control, and increased spiritual fulfillment. This study had stricter control than others in this review. In contrast to most others that included some aspect of education or alternative treatment, the control group in Astin’s study received only pre and post assessment tools and a promise to be included in a future treatment group (Astin, 1997). Unfortunately, this also created a study with the least control for the placebo effect. It may, in fact, be difficult to design a prospective meditation study that adequately controls for the placebo. In psychologically oriented interventions, as Astin notes, “unlike pharmacologically oriented interventions, [one cannot] simply administer a sugar pill as a placebo treatment” (1997, p.104). The larger problem with this study, however, is that the sample size (28) was small and included only one male.
In contrast, a 1998 study by Shapiro, Schwartz and Bonner had a larger sample size (78) and matched control group and treatment group demographics during randomization. Despite the fact that this study specifically looked at the effects of MM on primarily Caucasian medical and pre-medical students, it has a stronger application potential due to its rigorous design. It employed an adaptation of the well documented eight week MBSR program as treatment and used standardized psychological assessment tools with well documented validity that have been used in many other similar studies (see Table 1). This study showed increased spiritual and decreased anxiety scores for the treatment group versus the control group (Shapiro, Schwartz, & Bonner, 1998). In this case, the control group was used as the treatment group in a consecutive replication study. The replication study, while not including all results from the original, reported strikingly similar results, reinforcing the original’s validity (Shapiro et al., 1998). Unlike the 1994 study by Pearl and Carlozzi, this study showed an increase in empathy scores for the treatment group (Shapiro et al., 1998). While the results may be most specific to Caucasian medical and pre-medical students, all health care providers, students, and teachers may find these results of interest. Empathy in health care providers has been shown to benefit both clients and caregivers (Baillie, 1996). Significantly, the results of Shapiro, Schwartz and Bonner were reinforced by a 2004 study finding that a similar MM program increased empathy among a more ethnically diverse group of nursing students (Beddoe & Murphy). While not included in this review due to lack of a control group, Beddoe and Murphy’s study seems to reinforce the Shapiro study and suggests a meditation benefit that warrants additional research.
In keeping with previous research on TM, a 2000 study evaluated its effect on plasma melatonin levels (Tooley, Armstrong, Norman, & Sali, 2000). This small study (n=28) found a statistically significant increase in plasma melatonin levels after meditating by the treatment group versus the control group. The conclusion that “melatonin might be one avenue through which the claimed health promoting effects of meditation occur” was supported with an extensive amount of biochemical evidence behind the effects of melatonin (Tooley et al., 2000, p. 69). The clinical relevance of transiently elevated night-time melatonin levels was not clear from this article, however.
A larger scale study by Williams and colleagues (2001) seems to reinforce previous findings regarding the anxiety-reducing benefits of mindfulness meditation. This study closely followed Astin’s 1997 study. Williams, however, had a power analysis done to determine the sample size necessary to produce reliable results. This was the single study in this review that reported the demographic characteristics of its participants. The main findings of the study were a 24% decrease in daily hassles, a 44% decrease in psychological distress, and a 46% decrease in medical symptoms in the treatment group by analysis of validated assessment tools (see Table 1) (Williams, Kolar, Reger, & Pearson, 2001). This effect was not only significantly more than in the control group, but the three-month follow-up assessment showed maintenance of these effects (Williams et al., 2001). A potential barrier to external validity was that 95% of the participants were college educated (Williams et al., 2001). Researchers found, however, that their data correlated well to a non-controlled study of an inner city Spanish-English bilingual MM program by Roth and Creaser in 1997.
The most recent study was conducted by Harinath, et al. on 30 healthy males aged 25-35 (2004). The results were favorable for all psychological and biophysical findings. However, the intervention was three months of yoga and meditation, making it impossible to determine which intervention affected which dependent variable. Neither the style of yoga nor information about how it was implemented was described in the article. In addition, the sample of only male army soldiers does not generalize to the U.S. adult population at large.
Summary of Adult RCTs
Of the eight RCT’s included in this review, three studied transcendental meditation (TM), two studied mindfulness meditation (MM), one studied Omkar meditation, one studied “clinically standardized” meditation, and one studied an unspecified style of meditation. The majority included primarily Caucasian participants and only one study identified its funding source. All found favorable results, but the outcome measures varied widely between many of the studies. TM studies focused on biophysical/biochemical markers while MM studies focused on psychological outcomes. The two largest studies used MM. The MM studies also had greater consistency of design and outcome measures.
Findings from these studies appear to support the assertion that TM increases melatonin levels, but the health outcomes for this are poorly supported. It can be more confidently stated that MM decreases anxiety and medical symptoms and enhances spiritual fulfillment in healthy white adults in the U.S. Other types of meditation may improve psychological outcomes, but more research is needed. The primary conflict in the data is the effect of meditation on empathy. The “clinically standardized” meditation used by Pearl & Carlozzi in 1994 showed no statistical difference in empathy, whereas Williams et al. (2004) showed a significant increase in empathy using the MM program. Both were moderately large studies and both were conducted in a university setting. It may be possible that another aspect of the MBSR program other than meditation was responsible for the increase in empathy found in the Williams study.
Knowledge Gaps in Meditation Research
The data that MM may increase empathy in health care workers is compelling and warrants further investigation. It is unknown from the current research if TM has an effect on psychological outcomes. Despite the fact that MM and TM are the most commonly studied types of meditation, there are no RCT’s comparing their effectiveness to each other. There is also a striking lack of inclusion of ethnic minorities in RCT’s investigating the use of meditation for stress reduction in healthy adults. In addition to gaps in the adult literature, there have been few research studies evaluating the effectiveness of meditation in healthy children.
Research Studying Meditation for Stress Management in Children
A small but growing body of literature regarding the use of meditation in adolescents and school-aged children was uncovered during the adult literature review. One uncontrolled study was conducted on a middle school population (Wall, 2005) and two RTC’s were conducted on adolescents (Barnes, Bauza, & Treiba, 2003 and Barnes, Treiber, & Johnson, 2004). The results are promising, but there are few controlled studies at this time.
A pubmed search was conducted using the keyword “meditation” and the following limits: published in the last ten years, English only, human and Age eight to twelve years. This search revealed two research studies, one RCT and the other a qualitative study. Both revealed that middle school-aged children were amenable to learning and performing mindfulness meditation and both showed benefits.
The article by Wall (2005) described a variety of psychological benefits experienced by the children: well-being, calmness, relaxation, improved sleep, less reactivity, increased self-care, self-awareness, and a sense of interconnection or interdependence with nature. The RCT by Barnes (Barnes, Davis, Murzynowski, & Treiber, 2004) demonstrated improvement on several physiologic markers of stress, including blood pressure, heart rate, and ambulatory blood pressure in healthy normotensive children aged 12 ± 0.6 years. In addition to these research articles, a 2002 article by Mary Jane Ott, a pediatric nurse practitioner, describes her successful use of meditation in the treatment of stress-related illness in children as young as seven years. Ott (2002) references a 1989 book by Deborah Rozman that describes techniques for the successful use of meditation for children.
Taken together, the evidence suggests that using meditation for children may be feasible and beneficial. There is, however, much that is not known. Significantly more research is needed to determine the consistency of beneficial findings and the ideal methods for teaching and promoting meditation to children. Future research must first define the differences between age groups. Each group will have a different set of developmental assets, different perceived stressors and different ideas about stress and meditation.
For the purpose of this research, middle school-aged children were chosen as a good population to begin with. Middle school-aged children have the capacity for abstract thought and are at a life stage preceding adolescence, which is commonly associated with a drastic increase in perceived stressors. This research seeks to more carefully define how middle school-aged children think and talk about personal stressors, stress management strategies, and their beliefs and opinions about mindfulness meditation before and after a short mindfulness meditation exercise. The following chapter will describe the design, methods and procedures of this focus group study intended to elucidate sixth-graders’ perceptions about mindfulness meditation in the context of stress management.
Table 1 Notes
1 Mindfulness meditation (MM) also has as its goal a heightened sense of awareness. It is characterized by simple observation of the body, its thoughts and process and/or one’s personal surroundings without attachment to them. The health effects and mechanisms are thought to be similar to other forms of meditation (Bonadonna, 2003). The formal stress reduction program developed by Jon Kabat-Zinn, which is the basis for much of the recent research into mindfulness meditation, is entitled Mindfulness Based Stress Reduction (Kabat-Zinn & Santorelli, 1992).
