F E A T U R E

Patricia C. Broderick
Stacie Metz
Learning to BREATHE: A
Pilot Trial of a
Department of Health, West Chester
University of PA, USA Mindfulness Curriculum
for Adolescents

Key words: mindfulness; meditation; emotion regulation; acquisition in the interest of preparing students for the
adolescents; program evaluation global economy they will enter. This emphasis reflects
the context in which schools function today, one of rapid
Introduction social change, high demands for vocational preparation,
and knowledge overload. Such reforms, however,
Contemporary education reforms have placed a necessary have also contributed to a surge in high-stakes testing
and well-intended emphasis on skills and knowledge and an increase in competitive educational environ-
ments. Schools now function under a set of pressures
A B S T R A C T that early creators of our school system could hardly
have imagined. Clearly, the mission of schools remains
This study reports the results of a pilot trial of Learning to BREATHE, one of preparing students academically for the world
a mindfulness curriculum for adolescents created for a classroom of higher education, work, and good citizenship.
setting. The primary goal of the program is to support the development However, the social landscape has shifted and,
increasingly, schools are also charged with oversight
of emotion regulation skills through the practice of mindfulness, which and management of students’ social and emotional
has been described as intentional, non-judgmental awareness of problems, which often seep into the fabric of their
present-moment experience. The total class of 120 seniors (average age academic pursuits.
By most accounts, mental health problems are
17.4 years) from a private girls’ school participated as part of their increasing among young people, possibly reflecting
health curriculum. Relative to controls, participants reported greater awareness of disorders (Achenbach, 1995),
decreased negative affect and increased feelings of calmness, relaxation, and also resulting from the increased number and
intensity of stressors on young people (Caspi et al,
and self-acceptance. Improvements in emotion regulation and 2000). Problems such as depression, which used to be
decreases in tiredness and aches and pains were significant in the the province of adults, now beset younger and younger
treatment group at the conclusion of the program. Qualitative generations (Cross National Collaborative Group,
1992; Kovacs & Gatsonis, 1994). Rates of anxiety
feedback indicated a high degree of program satisfaction. The results disorders in children and young people are also high
suggest that mindfulness is a potentially promising method for (Foa et al, 2005). Some conclude that the rise in mental
enhancing adolescents’ emotion regulation and well-being. health problems stems from the pressures associated
with rapid social change, combined with the breakdown

Advances in School Mental Health Promotion VOLUME 2 ISSUE 1 - January 2009 © The Clifford Beers Foundation & University of Maryland 35
 F E A T U R E

