CLINICAL PERSPECTIVES
Being Mindful of Mindfulness: Past, Present,
and Future of Mindfulness in Child and
Adolescent Psychiatry
David C. Saunders,
Max, a lively and precocious first-grade boy, raises his
hand enthusiastically when I ask the class if anyone has
ever heard of mindfulness. He excitedly stands up in the
middle of the classroom, balances on his left foot, puts
his palms together in front of his chest, bows, and ex-
claims, “My mom says that mindfulness happens when
you do the peace tree!”
Julio, a quiet and withdrawn ninth-grade boy in foster
care, sat in back during a meditation session and silently
wept. When I asked him if everything was okay, he said
that he was “good” but “had never taken the time to
just . feel.” A participant in a study investigating medita-
tion in the setting of foster care, Julio was fond of mindful-
ness practice despite the emotional response and
contacted me after the class about continuing his practice.
T
ogether, these examples, drawn from my experience
teaching mindfulness to children and adolescents in
research settings, convey 2 of the many different con-
texts in which the study of mindfulness takes place. Within
this article, I consider the past, present, and future of the use
of mindfulness in child and adolescent populations. First, I
examine the origins of mindfulness in the clinical setting.
Second, I consider the myriad manifestations of the practice
in child and adolescent psychiatry (CAP), from schools and
homes to foster care and hospitals. Third, I look ahead and
offer recommendations for the study and practice of mind-
fulness in CAP going forward.
Contemporary mindfulness has roots in Buddhist
contemplative practices that stretch back centuries. The
kind of mindfulness meditation used in the clinical
setting—including CAP—is a secularized amalgamation of
Zen, Tibetan, and Burmese Buddhist practices. Although the
exact referent of the term mindfulness is the subject of much
scholarly debate, one heuristic for navigating the plurality of
meanings is to distinguish between mindfulness as a “state”
and mindfulness as a “trait.” Although the latter refers to an
enduring personal characteristic, the former—which this
article considers—amounts to a certain way of relating to
experience. In any case, the most widely used definition
of mindfulness in current research settings is attributed to
Jon Kabat-Zinn: “paying attention in a particular way: on
purpose, in the present moment and non-judgmentally.”1
Perhaps the signature feature of mindfulness is the cultiva-
tion of a nonjudgmental stance toward one’s thoughts,
feelings, and mental states. Among other features, mind-
fulness is not a mystical mental state, but rather a normal
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY
VOLUME 54 NUMBER 6 JUNE 2015
MD, PhD
characteristic of the mind that many believe everyone
possesses innately; it is not directed toward a goal or aimed
at cultivating a particular blissful state, and it is not about
disengaging from one’s experiences or “zoning out,” but
instead engaging with thoughts and feelings in a different
manner.
Mindfulness was first studied as a clinical intervention in
the early 1980s, when it was taught to adults with treatment-
refractory chronic pain conditions. Since that time, the study
of mindfulness has proliferated exponentially, with 5 articles
published in 1990, 21 in 2000, 353 in 2010, and 549 in 2013
alone—including some in the child and adolescent context.2
Among these studies, mindfulness has been appropriated
and tailored to treat a broad array of disorders, such as
depression, anxiety, suicidality, anorexia, obesity, attention-
deficit/hyperactivity disorder, and substance abuse, among
many others.
However, caution is in order because enthusiasm for
mindfulness programs may outpace the evidence. Currently,
mindfulness appears to be a useful intervention in adults for
a number of conditions, but more studies are needed. To this
end, researchers in the Department of Medicine at Johns
Hopkins University published a 2014 meta-analysis in the
Journal of the American Medical Association to determine the
efficacy of mindfulness for improving stress-related out-
comes. They reviewed 18,753 citations and concluded that
clinicians should “be aware that meditation programs can
result in small to moderate reductions of multiple negative
dimensions of psychological stress,” but that more rigorous
study designs are needed, including better randomization,
placebo control, and single-blinded designs.3 Indeed, several
studies are notable for their methodologic rigor, including a
study by Segal et al.,4 which skillfully combined mindfulness
and pharmacotherapy to create an improved study design.