2 The Daily Stress Inventory Professional Manual (Brantley & Jones, 1989).
3 Revised Hopkins Symptom Checklist (Derogatis, 1994).
4 Medical Symptom Checklist (Travis, 1997).
5 Transcendental meditation (TM) is an East Indian meditation technique that increases awareness through concentration, contemplation, visualization or thought control. Highly focused concentration on one thing is the differentiating characteristic of TM. It is typically practiced for twenty minutes twice a day. The goal of TM is to reach the highest state of awareness possible. The traditional Vedic understanding of TM is that this state allows the inherent intelligence of the body to restore balance. From the western perspective, TM exerts its health effects through regulation of the autonomic nervous system, neuroendocrine axes, and the cardiovascular and immune systems (Walton, Schneider, & Nidich, 2004).
6 Empathy Construct Rating Scale (La Monica, 1981).
7 State-Trait Anxiety Inventory (Spielberbger, Gorsuch, & Lushene, 1970).
8 Index of Core Spiritual Experiences (Kass, Friedman, Leserman, Zuttermeister, & Benson, 1991).
9 Shapiro Control Inventory (Shapiro, 1994).
10 Growth hormone
11 Thyroid stimulating hormone
12 Multiple Affect Adjective Check List (Zuckerman & Lubin, 1965).
13 Affective Sensitivity Scale (Kagan & Schneider, 1977).
14 Epinephrine
15 Norepinephirne
16 Dopamine
17 Profile of Mood States (McNair, Lorr, & Droppleman, 2003).
Chapter III: Methods
Design
This qualitative study uses a semi-structured interview design known as a focus group. A group of sixth-grade-aged children were recruited from the middle school Sunday school group at a large church in Seattle, Washington. Participants were eleven to thirteen years of age, willing to participate, and had the written, informed consent of a parent or legal guardian. A focus group is ideally suited to study the topic of meditation for stress reduction in children, a topic about which there is little literature. This design allows for the generation of qualitative information about the perceptions of sixth-graders about mindfulness meditation in the context of stress management.
Setting
The group was conducted in a private room at the church. The location was well known and easily accessible to the participants and their parents or guardians. This provided a familiar space that was unlikely to provoke undue stress and inhibition. Students were seated around an oval table with the moderator in the middle of one side and the assistant in the middle of the other side. The Sunday school staff members were available nearby in a separate room in case any participants desired to leave the group before its conclusion.
Sample
This study used a convenience sample from the recruitment group described above. The final sample consisted of seven girls and one boy all aged between eleven and thirteen years. The participants were all known to each other from their common participation in the Sunday school program. Some within group homogeneity may desirable (Polit & Beck, 2004, p. 342). However, the participants attend several different Seattle area schools, allowing the focus group to reflect broader peer group perspectives. Selection into the sample was determined by the students’ willingness to participate and match to the inclusion criteria.
Inclusion criteria were: age eleven to thirteen, willingness to participate, written parental informed consent, and written participant assent. Those willing and able to participate were excluded only if they did not fall within the stated age range. Prior knowledge about or experience with meditation were not requirements of participation.
Measures
Demographic data. Participant age, sex, ethnicity, and family income rage were reported by the parents/guardians the day of the group (See Appendix B). Providing information about ethnicity and income was voluntary and anonymous.
Qualitative data. The primary data were generated through the focus group discussion. The data consists of the participants’ answers to both pre-formulated questions and questions that emerged from within the discussion. The measures for this qualitative information were the questions posed by the group moderator. To ensure reliability, the principal investigator was the one and only moderator. The questions were determined by the specific aims of the study. They fall into three major categories:
1. Conceptualizations of personal stressors and stress management strategies.
2. Stress management strategies used by participants and method of exposure.
3. Beliefs and opinions about mindfulness meditation before and after a short mindfulness meditation.
See Table 2 for the pre-formulated questions corresponding to these categories. Additional questions were asked by the moderator during the group to elucidate ideas brought up by participants and to follow possible themes. To the extent possible, all questions remained within the context of the category being discussed.
Table 2: Measurement categories and corresponding group questions
|Category |Group Questions |
|Conceptualizations of personal stressors and |What does it mean to have stress? |
|stress management strategies. |What does it mean to manage stress? |
| |What things do kids your age worry about? |
| |4. How does worry change how a person feels? |
|Stress management strategies used by |What helps kids your age when they worry? |
|participants/ Method of exposure to stress |2. What have you done in the past to manage stress? |
|management strategies. |3. How did you learn about your stress management skills? |
| | |
|Beliefs and opinions about mindfulness |1. What is meditation? |
|meditation before and after a short mindfulness|2. What do you think about meditation? |
|meditation. |3. Can you imagine yourself meditating? |
| |Brief mindfulness meditation exercise (see Appendix B). |
| |4. How, if at all, did the meditation exercise |
| |change how you feel? |
| |5. What new thoughts do you have about meditation? |
| |6. How would you describe meditation to others? |
| |7. What things might make you want to meditate? |
| |8. What things might keep you from meditating? |
Process reliability. In focus groups, process reliability may be evaluated on three criteria: stability, equivalence, and internal consistency (Kidd & Marshall, 2000). Stability is the consistency of issues over time. This is primarily a challenge for studies involving multiple groups over a period of time. For the purpose of this study, stability was maintained by confining the questions to the three major categories previously described. Equivalence and internal consistency are determined respectively by the consistency of group moderation and coding. In this study, equivalence and internal consistency were not an issue, as there was only one moderator and one coder.
Content validity. In focus group research, content validity is determined by the extent to which participants’ responses truly reflect their thoughts and feelings. Important factors in content validity include the skill of the moderator and group composition (Speziale & Carpenter, 2007, p. 40). The members of a group must share a common experience and/or background to ensure that individuals share their thoughts freely (Polit & Beck, 2004, p. 342). Creating a diverse group presents a challenge to validity. The homogeneity in terms of age, geographic location, and Sunday school attendance all enhance the internal validity of this study. Moderator skills important to content validity include the ability to gain trust, foster an atmosphere of respect, maintain the focus of the conversation, and manage groupthink[1] (Speziale & Carpenter).
The content validity of this study was also enhanced by the extensive experience of the moderator in conducting groups and moderating group discussions. The moderator also has experience working with middle school-aged children in group settings facilitating health educational learning activities. Key steps utilized to enhance validity included introductions, developing ground rules, and guiding the flow and focus of the conversations.
Procedures
Recruitment. The youth were informed of the purpose of the study directly by the principal investigator. Youth were told that information gained from this study may be helpful in the planning of stress reduction programs for children their age. They were informed that they would receive written information about stress management and meditation specifically written for children their age. No coercion was used during recruitment. The children were told that participation was strictly voluntary. The children were informed that, even if they agree to participate, a parent or legal guardian must agree and give written informed consent. No money or rewards other than the food and beverages were promised or given to either the participants or the consenting adults. This information was explicit in the consent forms. In addition, the following was stipulated on the flyer and in the consent forms: “This research is not linked to [name of church withheld to maintain the confidentiality of the participants].” Teachers and church officials will not have access to the data collected.” All procedures and materials used for this study were reviewed and approved by an institutional review board of the University of Washington prior to recruitment and before parental consent and participant assent.
The Group. Before the groups began, final questions were answered and the consent and assent forms were signed by the parents and participants. After all parents and persons other than the moderator, the assistant, and the participants had left the room, the group began. The group lasted a total of forty-five minutes. The first seven minutes included introductions, a reminder of the purpose of the study, and the development of ground rules for the discussion. The purpose of the introductions was to familiarize the participants with the moderator, the expectations for the group, and each other. The purpose of developing ground rules was to give the participants a sense of structure and individual control.
In developing ground rules, participants were asked to write anonymously on a piece of paper two or three things they liked and two to three things they disliked about talking in groups. The moderator discussed the themes of these responses and elicited group approval of ground rules to ensure that all participants agreed on the fairness of the process. Ground rules included the use of respectful language, speaking one at a time, and limiting the length of comments by any one person (See Table 3: Ground Rules Script). A small red flag was raised by the assistant as a gentle reminder when ground rules were not being followed. This was accompanied by verbal redirection by the moderator as needed. These procedures helped maintain the flow and focus of conversation with minimal confrontation and disruption.