of many traditional cultural anchors, such as families, to produce maladaptive psychosocial outcomes, and
neighborhoods and institutions (Kovacs, 1997). A how protective factors can operate to foster resilience
report by the U.S. Surgeon General (U.S. Public Health (Cicchetti & Cohen, 1995; Luthar & Cicchetti, 2000;
Service, 2000) reported that one in ten children suffers Richardson, 2002; Rutter, 1987). The presence of risk
from a mental health condition that meets diagnostic factors, in the absence of sufficient protective factors,
criteria, and one in five suffers from problems that can foreshadow problem behaviors. When protective
significantly impair day-to-day functioning. Most factors are strengthened, more positive outcomes can
young people with mental health problems do not occur. Good prevention programs are rooted in a
receive treatment, and those who do receive services fundamental understanding of human development,
access the services primarily through their schools namely that the developmental work of childhood and
(Burns et al, 1995; Rones & Hoagwood, 2000). The adolescence is facilitated in circumstances that promote
U.S. Surgeon General report explicitly recognized the resilience (Catalano et al, 2004).
need to consider mental health as a critical component Not only do evidence-based prevention programs
of overall child health, and advocated active promo- in schools reduce problem incidence; they also build
tion of social, emotional and behavioral well-being. on skills for mental health throughout life (Greenberg
The Carnegie Task Force on Education (1989) et al, 2003). Thus, prevention reaps a double benefit:
wrote in its landmark report: reducing social and emotional problems, and promoting
positive behavior in young people. Teaching students
School systems are not responsible for meeting every need a skill set for social and emotional well-being also
of their students. But when the need directly affects learning, supports qualities of attention, reflection, and motivation
the school must meet the challenge (in Adelman & Taylor, that make learning effective. When students suffer from
2006 p296). mental health problems related to stress, violence,
depression, eating disorders, or drug abuse, the quality
Schools have tried to respond to the challenge of of their educational experience is diminished, no matter
students’ mental health problems in many ways, how skilled the teacher or how well-developed the
including provision of special education services and curriculum (Sroufe, 1997).
implementation of clinical services. Such treatment
approaches have been criticized for being fragmented, Teaching emotion regulation
exclusively problem-focused, and dependent upon
meeting criteria for psychiatric diagnosis or special A major contribution to the social and emotional skill
education in order to be accessed (Slade, 2003; set and a mainstay of mental health is emotion reg-
Weist, 1999). In addition, competing approaches to ulation. Emotion regulation is a broad construct which
providing mental health services in schools derive generally refers to the ability to recognize and manage
from multiple theoretical models (for example educa- emotions adaptively. Specific skills of emotion regulation
tional v. psychological), each with its own language might include awareness of emotional experience,
and set of assumptions (Kutash et al, 2006). identification of specific emotions and their intensity,
Recently, there has been increased emphasis on constructive emotional expression, and distress tolerance
closing the gap between the needs of young people (Cole et al, 2004; Davidson et al, 2000; Thompson,
and the services available to meet those needs (New 1994). It is recognized that emotion dysregulation
Freedom Commission on Mental Health, 2003). To underlies a broad array of psychological problems,
accomplish this goal, a comprehensive model is needed, such as depression, anxiety, eating disorders, conduct
such as the collaborative and holistic system of disorders and substance abuse (Bradley, 2000; Cicchetti
‘expanded school mental health’ (ESMH) proposed by et al, 1995). It also inhibits achievement of social and
Weist (1997). This approach incorporates existing emotional milestones in development (Siegel, 1999).
relevant services and broadens them into a compre- Currently, ancient contemplative or mindfulness-
hensive network that includes assessment, case based practices are moving into secular settings as a
management, therapy and prevention. way of fostering emotion regulation skills and cultivat-
Prevention is a fundamental component of any ing well-being (Hayes et al, 1999; Kabat-Zinn, 1990;
comprehensive plan. Recent research describes how Linehan, 1993; Segal et al, 2002). As Germer points
internal vulnerabilities interact with external conditions out, the word ‘mindfulness’ can be used to describe:

36 Advances in School Mental Health Promotion VOLUME 2 ISSUE 1 - January 2009 © The Clifford Beers Foundation & University of Maryland
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a theoretical construct (mindfulness), a practice of cultivat- achievement in college students (Hall, 1999), enhanced
ing mindfulness (such as meditation) or a psychological empathy (Shapiro et al, 2007) and reduced physical
process or state of consciousness (being mindful) (2005 symptoms and stress (Grossman et al, 2004). Research
p6). with children and adolescents is more limited. Some
studies have documented improvements in children’s
For sake of clarity, we define mindfulness as a way of and adolescents’ attentional skills following meditation
paying attention (being mindful) that is intentional, training (Napoli et al, 2005; Zylowska et al, 2008).
trained on the present moment, and maintained with Others have shown beneficial effects of meditation
an attitude of non-judgment (Kabat-Zinn, 1994) and techniques when used to alleviate children’s anxiety
meditation (or mindfulness meditation) as deliberate (Semple et al, 2005), to reduce aggression in a mentally
training of attention to cultivate this state. Contemplative retarded individual (Singh et al, 2003), and to promote
practices and mindfulness practices are used synony- adolescent individuation (Birnbaum, 2005). Empirical
mously, as both are means to still the mind and promote work is supported by theoretical and narrative descrip-
insight and concentration (Zajonc, 2006). tions of the benefits of bringing contemplative practices
Recent research has demonstrated the potential of to educational settings (Brady, 2004; Hart, 2004;
meditative practices to support the goals of education Holland, 2004; Wall, 2005; Zajonc, 2006). Ongoing
such as improved attention, concentration, creativity, applications of mindfulness in education attest to the
and emotional intelligence (Cowger & Torrance, dynamic quality of this movement (Brown, 2007).
1982; Goleman, 1995; Mayer & Salovey, 1997; see At present, no school-based mindfulness curriculum
also Shapiro et al, 2008, for a review of research on for adolescents has been reported in the literature,
meditation and higher education). In addition, the although mindfulness skills could be important for
practice of mindfulness meditation increases aware- facilitation of emotion regulation skills and for well-
ness of the mental processes that contribute to emo- being in the general adolescent population. Because
tion dysregulation and offers a means of coming back adolescence is a time of heightened emotionality and
into balance when strong emotions arise. Mindfulness increased pressure to adapt to stress constructively,
provides a way of working with emotions as they are Learning to BREATHE was created to facilitate the
experienced. In addition to learning about emotions, development of emotion regulation skills during this
there is a distinct advantage in learning how to notice period.
what is occurring in the present moment. Attending to
and identifying emotions can mitigate the emotional The study
response or reactivity and increase emotional balance
and clarity (Silvia, 2002). This practice offers the This study reports the development and evaluation of
opportunity to develop hardiness in the face of Learning to BREATHE, a mindfulness curriculum for ado-
uncomfortable feelings that otherwise might provoke a lescents created for a classroom setting. Results are
response that could be harmful (such as ‘acting out’ reported from a pilot trial of the program in a senior
by taking drugs or displaying violent behavior, or ‘acting class from a private high school for girls. It was hypothe-
in’ by becoming more depressed). Learning to attend sized that participants would show reductions in negative
to one’s present moment experience offers a tool to affect, greater understanding of emotions, reduced
manage emotions as they are perceived and potentially tendency to rumination, and decreased somatic symptoms
increase in magnitude. Mindfulness training can after completing the program than a control group.
complement and strengthen other approaches that
promote emotion regulation, reduce stress, and Methods
develop attention.
Research on the effects of mindfulness meditation Program development
training with adults has shown an array of benefits.
Some of these include changes in brain structures in Over three years prior to the initiation of this current
areas related to attention (Lazar et al, 2005), enhanced project, the program developer (P.B.) offered an ongo-
performance in attentional tasks (Jha et al, 2007), ing series of mindfulness classes during lunch periods
increases in positive mood and immune system func- and study halls for high school students who were
tioning (Davidson et al, 2003), improved academic interested in learning about stress management.