Given the proviso on the difficulty of defining mindfulness,
it comes as no surprise that one of the chief obstacles to
rigorous mindfulness studies involves its operationalization
and assessment within a research paradigm.
Given the growth of mindfulness in adults, what is the
role of mindfulness in CAP? Although they have not infil-
trated pediatric populations to the same extent as adults,
mindfulness interventions have nevertheless increased in
CAP. Two 2014 review articles (1 meta-analysis and 1 sys-
tematic review) evaluated results from 20 and 24 studies of
mindfulness in CAP, respectively, and came to a similar
conclusion as the Johns Hopkins study for adults: mind-
fulness appears to have beneficial effects for some pediatric
participants, but more rigorous studies are needed.5,6 The 2
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SAUNDERS
reviews usefully evaluated mindfulness in CAP from a
broad and inclusive perspective, but the breadth of the
studies reviewed also betrays the nuances of the variety of
settings in which mindfulness is used, some of which
are more effective than others. Consider the earlier case
vignettes: Julio and Max encountered meditation at pro-
foundly different developmental stages, with crucial differ-
ences on a litany of indices, including (but not limited to) a
history of trauma and psychopathology, level of education,
family support, and so forth. Importantly, mindfulness was
shown by Zoogman et al.5 to be more effective for clinical
samples in CAP but less effective for nonclinical pop-
ulations—an additional variable to keep in mind. Although
a handful of studies are exemplary for their excellent
methodology and study design—such as a study by Biegel
et al.7—researchers still widely agree that more methodo-
logically sound studies on the beneficial and adverse effects
of mindfulness in CAP are needed.
Given the past and present of mindfulness in CAP,
what about the future? What should we be mindful of as
mindfulness continues to proliferate within the field?
Indeed, it would behoove all researchers of mindfulness to
note the recommendations of the recent review articles,
that is, to study the efficacy of mindfulness in CAP in a
more rigorous fashion, but what do these gold-standard
studies of mindfulness look like? To start, active rather
than waitlist controls are needed, and participants should
be randomized rather than self-selected, which are unique
challenges in mindfulness studies. In addition, partici-
pants would ideally be blinded to the type of intervention,
although mindfulness studies present nontrivial chal-
lenges on this front. More importantly, however, re-
searchers need to be specific and precise about what they
are studying, because not all mindfulness interventions or
target CAP populations are the same. Clinical in-
terventions are obviously different from school, home, and
after-school situations, and results should be expected to
vary accordingly. Demographics also matter: urban, sub-
urban, elementary, high school, underprivileged, and
affluent populations offer unique settings for the teaching
of mindfulness. Even within the general category of clin-
ical interventions, inpatient populations differ from
outpatient programs, which differ from partial hospitali-
zation or intensive outpatient settings. In short, the
promise of mindfulness also can be its downfall: it can
theoretically be incorporated into an immense variety of
settings, but some situations might be more effective than
others. It is the responsibility of researchers and teachers
to adhere to rigorous standards in the study of mindful-
ness in CAP and be aware of the nuances of each potential
intervention.
Nevertheless, studying mindfulness in the setting of
CAP offers promising avenues for research not available to
those who study adult populations. For example, taking a
developmental perspective to mindfulness research raises
intriguing questions that should be addressed in the
coming years. Indeed, several researchers have already
begun to ask such questions. Because the brain is an
inherently adaptive and plastic organ that is subject to
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change based on experience, training, and education, the
field should direct resources to understanding how mind-
fulness affects development. In addition, childhood and
adolescence are times of profound physical, social, and
emotional change. Importantly for psychiatrists, it is also a
period when psychiatric disorders, behavioral problems,
interpersonal difficulties, and risk-taking behaviors can
arise. There are windows of opportunity in the lifespan
when specific brain regions and networks are particularly
modifiable, and the introduction of certain forms of
enrichment (i.e., mindfulness) could produce salutary
effects. A sophisticated developmental approach to mind-
fulness in CAP might allow researchers to elucidate how a
child’s relation to experience can affect the trajectory of
that child’s development—on biological, psychological,
and social levels.