Direct CD-R recording, managed by the assistant, began after the ground rules were discussed and conversation continued for the following thirty-eight minutes. During that time, the participants were asked the predetermined and evolving questions while being recorded (See Table 2). The group included a five-minute guided group meditation called the raisin exercise (See Appendix G) and a three-minute wrap up. At that time, the moderator verified key points made by participants, reminded them of the confidentiality agreement, and invited them to share final thoughts, feelings, and questions.
Table 3: Ground Rules Script
Before we start, I’d like us to agree on the ground rules for this talk. You each have a piece of paper in front of you. I want everyone to write down 2 things that worry you about this group talk. One example
of a worry might be, “being laughed at.” Please do this now and place your paper in the box in the center of the table.
[After collecting responses, the moderator will talk about how the worries can be addressed through the group ground rules]
Some have said that they [don’t like or are worried about (WORRY)]
One thing we can do about this is (strategy to address worry).
[Continue until all worries/dislikes have been addressed (combine similarly themed responses). See table below for responses. Address all concerns listed by participants as well as the concerns below, whether or not they are listed by participants.]
|Worry |Possible response |
|Others will find out what I said |I won’t tell anyone what you say. The report I write about this study |
| |won’t have your name in it. You can help by promising not to repeat what |
| |others say here today. |
|Embarrassment |Don’t talk about anything very personal or embarrassing. Don’t laugh at |
| |others or make fun of what they say. |
|Can’t understand what others are saying |Speak slowly. Don’t yell. Speak one at a time. |
|Won’t get to speak |Keep your comments short – less than 2 minutes. |
|Others won’t follow rules |I’ll ring this bell and remind the group about the rule. |
What other ideas do you have to help everyone feel ok about talking? [Discuss if appropriate]
Can everyone agree to following these ground rules: [Re-read the list of responses to the group; ie keep it a secret who is here tonight and what they said, speak one at a time, don’t yell…]?
Discuss the rules until all participants agree.
I’ll do all I can to keep your answers confidential. It is still possible, however, that someone else will repeat what you say here tonight. You don’t have to answer any question you don’t want to. You may leave the talk at any time. If you want to leave, let me know and [name of assistant] will go with you. Are there any questions?
We’ll start the talk now. [Go to Focus Group questions]
Immediately following the group, the moderator and assistant moderator conducted a debriefing. During the debriefing, the moderator and assistant shared and compared first impressions of the participant responses, including key points of each question and major themes. Discrepancies between participant responses and moderator observations were noted at this time.
Role of the moderator. The moderator’s notes were limited to group observations for the purpose of making clarifying and summarizing statements, without identifying individuals. This allowed the moderator to focus on facilitation of the discussion. At the beginning of the focus group session, the assistant was introduced to the youth, and during the session he took written notes, which were later transcribed into a word document.
Data collection. The primary data collection method was the audio recording of the responses by group participants. Written notes were also taken by the assistant during the group regarding the verbal and non-verbal responses of the participants. Secondary data consist of the demographic information, which was obtained through voluntary completion of the demographic form (See Appendix B) by parents and guardians immediately prior to the group. Additionally, notes were taken during the debriefing.
All data was stored directly to a password protected file for protection. The written notes were destroyed immediately after entering into a computer document. The CD recording of the group was delivered directly by the moderator to a professional transcription service soon after completion of the group. Written transcripts were returned and saved to the same password protected file within one week pending analysis.
The consents and assents have been stored on paper forms in a locked file cabinet separate from the contact information forms (See Appendices C and D). This data will be destroyed upon completion of the study or on or before September 1, 2007. The original audio recording is also stored in a locked, secured space at the University of Washington. This recording will be destroyed on or before September 1, 2007. Transcripts will be held indefinitely in a locked, secured space at the University of Washington for potential use in future research.
Analysis Plan
Anonymous demographic data was collected on the optional demographic form by the parents at the time they gave informed consent. This information was compiled into a summary table. Later, the table was used to create the summary statement about the group characteristics found in chapter four of this report.
Qualitative analysis began with the final summarizing statements by the participants and the moderator and continued in the following order:
1. Debriefing – The moderator and assistant moderator shared their initial impressions at the end of the group. They identified common themes and discussed possible reasons for any discrepancies.
2. Transcription –Transcripts of the focus group were completed by a professional transcription service within one week of the group.
3. Transcription verification – Transcripts were reviewed by the principal investigator to verify accuracy of the transcription. Minor changes were made as necessary.
4. Thematic analysis – The themes are the three categories of questions. The transcripts were reviewed to identify and highlight the questions relating to the major themes. Questions actually asked during the group were compared to the proposed questions to verify their relevance to the themes. See Table 4 for a comparison of proposed questions versus questions actually asked. Additional questions were identified for thematic analysis. They were identified as either an evolving question related to one of the three themes or as a summary question. See Table 5 for all questions asked listed by category.
5. Data sorting – All questions were sorted into the categories they were most identified with. All responses were then sorted to the question they most accurately corresponded with. This was typically, but not exclusively, the question that was asked just prior to the response.
6. Content Analysis – The responses were reviewed to characterize them according to extensiveness (the amount of variety in all responses for the same question), intensity (emotional tone), and frequency (how often the same or similar answer was given).
7. Cross analysis – A second experienced analyst also performed steps 4-6. The moderator and second analyst reviewed the results of cross analysis and discussed minor discrepancies.
Table 4: Proposed versus Actual Questions
|Category |Group Questions |
|Conceptualizations of personal|What does it mean to have stress? |
|stressors and stress |Actually asked: “What does it mean when you have stress?” |
|management strategies. |What does it mean to manage stress? |
| |What things do kids your age worry about? |
| |Actually said: “I’m interested in hearing about what kinds |
| |of things cause worry to kids your age.” |
| |4. How does worry change how a person feels? |
| |Actually asked: “How does stress change the way you feel?” |
|Stress management strategies |What helps kids your age when they worry? |
|used by participants/ Method |Actually said: “…what kinds of things you do about it to help…” |
|of exposure to stress |2. What have you done in the past to manage stress? |
|management strategies. |Didn’t ask - See answers to questions in number one above. |
| |3. How did you learn about your stress management skills? |
| |Actually asked: “How do kids your age learn about |
| |what to do about stress?” |
| |Answers: Figure it out on my own, Do what you most like to do, teachers |
|Beliefs and opinions about |1. What is meditation? Actually asked: “.. what you think |
|mindfulness meditation before |meditation is. What do you think it is, just in a few words? |
|and after a short mindfulness |2. What do you think about meditation? |
|meditation. |Not asked. |
| |3. Can you imagine yourself meditating? |
| |Brief mindfulness meditation exercise (see Appendix G). |
| |4. How, if at all, did the meditation exercise change how you feel? |
| |Actually said: “…did it change at all how you felt?” |
| |5. What new thoughts do you have about meditation? |
| |Actually asked: “Does anybody feel differently about meditation |
| |after this exercise than you did before?” |
| |6. How would you describe meditation to others? |
| |Not asked |
| |7. What things might make you want to meditate? |
| |8. What things might keep you from meditating? |
| |Additional question: “What, if anything, would make it |
| |more appealing to kids your age? |
| |Additional Question: “I want to find out what questions that I didn’t |
| |ask today that you think I should have asked.” |
INSERT TABLE FIVE
Risks and Benefits.
Because this study is conversational in nature, the risk of physical injury to the participants was unlikely. Because the participants knew each other, there was a risk of distress related to invasion of privacy. The consent and assent forms informed the parents/guardians and participants of their right not to answer any question they did not want to answer. It was also stated that it was not possible to guarantee the confidentiality of information shared in a group setting. Uncommonly, individuals may experience anxiety, stress or psychological discomfort from the state of heightened emotional awareness resulting from the idea or practice of meditation. The assistant moderator (trained to this possibility) was available to accompany any child who experienced distress and confer with his/her parent or guardian. No such incident occurred during this study.
Because this study involves minors, special care was taken to assure their protection from harm. This was partially accomplished through the use of assent forms. Having the parents nearby during group discussions provided for both the psychological and physical well-being of the participants. Having two adults present also offered an extra layer of protection and reassurance of safety. In addition, information regarding health referral and emergency mental health services was made available in writing to consenting parents/guardians (see Appendix I). A detailed study proposal was reviewed and approved by a full committee institutional review board of the University of Washington prior to the recruitment of participants.