Advances in School Mental Health Promotion VOLUME 2 ISSUE 1 - January 2009 © The Clifford Beers Foundation & University of Maryland 37
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Although students reported being pleased with the Each lesson includes a short introduction of the topic,
program and data indicated reductions in negative several activities for group participation and discussion
mood after completing the sessions, this delivery system to engage students in the lesson, and an opportunity
had limitations. Students who wished to participate for in-class mindfulness meditation practice. Workbooks
were required to give up an opportunity to socialize and CDs for home meditation practice are provided to
with friends at lunchtime or forego time to complete students as part of this program.
assignments in study hall. Other activities were sched- Program development was based on certain
uled concurrently with lunch and study periods (music assumptions about adolescent development (Broderick
lessons, clubs, etc) and competed for students’ limited & Blewitt, 2006). Adolescents are involved at a deep
free time. Only a small self-selected group was able psychological level with constructing an identity and
to benefit. Consequently, finding a way for all students developing autonomy from adults. Emotions can
to participate within their regular class day became a become overwhelming and confusing and, although
primary goal. adolescents’ ability to understand and manage emotions
The classroom-based Learning to BREATHE program can advance, training in this area has often been
was refined and prepared for implementation over the neglected in school settings. This school-based program
course of a fourth year. During this time, funding was format provides for exploration of emotion regulation
sought for partial release time for the principal researcher strategies and invites students to consider the useful-
to implement the program, as well as for assistance ness of these tools for their lives. The discussion and
with preparation of materials and data analysis. Both practice sessions complement adolescents’ increased
the principal researcher and the assistant, who was a capacity for introspection, while maintaining sensitivity
certified teacher with classroom experience, had training to adolescents’ internal pressure for social conformity
in Mindfulness–Based Stress Reduction (Kabat-Zinn, and tendency to social comparison. Non-intrusive
1994) and were familiar with the theory and practice discussion of general stressors facilitates self-discovery
of mindfulness. In order to ensure a fit for the program in the peer context. Finally, the active participation of
within a school curriculum, Learning to BREATHE students in practice in-class and at home supports
program objectives were linked to standards of various integration of program content.
curricular areas, such as school health, and to those
of school professionals, notably school counselors Participants and method
(Bowers & Hatch, 2005).
The entire senior class (N = 120) of a private Catholic
Program structure and assumptions high school for girls in suburban Pennsylvania partici-
pated in the six-session Learning to BREATHE program
Learning to BREATHE tailors mindfulness-based as part of their health curriculum. All the participants
approaches to the developmental needs of adolescents. in the previously reported lunch time and study hall
Goals of the program include helping students under- classes had graduated by the start of this implementa-
stand their thoughts and feelings and learn mindfulness tion. Before the start of the program, a letter was sent
tools for managing negative emotions, and providing by the school principal informing parents about the
opportunities to practice these skills in a group setting. program. The letter described the program and
Six lessons are built around the BREATHE acronym, and assessments, and provided parents with the investiga-
each lesson has a core theme. The six themes include tor’s contact information in order to discuss any ques-
body awareness, understanding and working with tions they might have. The instructor presented the
thoughts, understanding and working with feelings, goals and objectives of the program to the entire
integrating awareness of thoughts, feelings and bodily senior class at an introductory assembly two months
sensations, reducing harmful self-judgments, and before program initiation (November). Before the
integrating mindful awareness into daily life. The overall administration of pre-tests and post-tests, students
goal of the program is to cultivate emotional balance were informed that they could refuse to complete the
through the practice of mindfulness, an advantage assessments without any penalty. The procedures
referred to as gaining the inner edge. Students are used to obtain informed consent from participants
repeatedly reminded of the intent to develop inner strength were approved by the university’s Institutional
and balance as they proceed through the sessions. Review Board.