Viewing mindfulness through the lens of attachment
theory also opens new doors for mindfulness researchers.
When foregrounding the importance of the mother–infant
relationship, for example, one is forced to consider how a
mother’s capacity for self-regulation can affect her child’s
development. Of course, the impact of the early mother–
infant relationship on child development is well established
in the literature. Given that mindfulness has been shown in
some studies to affect self-regulation and decrease stress and
anxiety, it is sensible to wonder how a mother’s ability to be
mindful could be advantageous for development. Further-
more, initiatives to study the teaching of mindfulness to
parents and children simultaneously are suitable for study.
Because the rapidly evolving social worlds of children
extend far beyond the mother–infant relationship, studying
mindfulness in families also provides a rich opportunity for
research.
Here I conclude by offering 3 recommendations for the
study and practice of mindfulness in CAP. First, it should
go without saying that children and adolescents who
participate in research need to be protected. Their well-
being needs to overrule any eagerness to understand
whether or how mindfulness does or does not work. Un-
fortunately, acknowledgement of the adverse effects that
can result from mindfulness research has not been
adequate—virtually nonexistent, in fact. To my knowledge,
there are no quantitative studies on the percentage of par-
ticipants who report adverse outcomes, and no qualitative
catalog of such effects has been collected. And yet, it is
known that in certain settings—especially in the context
of Buddhist meditation—psychosis, panic attacks, and
traumatic flashbacks can result from meditation.8 CAP
researchers need to be especially cognizant of the possibility
of such outcomes, given the fragility and developmental
immaturity of pediatric participants. As the study of
mindfulness in CAP populations grows, we cannot afford to
ignore the adverse effects of mindfulness practice; perhaps
one way to address this gap is by reaching out to contem-
plative communities that have a history of observing such
adverse effects.
Second, interdisciplinary work needs to be fostered. Phi-
losophers, neuroscientists, cognitive psychologists, develop-
mental psychologists, teachers, administrators, nurses, social
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VOLUME 54 NUMBER 6 JUNE 2015

workers, public servants, and, of course, child and adolescent
psychiatrists need to be involved in mindfulness research. A
multidisciplinary approach is needed in adult populations,
but even more so in the pediatric context because of the
complexities of human development. Third, it cannot be
overstated that rigorous standards for the study of mind-
fulness in children and adolescents need to be upheld. Rather
than defending and promoting mindfulness before results
are even published (as mindfulness enthusiasts are wont to
do), we must emphasize the publication of positive and
negative results and “let the data do the talking.” After all, it
is the health and well-being of kids like Max and Julio that are
at stake. Surely, we should be most mindful of this. &
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JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY
VOLUME 54 NUMBER 6 JUNE 2015
CLINICAL PERSPECTIVES
Accepted March 12, 2015.
Dr. Saunders is with Emory University, Atlanta.
The author thanks John Dunne, PhD, of Emory University; Rebecca Rendleman,
MD, of Weill Cornell Medical College; and Andres Martin, MD, MPH, of
Yale University.
Disclosure: Dr. Saunders reports no biomedical financial interests or potential
conflicts of interest.
Correspondence to David C. Saunders, MD, PhD, 76 West 85th Street,
Apartment 5D, New York, NY 10024; e-mail: david.c.saunders@gmail.com
0890-8567/$36.00/ª2015 American Academy of Child and Adolescent
Psychiatry
http://dx.doi.org/10.1016/j.jaac.2015.03.006
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