There were no direct benefits for study participants. The print materials given to participants at the conclusion of the group could potentially improve their ability to cope with physiological and psychological stressors and/or facilitate their willingness to seek help. This research may have indirect benefits for both the participants and society through contributions this study will make to the body of knowledge regarding the application of meditation for stress reduction in middle school-aged children. This study may be used to help plan future programs to reduce stress for children.
Chapter IV: Results
This chapter will present the characteristics of the group and the responses of the participants. The major headings represent the categories, and the sub-headings represent the individual questions that were asked. These headings and subheadings are summarized in Table 5: Themes and Questions. For each individual question, responses are first summarized then analyzed in the context of extensiveness, frequency, and intensity.
Extensiveness refers to the range or amount of different answers to any given question. Frequency refers to the number of responses to any given question that are similar or the same. Intensity refers to the emotional and non-verbal context in which the responses occurred. A short interpretation follows each summary and analysis. Anonymous direct quotes are included to illustrate key points. For questions for which the responses were short in length and small in number, direct quotes are listed rather than answer summaries. This chapter focuses on presentation of the results; further discussion of the possible meaning of the findings will be presented in Chapter V.
Characteristics of the Group
The group consisted of seven girls and one boy all aged eleven to thirteen. By anonymous report of the consenting adult, six participants were white and two were of mixed race. All parents reported a combined yearly gross family income of greater than $50,000.00. By observation of the moderator, all participants shared their thoughts in an honest, thoughtful and uninhibited manner.
Category One: Conceptualization of Stressors and Stress Management Strategies
What does it mean when you have stress? This was the first question posed to the group. All participants responded thoughtfully. Responses included anxiety, pressure, worry, too many things going on at once, frustration, anger, and a human emotion. More than half of the participants responded or agreed to the words anxiety and pressure to describe stress. A majority of participants gave responses that connoted that they felt overwhelmed.
The discussion that followed was of low intensity. The frequent use of and general agreement about the words anxiety and pressure indicate that the participants have been exposed to common terms and concepts related to stress. The low level of intensity is consistent with the placement of the question. There were extensive responses expressing the concept of feeling overwhelmed. Illustrative examples include, “...so many things going on at once that you can’t handle it,” “...pressure ...from something I can’t handle,” and “You have a little amount of time to do a bunch of things.” The extensiveness and the length and specificity of the answers suggest that feeling overwhelmed by having more to do than they think they can handle is an important stressor for the participants.
What does it mean to manage stress? Responses included have a schedule, relax, look at the big picture, learn how to deal with it, make things easier, manage life, down time, chill out, recuperate. The word relax was used by a majority of the participants. The word pressure was used by many of the participants. The low intensity discussion following this question revealed themes of time management, prioritization and reassessing a situation. In addition to the frequency of the words relax and pressure in the responses, there were also extensive responses relating to time management. The use of complex concepts of time management such as scheduling and prioritization suggest they are learning about time management in a structured way. An illustrative response is, “To have a schedule of what you really want to do and when you want to do it. To do things when you say you want to do them; managing life.”
The concept of reassessing a difficult situation was described with less specific language and in a greater variety of ways, perhaps suggesting that this is a self-learned strategy. One response illustrating this concept is, “Just taking a step back and dealing with it. Looking at the picture and how to make it better.”
The high frequency of the specific word relax suggests a very basic idea of the meaning of stress management. The extensiveness of responses relating to time management represents the framing of stress management by the participants in the context of time pressure.
What kind of things cause worry to kids your age? Responses included having a busy schedule, getting behind at sports or school work because of being sick, what other kids think about you, getting enough sleep, grades, parents checking grades online, security of online grade reports, school, pressure from others, worry about something coming up, music performance, other people, having a busy schedule, school work, performance at sports, and getting interrupted in the middle of something. There was a particularly high frequency of the following responses: having a busy schedule, getting behind at sports or school work because of being sick, what other kids think about you, getting enough sleep, grades, parents checking grades online, and security of online grade reports.
Time pressure was also a major theme during the discussion following this question. Because of busy schedules, missing just one day at school or one sport team practice is highly anxiety provoking to the participants. Illustrative responses include, “At my school if you miss a day you have to go in the morning and go to all you classes and get homework. But then for the rest of the time you feel so behind,” and, “I have activities every day after school, so I never get a chance to recuperate.”
Another major theme of these responses was worry about the security of personal information online. The participants offered strong opinions about what constitutes an adequate password to access the grade reports their schools make available online. Two illustrative responses are, “We have passwords but you can’t change your password so if someone finds out…” and “Ours is so easy, it is your birthday, and if someone finds out your birthday…”
The high frequency of reports and intensity of emotions surrounding missing school and getting behind on homework highlights the impact of time pressure on these children. The list of worries is also important both in its extensiveness and focus on school and after-school events.
How does stress change the way you feel? Responses included mental and physical exhaustion, get sick, get a headache, don’t sleep, and just break down. There was general agreement with the word exhaustion. Many of the participants reflected on physical symptoms in their responses. This moderately intense discussion focused on a common theme of the physical and psychological results of the breakdown of coping mechanisms.
The physical symptoms described were very profound, illustrated by the statements, “I often find that when I get stressed I also get sick, like, I am like sick 90% of the time,” and “I get a headache. I start crying and crying makes you get headaches.” The psychological effects include crying, insomnia, mental exhaustion and fear about getting ill. Being sick causes fear in these kids because they have so much time pressure related to homework and after school activities. This illustrative quote was given by a participant discussing the results of her very busy schedule: “Every once in a while I get really stressed out with it all and I’ll get really exhausted, mentally and physically I just feel like I am going to break down any second, because I am just so stressed out.”
The frequency and extent of responses to this question demonstrate that the participants are affected significantly by stress and are aware of the physical and emotional results of that stress. The moderate intensity of these responses is in apparent contrast to the severity of symptoms described.
Do a lot of you have trouble sleeping at night? This clarifying question was the first evolving question of category one. It was added to explore the evolving theme of insomnia. Responses included trouble falling asleep, trouble waking up, and difficulty with an early start times of school. There was universal agreement about having difficulty falling asleep. Most participants reflected that they slept soundly after they fell asleep. One participant’s response elicited the agreement of all participants: “I have trouble going to sleep, but once I get to sleep I don’t ever want to wake up.”
The universal extent of responses indicating trouble falling asleep is important to note. Though it was beyond the scope of this study to explore the topic of insomnia, it is significant because lack of adequate sleep may be both a stressor and an effect of stress.
Stress can be good or bad sometimes? This second evolving question of category one elicited both positive and negative responses. The positive responses (good stress) included before a concert, before sports performance and parents checking grades. Negative responses (bad stress) included competition about grades and worry about poor grades. During this moderately intense discussion, all participants agreed that stress could be good or bad. There was general agreement that stress can be a motivation to improve performance (sport, music and grades). Again, the theme of stress related to school and after-school activities is prominent. In this case, some of the positive aspects of that stress were discussed. This discussion indicates that the participants have a sophisticated view of stress, one that incorporates the idea that stress is on a continuum of good to bad.
Category Two: Stress Management Strategies and Methods of Exposure
What kind of things do you do to help with stress? Frequent responses included exercise, napping and listening to music. Other responses included avoidance, hanging out with friends, taking a break, relaxing, listening to loud music, watching TV, lying down, getting warm, clearing thoughts, deep breathing, singing, humming, re-scheduling, making the most desirable activities a priority. Themes occurring in high frequency included the normalization of listening to loud music and re-evaluation during times of stress and prioritization. Illustrative quotes include: “What I do is put my I-pod music on super, super, super loud and that is the ultimate stress reliever for me,” “I just took a step back and thought about what really mattered,” and “I just take some things out of my schedule for a week or two just to kind of recuperate.”
These extensive responses reveal a great diversity in strategies employed by the participants in response to stress. Many of these responses were given in other sections of the conversation, and not in direct response to this question. This would suggest that many of the participants engage in activities that are relaxing to them but which they do not specifically identify as stress management strategies. With the exception of loud music, there was a lack of common language regarding things that help with stress, suggesting that the participants have not learned about how to manage stress from a common source. Also of note is that most activities listed are done alone. This highlights both the lack of incorporation of stress management into their regular daily activities and the importance of free time to the participants.