38 Advances in School Mental Health Promotion VOLUME 2 ISSUE 1 - January 2009 © The Clifford Beers Foundation & University of Maryland
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Students from two sections of juniors (N = 30) from Measures

the same high school served as the control group.
Only two sections of juniors were available to serve as The participants in both groups completed a battery of
controls. A total of 17 completed records from control instruments including demographic information and
participants were usable for comparison at conclusion. four other measures at pre-test and post-test.
Assessments from the remaining 13 students were not Demographic items assessed age, racial/ethnic origin,
included due to incomplete records or absences. Pre-tests and current or past meditation or yoga practice. The
were administered one week before Session 1 and main outcome variables were measured with various
post-tests were administered one week after Session 6. instruments, as detailed below. With exception of age,
Only one administration of the post-test assessments all variables were of an ordinal measurement level.
was possible. Use of juniors as a control group in this
study had clear limitations, arising from possible influ- Positive and Negative Affect Schedule (PANAS)
ences such as maturation or specific stressors of senior Positive and negative affect at the time of testing were
year. However, the nature of the program (universal measured by the 20-item Positive and Negative Affect
prevention) and the structure of course scheduling in Schedule (PANAS; Watson et al, 1988) with the addition
the school setting made other designs unfeasible. The of four items. The PANAS consists of two 10-item sub-
curriculum for all seniors included Health during the scales – positive and negative affect. In this study,
third quarter of the year, a period of approximately positive affect was measured by the 10 original
seven weeks (January to March). Learning to BREATHE PANAS items (Cronbach’s α = 0.82), while negative
program objectives were linked to the Health curriculum affect was assessed via 11 items (10 original PANAS
objectives and needed to be delivered to all students items and an added ‘anxious’ item) (α = 0.81). The
within this time period. Consequently, the window of addition of the anxious item boosted the Cronbach’s α
opportunity was limited for program delivery and from 0.78 to 0.81. The last three items added to the
assessment, and prevented use of other means such scale created a 3-item calm/relaxed/self-accepting
as waiting-list control or multiple baselines. subscale (α = 0.69). These three items were added to
For this trial, program sessions were delivered the scale by the primary investigator to fill a perceived
approximately twice a week during seniors’ regular gap in the scale’s measured constructs. All items were
health classes. In order to accommodate seven sections measured on a 5-point Likert scale with higher scores
of seniors with a variety of schedules, as well as indicative of greater perceived affect within the subscale.
school- and weather-related interruptions, classes
were staggered over a period of approximately five Difficulties in Emotion Regulation Scale (DERS)
weeks. Class sessions ranged from 32 to 43 minutes Ability to regulate emotions was assessed by the
each. A total of 42 class sessions were taught by Difficulties in Emotion Regulation Scale (DERS; Gratz &
the primary researcher (P.B.), with some support Roemer, 2004). The DERS is composed of six factors:
from the grant-funded assistant who was trained in non-acceptance of emotional response (six items; α =
the program. 0.88), difficulties in engaging in goal-directed activity
The majority of the girls in the treatment group (five items; α = 0.86), impulse control difficulties (six
were Caucasian (93.3%) with an average age of items; α = 0.84), lack of emotional awareness (six
17.43 years (sd = 0.53, range 17–19 years). Most items; α = 0.80), limited access to emotion regulation
girls in the control group were also Caucasian (88.2%), strategies (eight items; α = 0.87), and lack of emo-
but displayed a lower mean age (M = 16.41 years, tional clarity (five items; α = 0.76). Reported alpha
sd = 0.85, range 16–17 years). values for all measures were calculated based on the
current study at baseline. Items were measured on a
Design and measures 5-point Likert scale. Higher scores indicate more diffi-
culty in regulating emotions.
This pilot program evaluation used a non-randomized
pre-test/post-test control group design to assess the Ruminative Response Scale (RRS)
program’s impact on affect and behavior in female Type of ruminative response to a depressed mood was
adolescents. Pre-test and post-test measures were measured by the Ruminative Response Scale (RRS;
administered by the students’ health teacher. Nolen-Hoeksema & Morrow, 1991). The two factors of