What things help with school stress? This evolving question was asked to explore the theme of school stress. Responses included Online homework, limiting homework from multiple classes at the same time, having a free period, receiving teacher help with homework, and being able to check grades online. The frequent response of having homework available online elicited the intense agreement of all participants. All participants expressed a desire for methods to manage the stress of homework. Most liked being able to check their grades online but worried about password security, as discussed in the category one question analysis. Teacher support was also very important to participants. One very unsettling response significantly captures the tone of this conversation: “Yeah! That’s wicked (having homework available online) - it’s so helpful because I can do my homework when I am sick, like all day. It’s so helpful because I can even get ahead if I am going to be sick the next day.” The frequency and intensity of responses regarding the availability of homework online both highlights the importance of technology to the participants as well as the fear of getting behind in school work.
How do kids your age learn about what to do about stress? Answers to this question included, “I do what I enjoy”, “I figured it out on my own”, and “from a [school] teacher. The majority of participants reported that they were not taught strategies by anyone. The relatively few answers to this question may suggest that the participants have not given much thought to stress management and/or have not been taught how to manage stress in a structured way.
Category Three: Beliefs and Opinions about Meditation
What do you think meditation is? Typical responses to this question included calming down, relaxing, not thinking about anything, clearing your head, deep breathing, and focusing on breathing. The word relax was used with high frequency. The idea of clearing thoughts emerged as a theme in the responses to this question. Most were familiar with the concept of clearing the mind, though they used different words to describe this concept. A typical responses was, “To calm down and relax and not really think about anything.” The extensiveness of responses reflects varying levels of exposure to meditation. The frequent comments capturing the idea of clearing the mind are in contrast to the key concepts of mindfulness meditation and awareness.
Can you imagine yourself meditating? Typical negative responses included, “I don’t want to sit cross-legged” and “I like to move.” Typical positive responses included “just sitting or lying,” “Yoga,” “Pilates,” and “lying on my bed.” Miscellaneous responses included references to other activities such as singing, humming and dancing. There was a general intense negative response to the idea of sitting still and sitting cross-legged to meditate. A response which captures both positive and negative views was, “I can’t really imagine myself like meditating, like you know, sitting cross-legged and stuff like that. But I could imagine doing what I do, just like lay down and stuff like that.” Responses reflect a stereotypical view of traditional sitting meditation. It is interesting to note that this form of meditation was neither demonstrated nor discussed by the moderator during the group.
Did the meditation exercise change at all how you felt? This question was asked after a five-minute guided mindfulness meditation exercise (See Appendix B for the text guide for this exercise and Table 2 for placement of the exercise in relation to the questions). Typical responses included “more concentrated,” “nothing,” “calmer,” and “I felt the raisin in my throat.” The short discussion following this question of was of very low intensity and extensively featured the use of very concrete language. One response that demonstrates an extensive, yet very concrete understanding of the exercise was, “I felt like I was eating a little old man who’d been in the tub too long gone out and gotten a tan and got run over by a bulldozer.”
The brevity and lack of complexity of the comments suggests that most participants did not notice a difference in how they felt emotionally or physically, lacked the vocabulary to describe their feelings, or lacked the ability to think and talk abstractly about the exercise. This extensiveness of concrete response suggests that the participants were engaged in the exercise but primarily focused on the raisin as an object. This specific meditation exercise was simple enough to be accepted by most participants but, in this setting, had a minor affect on how they felt.
Does anybody feel differently about meditation after this exercise than you did before? Typical responses included, “I feel it could be a wider range of things,” “it could be different [from what I previously thought],” and, “it could be anything.” Most participants made comments that pointed to an expanded definition of meditation based on this group’s discussion. This discussion was short, but intense, in the sense that the small number of participants who responded were excited in a positive way about their discoveries.
What kind of things might make you want to meditate? Responses included using a different food (other than raisins) and getting very stressed out [to the point of feeling that it was necessary to do something about it]. The low extensiveness in response to this question likely reflects both the timing of the question late in the discussion and a lack of clarity about the meaning of the question. Because of the low response to this question, the following two evolving questions were asked.
What kind of things would keep you from meditating? Typical participant responses included, staying still, time, people in spandex, having something else more interesting to do, picturing Buddha, and fear of appearing different to their peers. The tone of this discussion was spirited and lively. The idea of sitting still and appearing un-cool are impediments to considering meditation for these children. Limited time is also a deterrent for them. A response that illustrates the theme of this conversation was, “I kept on thinking about my friends and if I told them that [what we are talking about] they would have made fun of me.”
References to the Buddha and aspects of formal sitting meditation reinforce the previous theory that many in this group have been exposed to traditional forms of meditation but perhaps not to other, less traditional forms. There was a high frequency of comments that suggested a fear of peer judgment. These responses point to social acceptability as a theme rising from the discussion of this question.
What, if anything, would make meditation more appealing to kids your age? Responses included, “Pickles,” “doing it with people like yourself,” “a huge ad campaign,” “something that made it look cool,” “anything that associates young cool people with meditating,” and, “pop stars [promoting meditation].” This high yield question reinforced the need for peer approval and the influence of pop stars. Not surprisingly, no participants stated that they would be more likely to meditate if their parents or teachers talked to them about it.
Summary Questions
What questions didn’t I ask today that you think I should have asked? To this summary question, one participant responded, “You should have asked what foods you associate with happiness.” There were no other responses to this question.
What was this like for all of you talking? There was a specific response of, “OK,” followed by gestures and remarks indicating agreement. One participant responded, “You didn’t say anything personal so it was fine.” Another participant stated, “I had fun.” These responses and the depth of conversation demonstrate that all the participants felt comfortable sharing their thoughts.
What would be helpful in leaving here today for you to know? The two responses to this final summary question were, “That there is not just one kind of meditation,” and “Basically anything that we did [could be considered] meditation.” Many participants described activities that they did not consider meditation but which clearly involve meditative concepts, such as focused attention and allowing the mind to be quiet.
Chapter V: Discussion and Conclusion
This chapter begins with a discussion of the themes of participant responses in the context of the specific aims of this study. Those aims are: to gather information about sixth-graders’ conceptualizations of personal stressors, the methods they use to manage stress, and their thoughts about meditation before and after a mindfulness meditation exercise. These aims were accomplished by gathering qualitative information from eight children, aged eleven to thirteen, in the context of a focus group discussion. Important themes evident from the data include those based on extensive, intense, and frequent responses, as well as those based on significant omissions in the responses. Following the discussion of themes related to each specific aim is a discussion of study limitations and research and clinical implications of this study. The chapter concludes with an overall summary,
Data Themes in the Context of Study Aims
Conceptualizations of personal stressors. In general, there was extensive language used to describe stressors. Specific words used with high frequency to describe stress included anxiety, pressure, frustration, and anger. There was a lengthy discussion of stress in the context of school and extra-curricular activities such as sports and music. The themes of time pressure and feelings of being overwhelmed by the large amount of homework and after-school activities occurred with high frequency. These themes correlate well to the research of Henker, et al (1995) which showed that the personal stressors described by school-aged children most frequently relate to academic or school-related activities. The intensity of responses about worry in the context of falling behind at school or after-school activities suggests that the busy schedules they described have had a significant emotional impact.
The information that was shared about internet security in the context of personal stressors was very intriguing. There was overwhelming agreement about the stress-reducing benefit of having access to homework and grades online. There was also, however, significant worry about the security of online grade reporting. They were very specific in their critique of the relative adequacy of various password protection methods used to protect their personal information. These students are knowledgeable about internet security issues and frustrated by their dependence on school officials to protect the security of their online grade reports.
Methods of managing stress. In contrast to the language used by the participants to discuss stressors, the language used to discuss stress management was relatively lacking in specificity and extensiveness. One frequently reported strategy, reported by a majority of participants, was listening to loud music. The responses, however, should be considered within the context of the specific question that was asked: “What kinds of things help with stress?” No distinction was made by the group moderator between types of responses to stress. The responses described by Kabat-Zinn (1990) that are nurtured by mindfulness meditation result in increasing levels of awareness and a heightened sense of control. These types of responses correspond to decreases in ongoing stress. The response to stress characterized by the participants (listening to loud music), seems to involve the suppression of thoughts and emotions. That response does not lead to increased awareness and may actually increase feelings of loss of control and exacerbate ongoing stress (Kabat-Zinn, 1990). The fact that these children are responding to stress by listening to loud music does not necessarily mean that activity is helpful. If, as their comments suggest, they are listening to loud music as a way to withdraw from overwhelming thoughts and emotions, then that activity may be considered to be very different in intent and effect from mindfulness meditation.
Another theme surrounding strategies to help with stress was time management. The specificity and similarity of language used by the participants to describe time management strategies suggests that this knowledge has been imparted to them in a structured way. This structure may be intentional, as through school curriculum, or unintentional, as by way of youth modeling language and behavior of adults in their lives and in media they are exposed to. As with listening to loud music, however, it is not clear whether time management as described by the participants, is a mindful and helpful strategy. The participants discussed time management in the context of having more to do than they could manage. That would suggest that they are using time management to attempt to regain a sense of control. A sense of control, while an important factor in the experience of stress, does not necessarily change one’s relationship with stress. The philosophy of mindfulness involves the retraining of one’s relationship with stress rather than simply reacting to stress when it occurs (Kabat-Zinn, 1990).
More important than characterizing these strategies by type, however, is quantifying how effective they have been. These children are experiencing significant effects, both physical and emotional, from stress. Headaches, exhaustion, and insomnia were frequently reported in response to the question, “How does stress change the way you feel?” This would indicate that the strategies they are employing, however they are characterized, have not been fully effective.
Thoughts about mindfulness meditation. Responses to questions about meditation prior to the mindfulness meditation exercise reflected a detailed yet superficial understanding about traditional Buddhist sitting meditation. In this style of meditation, the meditator sits cross-legged with the backs of the hands resting on the knees, palms open and the thumb and pointer finger touching. One participant demonstrated sitting meditation, accompanied by vocalizing “omm” during a response by another participant describing why meditation did not seem appealing. The fact that the demonstration evoked smiles and laughter from most other participants may be interpreted as indicating that this traditional form of meditation was universally considered to be unappealing by the participants. Other factors may also explain this response, such as the influence of peer responses (Speziale & Carpenter, 2007, p. 40). However, comments made after the mindfulness meditation exercise by several participants that elicited general agreement from the group indicated that awareness of meditation was expanded through the focus group exercise and the group discussion that followed.
The concrete answers given to describe the effects of meditation after the mindfulness exercise may simply indicate the developmental stage of the participants. Comments such as the one describing the raisin as “a little old man,” for instance, are reflective of the concrete operational stage of development, characterized by the ability to understand direct rather than abstract relationships (Murray & Zentner, 2001). A child in the next developmental stage of abstract relations, on the other hand relationship, may be more apt to see and describe “the sun and earth in the raisin,” as Kabat-Zinn describes in Full Catastrophe Living (1990). While the language used to describe the mindfulness exercise were largely concrete, several responses did indicate that some children felt calmer and could concentrate more easily after the exercise. Encouraging discussion regarding the connection between focused attention and emotional responses may have been helpful at eliciting more abstract ideas about their responses to the exercise.
The specific and enthusiastic recommendations of the participants regarding promoting meditation are quite instructive. Their comments about being made fun of and wanting to see advertisements showing kids like themselves indicate that they will be reluctant to engage in any activity that is deemed un-cool by their peer group. Strategies identified by the participants included enlistment of music performers popular with this age/demographic group and the use of images showing other kids they identify with.
Significant omissions. There were no comments about stress in the context of the family unit. When a theme is anticipated, but does not surface during a focus group, it typically indicates that the topic is less important than it was thought to be (Kreuger, 1998). One explanation may be that he participants, being from affluent families who are engaged in their community, simply have few stressors related to family. To confirm this assumption, however, would require posing a confirming question to the group, such as, “The topic of stress caused by parents or brothers and sisters was not mentioned. I’m assuming that is not as important as other factors that were mentioned. Is that correct?” Because confirmation was not elicited and data was collected from only one group, it may have simply been an aberrancy that no one in this group mentioned family stressors.
Other research supports the findings in this study that academic and school-related worries are the most common stressors identified by middle school-aged children (Henker, Whalen & O’Neil, 1995). However, Henker, et al found that 14.4% of children in grades 4-8 reported worries about family relations. That finding is in apparent contrast to the omission of talk about family relations in this focus group.
The lack of identification of sources of information about stress management is another significant finding. Responses about strategies were specifically sought. Despite this, most participants, all of whom were quite talkative during other parts of the conversation, had little to say on this topic. The little that was said indicated that the activities they do in response to stress are things they thought of on their own.
There was little response to questions about the effects of the meditation exercise. The responses that were given were largely absent of evidence of abstract thought. Because students at this age are in the beginning stages of developing the ability for abstraction, it is possible that the responses sought were simply beyond the developmental level of the participants. The participants were not asked to take note of their thoughts and feelings before the exercise, which may have served as a comparison. Future focus groups could attempt to distinguish between lack of ability of the participants to understand the question and failure of the moderator to effectively elicit the desired information by asking the children to note their thoughts and feelings before as well as after the meditation exercise.
Limitations
The content validity of this research is relatively strong due to the homogeneity of the group and statements made by participants that reinforce the moderator’s observations that the participants were uninhibited in their responses. There are, however, limitations to the study. One important limitation was that only one focus group was conducted. Typically focus groups are conducted in a series of three to six groups for the purpose of discovering patterns of similarities and differences among groups. It is this comparison that allows assessment of process reliability (Krueger, 1994). The process reliability of the data from this study, therefore, is limited by the fact that it represents the responses of only one focus group. An additional limitation to process reliability is the lack of results verification. To improve process reliability, preliminary results analysis could be verified with the participants. For example, the meaning of the omission of family relations as an identified stressor could be confirmed with the participants.
Some limitations were the result of methodological and procedural challenges. These include choosing a broad topic, asking a large number of questions and lack of sufficient clarification of certain terms such as stress management, time management, and coping mechanisms. Other limitations of the study were unanticipated and include the lack of gender balance, the narrow demographics of the participants, and having less time than anticipated for group discussion.
Implications for Research
Further research into stressors and methods used to manage stress by middle-school aged children is indicated by this study. Recommendations include specific future research questions to be explored as well as methodological and substantive recommendations that address the limitations of this study.
Substantive recommendations. Substantive recommendations include providing participants with concrete definitions of stress management terms and prefacing the meditation exercise with a basic statement of the philosophy of mindfulness and a request to notice thoughts and feelings. The concrete responses to questions regarding the effects of the meditation exercise reflect a need to anticipate that children of this age may fall in a range within a continuum between concrete and abstract operational stages of language development. Offering concrete definitions to terms salient to the discussion may increase the richness of the responses. This may include contrasting concepts related to mindfulness meditation such as focused awareness to other responses to stress that involve suppressing thoughts and emotions. One way of approaching this might be to give participants a list of definitions and allow time during the group to discuss them.
Methodological recommendations. Methodological recommendations include providing additional time for group discussion, adding three or more additional focus groups, and incorporating results verification into the analysis plan. The actual time of group discussion for this focus group was thirty-eight minutes. The ideal time for focus group discussion is more than one hour, but less than two hours, while the ideal number of focus groups is four to six (Kreuger, 1994). Verifying the results with each group would increase the process reliability of future focus groups.
Important questions for future research to address include the following: How do parental assumptions about their children’s stress and stress management approaches compare to statements made by the children? What types of meditation and what specific meditation exercises would be most accepted by this age group? What is the relative effectiveness of different methods of promoting meditation to this age group?
Implications for Practice
It is clear from this study that, at least for these particular children, their experience of stress far exceeds their exposure to effective stress management strategies. Strategies should be offered in a ways that are accepted by the children and do not create additional time pressure on them. Based on this research, stress management programs designed for this age group might be more successful if they incorporate some simple recommendations. These include use of concrete language, incorporation of movement, use of normalizing images and incorporation of programs into structured daily activities. Additionally, there are significant implications of the participants’ thoughts about the security of their online personal data.
Concrete language. When developing programs to address stress management with school-aged children, select words carefully using language that will be understandable to both abstract and concrete thinkers. Solicit consultation from developmental experts in developing a glossary of stress management terms and a script to guide the discussion of concepts relating to mindfulness meditation.