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the RRS used in this study consisted of reflective pon- control groups did not display any significant differ-
dering (five items, α = 0.65) and moody pondering ences in pre-test subscale scores within any outcome
(or brooding) (five items, α = 0.51) (Treynor et al, measure (p < 0.05) (results not included in article).
2003). Each item was measured on a 4-point Likert All participants in the control group completed the
scale with higher scores indicating a greater degree of post-test, but 15 students in the program group did not
the trait. complete the post-test, leaving 105 program participants
completing both assessments. No demographic char-
Somatization Index of the Child Behavior Checklist acteristics or pre-test subscale scores were significantly
(SICBC) different between the program participants completing
Frequency of somatic complaints was assessed via 10 both assessments (N = 105) versus pre-test only (N =
items from the Somatization Index of the Child Behavior 17) (results not included in article). In addition, mean
Checklist (SICBC; Achenbach, 1991). Examples of items imputation within respective subscales was performed
included feeling over-tired, and experiencing aches/ on individual missing items (<0.5% of all data) in
pains, headaches, or nausea (α = 0.65). Frequency of order to maximize the sample size in the analyses.
somatization was measured on a 3-point Likert scale Mean gain scores (post-test – pre-test scores) were
with higher scores comparable to greater perceived compared between groups to assess program effective-
frequency of complaint. ness (Table 2, opposite). The mean gain scores of two of
The evaluation also included a qualitative process the three PANAS subscales were significantly different
assessment at post-test of program student participation between program participants and the control group.
and satisfaction, as well as levels of homework practice Specifically, in comparison to the control group, the
throughout the program. program participants demonstrated a significant
reduction in negative affect (mean gain score -2.51
Statistical analysis vs. 1.63; t = 2.34, p < 0.05), and a significant
increase in feeling calm/relaxed/self-accepting (mean
Pre-test demographic data by program versus control gain score of 0.90 vs. -0.65; t = -2.06, p < 0.05).
group were summarized in tabular format. Using SPSS No other mean gain scores within the other three
15.0 software, chi-square tests (for nominal variables) measures (DERS, RRS, SICBC) demonstrated significant
and independent t-tests (for ordinal/continuous variables) differences between the program and control groups.
were calculated to detect statistical pre-test differences Since post hoc power analyses demonstrated low
between the program and control groups. To clarify, power to detect significant mean gain score differences
the non-parametric test equivalent to the independent between program and control groups, paired t-tests
t-test (Mann-Whitney U) was initially used to assess were computed within the program group to detect
differences of ordinal variables between groups, but differences from pre-test to post-test across the multiple
since results were comparable between the two tests,
the parametric test results were reported. Mean gain TABLE 1 Pre-ttest Characteristics of BREATHE Program
scores (post-test – pre-test) for each subscale within and Control Group Participants
each above mentioned measure were calculated and
Program Group Control Group
compared between groups with independent t-tests to N = 120 N = 17
assess program effectiveness. Using G*Power 3.0.10 Variable n (%) or M (SD) n (%) or M (SD) t or χ2
software, effect sizes were also computed for each test Age (years) 17.4 (0.5) 16.4 (0.5) -7.42*
using Cohen’s d. Cohen’s d is commonly interpreted Range 17–19 Range 16–17
Ethnicity
as: 0.2 small, 0.5 medium, and 0.8 large. White 112 (93.3) 15 (88.2) 1.49
Hispanic 3 (2.5) 1 (5.9)
Asian 3 (2.5) 1 (5.9)
Results Other 2 (1.7) 0 (0.0)
Current or past
Table 1, below, displays baseline demographic char-
meditation practice 21 (17.5) 2 (11.8) 0.35
acteristics by program group (N = 120) and control
Current or past
group (N = 17). Only age was statistically different yoga practice 42 (35.3) 4 (23.5) 0.92
between groups (Mprogram = 17.4 years, Mcontrol =
* Significant difference between groups at p < 0.05 level.
16.4 years; t = -7.42, p < 0.05). The program and