Incorporate movement. The participants in this study indicated they would be more likely to engage in meditation if it included movement. Successful movement-based approaches to stress management might include Yoga or Tai Chi (Wall, 2005). Walking meditation, a form of mindfulness meditation described by Kabat-Zinn (1990), has been utilized in pediatric practice (Ott, 2004). Walking meditation may be better accepted by a wide range of children because it involves activity, requires very little instruction, and can be done virtually anywhere without attracting negative attention to the walker.
Seek and verify influential images and role models. Utilize normalizing images and popular role models in program promotion. These images should be tailored to the specific group of children to whom meditation is being promoted. For example, if a program is planned for a school with a large number of students from a particular minority group, images of children of the same age and minority group should be used in the promotional media. Surveys could be distributed to determine what celebrities from local communities, professional sports and the music and film industry have the most credibility with a specific group of children. Any approach could be verified through focus group research with participants drawn from a specific population.
Incorporate programs into structured daily activity. Schools may be a good venue for these programs since much of the stress experienced by children of this age relates to school and extra-curricular activities (Henker, Whalen & O’Neil, 1995). Other possibilities include incorporation of meditation into family activities such as mindful walks or mindful eating. Parents can also play a role by discussing the concepts of mindfulness frequently and encouraging children to apply these concepts while doing everyday activities, such as walking to a bus stop or classroom or eating a snack.
Stressors and loss of control. Another important implication of this research is the elucidation of the need for individuals and institutions to seek input from the children they serve regarding the effects of school policies on their experience of daily stressors. In the context of this particular group, this manifested itself as anxiety regarding the security of online grade reports. While it is unknown if this issue is particular to this group, the underlying theme of loss of control could be effectively addressed in a broad cross section of children in this age group. For example, parents and schools may wish to seek input from youth about the effects of homework and extra-curricular activities on their experience of stress, both also issues raised by the participants of this study. This could be accomplished through the use of focus group interviews tailored to specific groups of children, such as sixth-graders of a particular school district. Moderators of these groups may wish to explore the ways in which anxiety related to loss of control expresses itself within the context of their group’s participants.
Summary
These eight youth gave a lively and thoughtful discussion of their perceptions of stress, stress management and mindfulness meditation. Their story is clear and, with little exception, they speak with one voice. They have a well developed vocabulary to describe stress, indicating that its effects are prominent in their lives. They worry most about school, extra-curricular activities, security of personal online information, and how they are viewed by their peers. They care a great deal about the privacy and security of information about them made available online by schools. Though they generally agree that having this information online is desirable, they have specific ideas about how to improve its security. Surprisingly, there was no mention of family relations during the discussion of stressors.
There can be no doubt that these youth are overwhelmed by busy schedules. They described physical and emotional ramifications of daily stressors in detail. Despite experiencing significant effects from stress, however, participants were not able to identify particular sources of information regarding stress management. There was also a disparity between the effects of stress and the effectiveness of measures employed to help with stress.
They are willing to engage in mindfulness meditation, though they fear judgment from their peers. Their concept of meditation is quite concrete and based on a very traditional view of meditation. This view, however, was expanded through the mindfulness exercise and the conversation that followed. Images of kids like themselves meditating and promotion of meditation by pop music stars could decrease the view of meditation as un-cool and increase the likelihood they would employ it as a stress management strategy.
Conclusion
This study collected qualitative data about the perceptions of sixth-graders regarding mindfulness meditation in the context of stress reduction. Use of a focus group interview for the study design allowed for the generation of data showing the language used by the participants to discuss stress, stressors, and meditation before and after a short mindfulness meditation exercise. One significant finding was the disparity between their experience of stress and the effectiveness of their methods to manage stress. Other significant findings include participant concern about the security of online grade reports, and a preference for meditation methods that incorporate movement.
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Appendix A
*Demographic Data
What ethnic group does the child most identify with? (circle one)
Black Hispanic/Latino White Asian/Pacific Islander American Indian
Native Alaskan Mixed ethnicity (please describe) __________________.
Approximate household income
(Combined income of all working family members before tax)
Circle one: 75,000
Age of Child __________________. Sex of child (circle one): Male Female
NOTE: Do NOT write your name or any other identifying information on this page. Providing this information is voluntary. It will not affect your child’s participation in this study. This information will never be directly linked to you or your child.
*To be filled out anonymously by the parent of the participant when they come to their scheduled group. This form will be stored anonymously with the age and sex data from the intake form until data analysis. The demographics forms will be destroyed after data entry into the demographics table and no later than one week after the final group.
Appendix B
*Mindful Eating Exercise
“You are each going to get two raisins. I’d like you to eat one and set the other one in front of you. For the next part, we’re going to use our imaginations. Take a deep breath in, now exhale all your air. Take the other raisin in your hand and look at it carefully. Pretend it is an object you have never seen before. Without speaking, think about how it looks and feels. Notice its color, its size, its shape, how it feels in your hands and between your fingers. Still, without speaking, compare one end to the other, see if it makes any sound, and imagine it growing and gathering energy from the sun above it and from the dirt below it. Now, keeping it in your hand, think about what it will be like to eat it. Notice any changes in your mouth or your body when you think about eating it. Next bring it just to your lips. Notice how you feel thinking about eating it. Now place it in your mouth. Slowly chewing it, carefully notice how it tastes and feels inside your mouth. Now swallow it, noticing how it feels in your throat and stomach.”
“How could the raisin be described to someone who’s never seen one before?”
“How was eating the second raisin different from eating the first?”
*This exercise is closely modeled after a mindful eating exercised described by Jon Kabat-Zinn, PhD in Full Catastrophe Living (1990, pp. 27–29). Kabat-Zinn (1990) states that this is a good mindfulness exercise to use when introducing meditation to those who have no previous experience. Even those who do not like raisins have responded favorably to this exercise (Kabat-Zinn, 1990). Acceptance of this exercise by children has been reported by Ott (2002).
Appendix C: Assent Form
UNIVERSITY OF WASHINGTON ASSENT FORM
Stress & Meditation Focus Group Study of 6th Grade Students
Researchers
|Investigator/Group Moderator |Department |Contact Numbers|
|Mark L. Anstadt, RN, FNP Graduate Student |Psychosocial & Community Health |(206) 384-0376 |
| | | |
|Thesis Committee | | |
|Elaine Thompson, PhD, RN, Chair |Psychosocial & Community Health |(206) 543-8555 |
|Cathryn Booth-LaForce, PhD, FAPS, RYT |Family & Child Nursing |(206) 543-8074 |
PURPOSE and BENEFITS
We are asking you to be in a study about stress and meditation. When people meditate, they focus on sounds, thoughts, feelings, or breathing. This helps some people stay calm. This study will help us learn more about what kids your age say about using meditation for handling stress.
STUDY PROCEDURES
If it is ok with you, we would like you to be in a discussion group with nine other kids your age. I will tape record the discussion. The group will meet during your regular Sunday school time. If your parents come with you, they will wait in another room. I will ask what kids worry about. I will also ask how kids deal with their stress and what you think about meditation.
I will talk about meditation. I will ask you to pay attention while you chew a raisin. You do not have to eat the raisin if you don’t want to.
RISKS, STRESS, OR DISCOMFORT
Kids in the group might tell others what you say, even though we will ask them not to tell. You might not want to answer questions. You don’t have to answer any questions if you don’t want to. You might not like the meditation exercise. You can leave if you want to.
OTHER INFORMATION
We won’t tell anyone you were in this study. We won’t put your name on the tape we use to record the discussion. Your friends, family, and people at school won’t be allowed to listen to the tapes.
If you tell us something that makes us think you are not safe, like someone is hurting you, we will tell someone so we can keep you safe. You don't have to be in this study if you don't want to. No one will be mad at you. We will give you a copy of this form to keep.
Mark L. Anstadt, RN
Printed name of researcher Signature of researcher Date
Subject’s statement: This study has been explained to me. I agree to take part in this study. I have had a chance to ask questions. I agree to be audio taped during the group talk. If I have questions later, I can ask Mr. Anstadt. I will get a copy of this paper to keep.
Printed name of subject (student) Signature of subject (student) Date
Copies to: Researcher, Subject, Parent/Guardian
Appendix D: Consent Form
UNIVERSITY OF WASHINGTON
Parent/guardian CONSENT FORM
Stress & Meditation Focus Group Study of Sixth Grade Students
Researchers
|Investigator/Group Moderator |Department |Contact Numbers|
|Mark L. Anstadt, RN, FNP Graduate Student |Psychosocial & Community Health |(206) 384-0376 |
| | | |
|Thesis Committee | | |
|Elaine Thompson, PhD, RN, Chair |Psychosocial & Community Health |(206) 543-8555 |
|Cathryn Booth-LaForce, PhD, FAPS, RYT |Family & Child Nursing |(206) 543-8074 |
Researchers’ statement:
We are asking your child to be in a research study. The purpose of this form is to give you the information you will need to help you decide whether to allow him/her to be in the study or not. Please read the form carefully. You may ask questions about the purpose of the research. You may ask what we will ask your child to do, the possible risks and benefits, your child’s rights as a volunteer, and anything else about the research or this form that is not clear. When all your questions have been answered, you can decide if it is okay with you for your child to be in the study or not. This process is called “informed consent.” We will give you a copy of this form for your records.
PURPOSE OF THE STUDY
Meditation is helpful when used by adults to lessen the effects of stress. More knowledge is needed about its use by children. Meditation is the training of attention. In mindfulness meditation, the focus of this attention may include sounds, thoughts, body feelings, emotions, or the breath. There are a few studies that show children this age benefit from meditation. Benefits included calmness, better sleep, and more self-awareness. This study will help us learn more about how young people think and talk about using meditation for stress.
STUDY PROCEDURES
For this study, I will conduct an informal group discussion called a focus group. The focus group will help me learn how the children think and talk about mindfulness meditation for stress reduction. During the focus group, I will ask questions to the group about:
1) Personal stressors.
2) Stress management strategies.
3) Beliefs and opinions about mindfulness meditation before and after a short mindfulness meditation exercise.
If your child is interested in participating, and with your written permission, your child will be asked to be in one focus group talk with about nine other students his or her age.
The most personal question that will be asked is: “What things do kids your age worry about?”
During the group, I will also guide the children in a short meditation exercise. This exercise will be done with the whole group at the same time. During this exercise, I will ask the children to pay close attention to the sensations they have while eating a raisin. Afterwards, I will ask them to talk about what this was like for them. The meditation exercise will last about five minutes and has no religious meaning. They may choose not to eat the raisin. The focus groups will be audio taped so I can capture all of the children’s comments. Please see “Other Information” below for a description of how the confidentiality of these tapes will be managed.
RISKS, STRESS, OR DISCOMFORT
Because the children may know each other, there is a risk of distress related to loss of privacy. Things the children say during the focus group could be repeated by other children present. Group participants will be asked not to mention what other group members say. We also ask that family members not to ask about what was said during the group.
Answering the questions or doing the meditation exercise may cause your child emotional discomfort. They have the right to leave the group at any time for any reason. If this occurs, the group assistant will go with him or her, talk with you, and tell you how to obtain help if it is needed.
You may wait nearby during group talks if you wish. Two adults (the moderator and one assistant) will be present during the focus groups.
If your child experiences emotional or psychological distress for any reason, we will talk to you about this and support you in arranging for your child to see his/her primary care provider. If they do not have a primary care provider, we will provide resources for you to call. We will also be available to help you seek support if necessary.
BENEFITS OF THE STUDY
There is no direct benefit to you or your child for being in this study. There are, however, potential benefits to society. This study may increase what is known about how to reduce stress for children in this age range. This study may be used to help plan future programs to reduce stress for children.
Your child will also be given a pamphlet about stress at the end of discussion. This pamphlet might improve their ability to cope with stress.
OTHER INFORMATION
Every effort will be made to protect the rights and privacy of you and your child during this study. All data, including the tapes and tape transcripts, will be anonymous. This means they will not have any information on them that could be used to identify you or your child. The person who transcribes the tapes will not have access to anything that may reveal the identity of you or your child except your child’s voice. The tapes will be destroyed after they have been transcribed or on or before September 1, 2007. Only the researchers and the person who transcribes the tapes will listen to the tapes or have access to the written transcripts. The transcripts and the tapes will be held in a locked cabinet in a secure space at the University of Washington School of Nursing.
The age, sex and ethnicity of the child, along with family income, will be recorded the day of the group. This information will never be linked to your name or contact information. You do not have to tell us your ethnicity and income if you do not want to. Only the researchers will access to this data. Contact information will be destroyed upon completion of the study or on or by September 1, 2007.
Everything your child says will remain strictly confidential with the following exceptions: If there is any reason to suspect a child is being harmed by another person, or, if we are concerned that a child might harm him/herself or others, we must report it to the authorities.
Government or university staff members sometimes review studies such as this one to make sure they are being done safely and legally. If a review of this study takes place, your child’s records may be examined. The reviewers will protect your child’s privacy. The study records will not be used to put you or your child at legal risk of harm.
Also, this research is not linked to St. Mark’s. Teachers and church officials will not have access to the data collected.
You may refuse to allow your child to join this study. You may withdraw permission for him or her to participate in the study at any time. The child may refuse to participate or withdraw from the study at any time even if you agree to their participation. No harm will come to you or your child for refusal to participate in this study. If your child does participate, he or she has the right to refuse to answer any question or any parts of any question.
Neither you nor your child will receive money or services for being in this study. There are no costs or fees for your child to be in this study. In the unlikely event that your child needs health or mental health care as a result of this study, it is your responsibility to arrange and pay for these services.
Names or other identifying information will not be in any reports of this study. Because summary data from this study may be used to provide pilot data for a grant as a follow-up to this study, we will keep an anonymous copy of the transcripts in a locked cabinet in a secure space at the University of Washington School of Nursing for an indefinite period of time. Only the researchers named above will have access to this data.
Mark L. Anstadt, RN
Printed name of study staff obtaining consent Signature Date
Parent/guardian’s Statement:
This study has been explained to me. I agree to allow my child to take part in this research. I understand and agree to the audio taping of my child during the focus group. Even if I agree, my child may choose not to participate. I have had a chance to ask questions. If I have questions later about the research, I can ask one of the researchers listed above. If I have questions about my rights as a research subject, I can call the Human Subjects Division at (206) 543-0098. I will receive a copy of this consent form.
Printed name of child
Printed name of parent/guardian Signature of parent/guardian Date
Copies to: Researcher, Subject, Parent/guardian
Appendix E: Mental Health Resources
Referrals for child health care in Seattle:
Community Information Line (For referral to mental health services in Seattle): 1-800-621-4636 or 206-461-3200, 8am-6pm M-F
Community Health Access Program (for all health referrals and assistance applying for the child health insurance program): (206) 284-0331 or 1-800-756-5437
For immediate help, you and/or your child may also use the following free services:
Crisis Clinic (24-hour confidential counseling for persons in crisis): 206-461-3222
Toll free: 1-866-4CRISIS (1-866-427-4747).
Teen Link Line (206-461-4922 or 1-866-TEENLINK / 1-866-833-6546) 6pm-10pm daily, is staffed by teen volunteers trained by Crisis Clinic staff.
Appendix F: Instant Meditation for Kids and Teens to Do Anywhere
Have you ever suddenly felt stressed? Has a teacher's question put you on the spot? Have you looked at test questions and drawn a blank?
Here is a very short meditation to help out in those stressful moments, so you can feel relaxed and calm again.
Do some regular breathing like this: Breathe in counts 1, 2; breathe out counts 3, 4; breathe in counts 1, 2; breathe out counts 3, 4; and continue on in this even breathing pattern.
Just a few moments of even breathing gives you a chance to relax and get back in control of the situation again.
Especially with a test, taking half a minute or more just to concentrate on breathing evenly stops those racing thoughts of "Oh no, I've forgotten everything!"
Taking this short time out for counted breathing calms both your body and mind. It is a short but sweet way to gain control on a moment's notice.
When you don't have time for a longer sitting or walking meditation during the day, you can still use this brief 'meditation on the breath' to get going on a positive track again!
Copyright Susan Kramer, Ph.D. Meditation Editor. Used with permission.
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[1] Groupthink, defined by Carey & Smith (2004) as quoted in Speziale & Carpenter (2007, p. 39) is “a process that occurs when stronger members of a group or segments of the group exert control or influence over the verbalizations of other group members.”
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