40 Advances in School Mental Health Promotion VOLUME 2 ISSUE 1 - January 2009 © The Clifford Beers Foundation & University of Maryland
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TABLE 2 Differences in Mean Gain Scores (Post-ttest – Pre-ttest Scores) by Group

Treatment Group Control Group

Scales †
n M (SD) n M (SD) t Cohen’s d††
PANAS
Positive affect 104 0.63 (7.32) 17 -2.47 (7.75) -1.61 0.41
Negative affect 104 -2.51 (6.59) 17 1.64 (7.92) 2.34* 0.57
Calm/relaxed/self-accepting 104 0.90 (2.86) 17 -0.65 (2.98) 2.06* 0.53
DERS
Total 104 -3.73(13.75) 17 0.33(15.55) 1.11 0.28
Non-acceptance of emotional response 104 -0.75 (4.33) 17 -0.23 (3.88) 0.46 0.13
Difficulties in goal-directed activity 104 0.14 (4.26) 17 0.41 (4.39) 0.24 0.06
Difficulties in impulse control 104 -0.40 (3.46) 17 1.05 (2.96) 1.63 0.45
Lack of emotional awareness 104 -1.19 (3.90) 17 -1.62 (2.63) 0.44 0.13
Limited emotion regulation strategies 104 -0.93 (5.43) 17 1.08 (5.33) 1.42 0.37
Lack of emotional clarity 104 -0.61 (2.86) 17 -0.35 (3.26) 0.33 0.08
RRS
Reflective pondering 105 0.06 (3.88) 17 -0.35 (4.27) -0.40 0.10
Moody pondering (brooding) 105 -0.49 (2.56) 17 0.18 (2.45) 1.01 0.27
SICBC Total 105 -0.75 (2.58) 17 -0.29 (1.93) 0.69 0.20

* Independent t-test significant at p < 0.05 level (NOTE: Non-parametric Mann-Whitney U tests were also computed and results were comparable with the para-
metric counterpart test)
†
PANAS (Positive and Negative Affect Schedule); DERS (Difficulties in Emotion Regulation Scale), RRS (Ruminative Response Scale); SICBC (Somatization Index of
the Child Behavior Checklist)
††
Effect size measured by Cohen’s d: 0.20 small, 0.50 medium, 0.80 large

measures (Table 3, overleaf). Within the PANAS, program of class during the length of the program. Multiple
participants displayed a statistically significant decline one-way ANOVAs and post hoc Tukey tests were
from pre-test to post-test in negative affect, and a sig- computed to assess whether mean gain scores for all
nificant increase in feeling calm/relaxed/self-accepting. measures (including SICBC somatic items) were statis-
They also demonstrated a significant decline from pre- tically changed by the amount of time the student
test to post-test in the total difficulty in emotion regulation practiced being mindful outside of class (categorized
(DERS) score, lack of emotional awareness DERS sub- as four or more days per week, once a month to three
scale, and the lack of emotional clarity DERS subscale. days per week, and none). Only three mean gain
No significant mean differences from pre-test to post- scores were significant: SICBC Total, item on dizzy,
test were found within the RRS measure, whereas, in the and item on over-tired. Overall somatic complaints, as
SICBC, program participants demonstrated a significant measured by the total SICBC score, were reduced for
reduction from pre-test to post-test in feeling over-tired those practicing mindfulness outside of class for four
and complaints of aches/pains (not headaches or or more days a week (Mean Gain Score = -2.53) in
stomach aches). comparison to both those practicing less than four
The process evaluation revealed that 86.5% of days a week (Mean Gain Score = -0.58) and those
program participants were satisfied or very satisfied practicing only in class (Mean Gain Score = -0.34) (F
with the Learning to BREATHE program. Specifically, = 5.20, p = .008). However, specific somatic com-
the in-class program activities rated most useful included plaints of dizziness and feeling over-tired increased for
in-class meditation practice overall, body scan meditation, those practicing mindfulness outside of class for four
and a music and emotions activity, while the activity or more days a week compared to those who prac-
rated least useful was in-class discussion (Table 4 , ticed being mindful only in class (respectively, F = 4.72,
overleaf). Approximately half of all participants reported p = 012; F = 4.55, p = .014).
that the most important skill they had learned from
the program was how to deal better with stressful Discussion
thoughts and feelings.
Students were also asked to indicate how often The results of these analyses demonstrate that partici-
they practiced mindfulness, and 64.6% of participants pants in the Learning to BREATHE program reported
indicated practicing some mindfulness techniques outside reductions in negative affect and increases in feelings

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TABLE 3 Pre-ttest – Post-ttest Differences for Treatment Group Participants

Pre-ttest Score Post-ttest Score

Scales †
N M (SD) M (SD) t Cohen’s d††
PANAS
Positive affect 104 26.09 (6.97) 26.72 (7.43) -0.88 0.09
Negative affect 104 20.71 (7.06) 18.20 (5.71) 3.89** 0.38
Calm/relaxed/self-accepting 104 8.97 (2.75) 9.86 (2.68) -3.21** 0.31
DERS
Total 104 88.39(18.27) 84.65(18.69) 2.77** 0.27
Non-acceptance of emotional response 104 13.08 (5.47) 12.32 (5.16) 1.77 0.18
Difficulties in goal-directed activity 104 16.19 (4.54) 16.34 (4.75) -0.34 0.04
Difficulties in impulse control 104 12.09 (4.22) 11.69 (4.63) 1.18 0.12
Lack of emotional awareness 104 16.84 (4.71) 15.65 (4.67) 3.12** 0.30
Limited emotion regulation strategies 104 17.51 (5.96) 16.58 (6.09) 1.74 0.17
Lack of emotional clarity 104 12.67 (3.18) 12.07 (2.88) 2.16* 0.21
RRS
Reflective pondering 105 23.60 (4.36) 23.66 (5.02) -0.15 0.02
Moody pondering (brooding) 105 12.42 (2.50) 11.92 (2.88) 1.98 0.20
SICBC
Total 105 8.39 (2.96) 7.64 (3.24) 2.98** 0.29
Dizzy 105 0.53 (0.59) 0.50 (0.62) 0.61 0.05
Over-tired 105 1.54 (0.57) 1.37 (0.59) 2.95** 0.29
Problems getting to sleep 105 0.94 (0.81) 0.82 (0.78) 1.79 0.17
Problems getting up in the morning 105 1.49 (0.65) 1.42 (0.68) 1.47 0.15
Aches/pains 105 0.86 (0.68) 0.71 (0.73) 1.99* 0.20
Headaches 105 1.12 (0.69) 1.02 (0.68) 1.82 0.16
Nausea/feeling sick 105 0.60 (0.66) 0.58 (0.64) 0.23 0.03
Problems with eyes 105 0.28 (0.55) 0.34 (0.58) -1.13 0.11
Stomach aches 105 0.93 (0.67) 0.82 (0.69) 1.68 0.15
Vomiting 105 0.10 (0.35) 0.07 (0.29) 0.82 0.11

* Significant at p < 0.05 level

**Significant at p < 0.01 level
†
PANAS (Positive and Negative Affect Schedule); DERS (Difficulties in Emotion Regulation Scale), RRS (Ruminative Response Scale); SICBC (Somatization Index of
the Child Behavior Checklist)
††
Effect size measured by Cohen’s d: 0.20 small, 0.50 medium, 0.80 large

of calmness, relaxation and self-acceptance compared

TABLE 4 Qualitative Process Evaluation of BREATHE
to controls. There was also an increase among program for Treatment Group Participants (N = 108)
participants in emotion regulation after program com-
pletion. Students indicated greater awareness of their Variable† N Mean SD
feelings as they were being experienced. They also Program Component
reported being clearer about the specific emotions they Body scan 107 7.46 2.58
Meditation practice 106 7.92 2.17
experienced. These findings suggest that this program
Mindful movement practice 97 6.63 2.59
may be an effective way to teach students to use Loving-kindness meditation 100 6.60 2.38
mindfulness to manage negative emotions and to Class discussion 107 5.37 2.35
Specific class activities/exercises:
understand thoughts and feelings. Acting out thoughts 92 6.25 2.43
Within the treatment group, students reported sig- Music and emotions 88 7.02 2.29
nificant overall reductions in tiredness and decreases Self-compassion exercise 100 6.17 2.19
Top ten list 68 6.44 2.28
in aches and pains from pre-test to post-test. Process Workbook 99 4.15 2.41
evaluation indicated that approximately two-thirds of CDs 102 6.91 2.71
the participants practiced mindfulness techniques out- Quality of Instructor 108 9.44 1.22
side of class. Of this group, those who practiced more Overall Satisfaction with BREATHE
Program 104 7.89 1.93
frequently reported feeling more tired and dizzy than
those who practiced less frequently. This finding is dif- †
Each item measured on a scale of 0 (least useful/satisfied) to 10 (most
useful/satisfied)
ficult to interpret, because students were not asked to

42 Advances in School Mental Health Promotion VOLUME 2 ISSUE 1 - January 2009 © The Clifford Beers Foundation & University of Maryland
 F E A T U R E

describe the specific nature of the mindfulness practice other forms of contemplative practices infused within
performed outside of class. In class discussions, students the curriculum. Long-term follow-up studies could
had reported that the experience of being still helped clarify this question.
them notice their chronic levels of fatigue. This might Lastly, research with adults has found that additional
help explain the increase in feeling over-tired in the cognitive and affective skills such as attention, concen-
frequent-practice group, but it is unclear why dizziness tration, empathy and creativity can be cultivated by
also increased in this group. More specific detail on meditative training. These are skills central to the
the nature of at-home practice is needed to answer goals of education. Examination of the connections
these questions. between mindfulness training and student attention,
Overall, participants were satisfied with the program, achievement, and peer relationships, in addition to
primarily because it helped them learn how to let go emotion regulation, would therefore provide important
of distressing thoughts and feelings in order to manage information about the significance of mindfulness
stress. One student’s comment captured the theme of skills as protective factors for adolescents. It is unlikely
empowerment noted by the majority of respondents. that a short program would have a significant impact
on these areas without additional practice. Benefits
‘I learned that I can control the way I react to things and accrued from participation in this program might be
that nothing is too overwhelming for me to handle.’ amplified if contemplative, reflective practices were
encouraged in other areas of students’ academic and
The results of this pilot study are promising but prelim- personal lives. Such practices might be useful as part
inary. Its limitations and unexplored questions, however, of an expanded program of mental health in schools.
offer an opportunity for further study in order to advance As we have indicated, mindfulness and contempla-
understanding about the most effective ways to facilitate tive approaches have been received enthusiastically by
emotion regulation skills in adolescents. researchers and practitioners because of demonstrated
First, this study relied on a relatively homogeneous effectiveness in improving the lives of adults. The work
student sample. Further research is needed to explore of bringing mindfulness to children and adolescents in
the generalizability of this program to other groups schools is just beginning. A growing evidence base
differing in gender, ethnicity and social class. The program suggests that childhood and adolescence are critical
curriculum was designed to be adapted for younger points for prevention and risk reduction. Helping young
adolescents by varying activities and adjusting the pre- people manage effectively the stresses they will surely
sentation level. It would be helpful for future studies to face by strengthening their capacity for emotion regulation
assess its effectiveness for younger groups. is a potentially promising way of actively promoting
Second, the use of juniors as the control group raises their well-being.
the possibility that seniors might have benefited from the
program because of their increased cognitive and emo- Acknowledgements
tional maturity. Attrition in the control group also may
have artificially inflated treatment effects. Future studies The authors are grateful to the Trust for the Meditation
should attempt to provide more robust control groups or Process for supporting this research, and to Patty Geist
employ a waiting-list control design if it is possible within for her assistance. In addition, gratitude is expressed
the constraints of the school curriculum. to the reviewers for their helpful comments.
Third, it is important to investigate the skills that
teachers need in order to offer this program effectively. Address for correspondence
It is our contention that instructors should have training
in mindfulness practices, but whether this is a necessary P. C. Broderick, Department of Health, Sturzebecker
condition for program effectiveness needs to be Health Sciences Center, West Chester University of PA,
examined. West Chester, PA 19383, USA; [email protected].
Fourth, the relatively short duration of the program
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